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Consolidation report (2009) - from testing to spread


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This publication reports back on a review undertaken by NHS Improvement to examine the progress and impact of 25 Acute Trusts who took part in the Transforming Cancer Inpatient Care Programme (July …

This publication reports back on a review undertaken by NHS Improvement to examine the progress and impact of 25 Acute Trusts who took part in the Transforming Cancer Inpatient Care Programme (July 2007-2008) and the subsequent spread of the Winning Principles and models of care across England (Published July 2010).

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  • 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKETransforming Inpatient Care ProgrammeConsolidation Report (2009)From testing to spread
  • 2. Consolidation Report - From testing to spread | 3Contents Foreword 4 Summary 5 Introduction 8 25 NHS acute test trusts: Progress, impact and benefits 9 Reported benefits and investments 10 Impact of the Winning Principles and Models of Care 11 Winning Principle 1 12 Winning Principle 2 16 Winning Principle 3 22 Winning Principle 4 23 Summary: Consolidation of testing 24 Beyond testing: Coverage and spread 25 Levers for spread 28 Conclusion 29 Acknowledgements and references 30
  • 3. 4 | Consolidation Report - From testing to spread Foreword The NHS has to identify ways to improve both quality and productivity in order to continue to improve patient care in a tight economic climate. This report provides significant encouragement that we can achieve the joint aims of quality and productivity in the care of people with cancer. It describes a range of ways in which cancer care can be streamlined and become more patient-centred. The techniques all follow the four Winning Principles. The report contains details of the spread of these techniques accompanied by an estimate of the potential savings that Celia Ingham Clark they can deliver in terms of bed-days and costs, and it demonstrates effective implementation of the Cancer Reform Strategy. I hope that Trust Medical Directors and Cancer Managers who have not yet adopted the ‘Winning Principles’ will be motivated to do so on reading this report. For those who have already delivered some quality improvements, many of whom are mentioned in the report, the challenge now is to implement the other improvements too! Celia Ingham Clark Colorectal Surgeon and Medical Director, Whittington Hospital, London. National Clinical Lead Transforming Inpatient Care Programme
  • 4. Consolidation Report - From testing to spread | 5SummaryThe Cancer Reform Strategy (CRS 2007) highlighted the need to focus attention on inpatientcare. Too many patients were being admitted into hospital and lengths of stay were oftenunnecessarily prolonged. The CRS established the Transforming Cancer Inpatient CareProgramme to take this forward and test out ideas that would improve quality and reduceunnecessary inpatient bed days.This report is the product of a review undertaken From testing to spreadby NHS Improvement examining the progress and The learning from testing was disseminated widelyimpact of 25 Acute Trusts who took part in the throughout the testing period (July 2007-2008) toTransforming Cancer Inpatient Care Programme encourage early adopters. Spreading the Winning(July 2007-2008) and the subsequent spread of Principles Strategy was launched in July 2008.the Winning Principles and models of care across Evidence from the subsequent spread surveyEngland. (December 2009) identified:The report forms part of NHS Improvement • 54 NHS Trusts (covering 72 hospital sites) wereevaluation strategy, and provides evidence of spreading the quality principles and models.progress to the Department of Health Cancer • 183 improvement activities have been reported.Programme Board supporting the quality, • The main focus for spread surrounds Winninginnovation, productivity and prevention Principles 1 and 2; emergency and elective care,(QIPP) agenda. the application of communication alert systems, enhanced recovery approaches, 23 hour breastAchievements of the 25 Acute Trusts model and symptom specific pathways e.g.The 25 Acute Trusts incorporates 37 hospital sites febrile neutropenia.which covered 16% of acute providers for cancer • Coverage increased across England from 16%services across England. In terms of improving to 34% of secondary acute providersquality and productivity good progress was made (see Figure 1).against the baseline position (see Figure 2). • The 2008/09 national picture shows that the total of bed days peaked at 5.25m in 2005/06.• Through testing the Trusts identified four simple Since then there has been a 15% fall. The quality principles, published as ‘The Winning ‘Spread activity’ contribution to the national Principles’ (July 2008); fundamental to picture over the last two years saw a shifted improving emergency and elective pathways, from 2.4% bed capacity released during testing clinical decision-making and enhancing patient to 34.17% as subsequent spread. self-management. • Nationally, 264,340 bed days were released• Across the Trusts 108,067 potential bed day towards saving a million beds days (2012). capacity was released (Figure 2). Progress is being made but the pace of spread• Based on the lower estimate of £200 per needs to be accelerated. patient, per bed day, the potential released • The four key levers identified by Trusts to efficiency saving for the 25 trusts was £21.6m. accelerate spread were planning for spread, having communication and awareness strategies, identify and the use of opinion leaders and sharing comparative data (see Figure 24).
  • 5. 6 | Consolidation Report - From testing to spread Figure 1: What contribution are the 54 Trusts making to the national picture and the potential impact? Spread strategy launched July 2008 2007-2008 2008-2009 2009-2010 Full year projection (provisional) 54 Trusts episodes ( emergency/elective 298,595 288,527 309,657 inpatients) 54 Trusts bed days 1,750,564 1,660,251 1,730,149 54 Trusts reduction in length of stay from 0 90,313 20,415 2007-2008 Year 54 Trusts reduction potential savings in £0 £18,062,600 £4,082,933 length of stay from 2007-2008 Year 54 Trusts % contribution bed days towards 0.00% 34.17% 16.03% national coverage 2007-2008 Year 2007-2008 2008-2009 2009-2010 Full year projection (provisional) National Episodes (emergency/elective 775,279 757,494 807,621 inpatients) National bed days 4,759,067 4,494,727 4,631,701 National reduction in length of stay from 0 264,340 127,366 2007-2008 Year National potential savings in length of stay £0 £52,868,000 £25,473,133 from 2007-2008 Year (£200 per patient per bed day lower estimate) National bed day saving from 0.00% 5.55% 2.68% 2007-2008 Year The national picture shows that the total bed days peaked at 5.25m in 2005/2006. Since then there has been a 15% fall to around 4.5m.
  • 6. Consolidation Report - From testing to spread | 7Where to next: A focus on spread • Spreading Winning Principle 2, key models:Retaining the focus on accelerating the pace of • The 23 hour breast model of ambulatory carespread remains a priority. across cancer networks. • Enhanced Recovery approachesThis review provides a useful baseline upon which • Shifting procedures from inpatient toto build the next stage of the Transforming alternative care settings.Inpatients Spread Strategy (2010-2012). This will • Repeating the spread survey during theinclude: summer of 2010 and 2011.• Emergency and Urgent Care Initiative led by The Winning Principles NHS Improvement. Due to the increasing number of emergency admissions, the focus 1. Unscheduled (emergency) patients needs to be retained on spreading Winning should be assessed prior to the decision Principle 1 and the new models of emergency to admit. Emergency admission should and urgent care that include: be the exception not the norm. • Triage, Treat, Transfer Pathways • Telephone triage • Crisis resolution teams and integrated 2. All patients should be on a defined community working inpatient pathways based on their • Improved patient signposting to urgent tumour type and reasons for care settings admission. • Proactive risk management by telephone to avoid unnecessary admissions • Communication Alerts 3. Clinical decisions should be made • Emergency Care Practitioner assessment on a daily basis to promote proactive case management. and triage • Home tele-monitoring - Diagnostics and testing at home • Patient ownership of health records and 4. Patient and carers need to know emergency/urgent care plans about their condition and symptoms • 24 hour pharmacies holding emergency drug to encourage self-management and to box (for OOH GPs) know who to contact when needed. • Pain management without hospital admission • Acute Oncology Models
  • 7. 8 | Consolidation Report - From testing to spread Introduction The report draws on 180 pieces of evidence from qualitative and quantitative sources, including; learning diaries, case studies spread planners, local data and a spread survey (October 2009 - December 2009). Hospital Episode Statistics (HES) provided baseline measures (2006/7) and measures of progress (2009). Review objectives Since the commencement of the Transforming The objectives of the review were firstly to Inpatient Care Programme 2007, the learning consolidate the progress of the 25 test gained has been disseminated nationally trusts by: (Transforming Care for Cancer Inpatients 2008- • Examining the progress and quantifying 2009) and shared with the Department of Health benefits, investments and potential reductions in Enhanced Recovery Partnership Programme (2009) lengths of stay and bed days. to accelerate the pace of spread; of Winning Principle 2 across the NHS. Secondly to: • Assess the coverage, spread of the Winning Continuous Improvement Principles and models There is a danger in a report of this nature, to • Provide direction for the next stage of the judge progress and success on ‘bottom line Transforming Cancer Inpatient Care Programme deliverables’, particularly at a time when Spread Strategy. productivity and cost savings are high on the health agenda. It is therefore important to Spread recognise that the improvements tested involve The definition of spread in the context of this many dimensions of change including systems, report has been used as a measure not only of process redesign, changes in behaviour and increasing numbers but also indicating which clinical and managerial practice. This report is winning principles and models have been spread based on the evidence received which may not or adopted and what local levers are being used reflect all the local variables. In most cases, the to support this. spread reported is ongoing and therefore the findings in this report should be read within this context.
  • 8. Consolidation Report - From testing to spread | 925 NHS acute test trusts: Progress, impactand benefitsAchievementsContinuous incremental progress has Figure 2: Average Length of Stay - All Cancers (All episodes emergency and elective inpatients)been achieved across the 25 test 25 Test Trusts Emergency and Elective Inpatient Cancer Admissionstrusts. The majority of sites achieved a Average LOS 2006/07 Baseline, 2007/08 Testingreduced length of stay from theoriginal 2006/07 Hospital Episode 9 2006 - 2007 2007 - 2008 2008 - 2009Statistics* baseline position (Figure 2). 8 Average Length of Stay (days) 7• 80% - Reduced length of stay during the testing period (July 6 2007/08). Releasing 73,582 5 potential bed day capacity 4• 80% - Continued to reduce length 3 of stay following the testing period• Overall - 76% reduced length of 2 stay from the 2006/07 baseline 1 position, releasing potentially 0 108,067 bed days, which is a 12% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 reduction from the 2006/07 Trust baseline position (Figure 3) NHS Trusts• The contextual information around 1. Barking, Havering and Redbridge 14. Royal Berkshire NHS Foundation Trust Hospitals NHS Trust 15. Sandwell and West Birmingham Hospitals the trusts where length of stay was 2. Barts and The London NHS Trust NHS Trust not reduced or sustained indicated 3. Blackpool, Fylde and Wyre Hospitals NHS 16. Scarborough and North East Yorkshire Health issues surrounding data collection, Foundation Trust Care NHS Trust 4. Brighton and Sussex University Hospitals 17. Sherwood Forest Hospitals NHS improvement work discontinued NHS Trust Foundation Trust and changes in leadership. 5. The Christie Hospital NHS Foundation Trust 18. South London Healthcare NHS Trust 6. East Sussex Hospitals NHS Trust 19. St Helens and Knowsley Hospitals NHS Trust 7. Great Western Hospitals NHS Foundation Trust 20. The Hillingdon Hospital NHS Trust 8. Hull and East Yorkshire Hospitals NHS Trust 21. The Whittington Hospital NHS Trust 9. King’s College Hospital NHS Foundation Trust 22. United Lincolnshire Hospitals NHS Trust 10. Milton Keynes Hospital NHS Foundation Trust 23. University Hospital Birmingham NHS 11. North West London Hospitals NHS Trust Foundation Trust 12. Northampton General Hospital NHS Trust 24. University Hospitals of Morecambe Bay NHS Trust 13. Oxford Radcliffe Hospitals NHS Trust 25. Whipps Cross University Hospital NHS Trust Figure 3: Inpatient episodes and bed day data 25 Test Trusts 2006/07 2007/08 2008/09 Baseline Testing Commence*All the HES data used in the review refers to: SpreadLoS = HES Length of Episode (Epiend - Epistart).If more than one episode was present in spell Episodes 144,442 148,222 141,650then episode LoS may not equal full spelllength. Bed days 894,417 859,932 786,350 108,067All HES data used is retrospective. Bed day capacity releasedHES Baseline Data - April 2006/07 - Used as aretrospective baseline. Range 7.8 - 4.28 7.57 - 3.97 6.9 - 3.61 Average LOS 6.9 5.8 5.5HES Testing Data – 2007/08 – Testingcommenced July 2007 to July 2008HES 2008/09 - Spread phase Hospital Episode Statistics
  • 9. 10 | Consolidation Report - From testing to spread Reported benefits and investments Review of the qualitative information Alert systems have improved Example: Breast 23 Hour Care identified common themes aligned to communication, reduced length of Model the current Quality, Innovation, stay and in some cases averted A reduction in wound drains and the Productivity and Prevention (QIPP) unnecessary admissions and enhanced intervention of not draining seromas. agenda. timely clinical decision-making. Saved patients extra visits to the hospital and released clinic time which Quality Productivity and prevention was utilised for breast pre-assessment. Key elements for improving the quality Reductions in unnecessary admissions of patients, and carers, experience and reductions in prolonged lengths Example: Enhanced Recovery were identified by the sites as: of stay can reduce the risk of hospital Models • Valuing patient’s time acquired infections, reduce demands The current work of the Enhanced • Setting and managing patients on staff and releases bed capacity. Recovery Partnership Programme has expectations identified the potential costs (Figure 4) • Improving communication and Capturing the benefits and investments required to support information How trusts individually captured the implementation, if organisations have • Removing duplication, and non- released capacity and finances in real none of the enhanced recovery value adding time through terms was a local decision and not elements in place. Dedicated time, streamlining the pathway of care. captured in the review. Feedback clinical leadership and change from test sites indicated some management skills are the key Innovation organisations utilised the released investments required. Changes in clinical practice such as capacity to achieve the18 week wait the enhanced recovery approaches and the cancer 62-day target. and 23 hour breast care model: Figure 4: Enhanced recovery • Improved the knowledge of Investment model estimated costs per patient outcomes Investment during testing varied from (8 major surgical procedures) • Reduced postoperative site to site dependent on trusts, complications. individual starting point and local Pre-referral £9 - 35 capacity and capability. Investment Pre-operative £20 - 82 This reflects the Varadhan reported was predominately time, Admission £4 - 10 study (2010) that indicated the support from clinicians, management Surgery £69 -111 implementation of four or more and service improvement and change elements of Enhanced Recovery leads management expertise. Costs Post- surgery £30 - 73 to a reduction in length of stay by identified were minimal and often Total net cost £142 to £311 more than two days and an almost offset by cost savings from reduction Department of Health Enhanced 50% reduction in complication rates in use of unnecessary equipment such Recovery Partnership Programme in patients undergoing major open as drains and by re-organising (2009) colonic/colorectal surgery. resources. These clinical models use the most up to date surgical and anaesthetic techniques, challenge traditional practices and promote the management of patient expectations.
  • 10. Consolidation Report - From testing to spread | 11Impact of the Winning Principles and Models of CareTesting identified four qualityfocused ‘winning principles’ andpractical models of care.The Transforming Inpatient Programmehas been acknowledged as providing The Winning Principlesexcellent examples of ‘Quality, Innovation Winning Principle 1and Productivity in Practice’ (David Unscheduled (emergency) patients should be assessed prior to the decisionNicholson CEO NHS, 2009), and the to admit. Emergency admission should be the exception not the norm.Transforming Inpatient publication (2009)Sharing the Learning, was commended Winning Principle 2as best professional education initiative All patients should be on defined inpatient pathways based on theirin Oncology (Excellence in Oncology tumour type and reasons for admission.2009). Winning Principle 3 Clinical decisions should be made on a daily basis to promote proactive case management. Winning Principle 4 Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed.
  • 11. 12 | Consolidation Report - From testing to spread Winning Principle 1 Unscheduled (emergency) patients should be Figure 5: Winning Principle 1 - Baseline and potential impact assessed prior to the decision to admit. 15 Test Trusts Emergency admission Emergency 2006/07 2007/08 2008/09 should be the exception Baseline Testing Commence not the norm. Spread Episodes 95,361 96,668 96,764 Fifteen trusts tested different models that included defining Bed days 560,516 540,418 518,371 42,147 emergency pathways for Bed day capacity symptoms, palliative care and released specific conditions such as neutropenic sepsis. Trusts tested a Range LOS 7.57 - 4.25 7.57 - 3.97 6.85 - 3.72 range of communication alert systems and approaches for rapid access to timely clinical decision making, which supports Winning The average length of stay for cancer Principle 3. related emergency admissions nationally by PCT is 6.5 days across Across the 15 test sites, the England, ranging from 4.1 days to potential of 42,147 bed day 9.0 days. (HES. 2008/09). capacity (from the baseline position) was released • Emergency bed days average 11.3 (Figure 5). bed days per new cancer case, ranging from 7.1 to 17.7 bed days. Model of Care: Communication Alerts Three trusts tested communication alert systems across specific tumour groups. Local data showed that alert systems had an impact on reducing length of stay by 25% in some tumour groups (Figures 6 - 9). Communication alerts were significantly effective for patients previously diagnosed with cancer admitted as an emergency (Sherwood Forest Hospitals NHS Foundation Trust case study 2008). Local dataWINNING PRINCIPLE 1 identified a number of admissions averted, this data is not captured by HES.
  • 12. Consolidation Report - From testing to spread | 13 Figure 6: Average Length of Stay: Emergency Lung Inpatients 10 2006 - 2007 2007 - 2008 2008 - 2009 9 Average Length of Stay (days) 8 7 6 5 4 3 2 1 0 Northampton Sherwood Forest United Lincolnshire General Hospital Hospitals NHS Hospitals NHS Trust NHS Trust Foundation Trust NHS TrustHES data. Figure 7: Communication Alert for Recurring Admissions Across Tumour Sites - Kings Mill Hospital. Comparison of median length of stay for non-elective breast, gynaecological, lower GI and lung patients, pre, during and post implementation of RAPA 15 15 Breast Gynaecological Lower GI Lung 10 Time (days) 9.5 8 5 6 6 6 6 5 4 4 3 3 0 Pre RAPA Feb 2007 April 2009 RAPA Trial Post RAPABased on local trust data.
  • 13. 14 | Consolidation Report - From testing to spread United Lincolnshire Hospitals NHS Figure 8: Trust commenced testing in urology Average length of stay by known cancer patients readmitted to hospital non and upper gastrology and this has electively with symptoms related to primary cancer or treatment - United Lincolnshire Hospitals NHS Trust now spread to lung cancer patients across four hospital sites (Figures 8 12 Upper GI Urology Lung and 9). 10 Number of days 8 6 4 2 0 2006/07 2007/08 2008/09 2009/10 Based on local trust data. Figure 9: Average length of stay by known cancer patients readmitted to hospital as emergencies with symptoms related to primary cancer or treatment - Lung - United Lincolnshire Hospitals NHS Trust 14 2008/09 2009/10 12 10 Number of days 8 6 4 2 0 Lincoln Louth Grantham Boston United Lincolnshire Hospitals NHS Trust includes Lincoln County Hospital, County Hospital Louth, Grantham and District Hospital and Pilgrim Hospital Boston. Based on local trust data.
  • 14. Consolidation Report - From testing to spread | 15Model of Care: Emergency andSymptom Pathways Figure 10: Emergency and Symptom Pathways Average Length of Stay All Cancers (All Episodes). Diagnosis = All Admission.13 trusts defined emergency Method Group = Emergency. Class of Patient = Ordinary Admissionpathways and symptom specificpathways. Models of care to improve 9daily clinical decision-making 2006 - 2007 2007 - 2008 2008 - 2009 8.5 Average Length of Stay (days)(Winning Principle 3), emergency 8triage approach to identify the 7.5patients preferred place of care 7(Figure 10). 6.5 6 5.5 5 4.5 4 Barts and Blackpool Brighton Christie Great Hull & Milton Oxford Royal St Helens The The University The London Fylde & Sussex Hospital Western East Keynes Radcliffe Berkshire and Hillingdon Whittington Hospitals of NHS Trust & Wyre University NHS Hospital Yorkshire Hospital Hospitals NHS Knowsley Hospital Hospital Morcambe Hospitals Hospitals Foundation NHS Hospital NHS NHS Trust Foundation Hospitals NHS Trust NHS Trust Bay NHS NHS NHS Trust Trust Foundation NHS Foundation Trustt NHS Trust Trust Foundation Trust Trust Trust Trust Trust HES data.
  • 15. 16 | Consolidation Report - From testing to spread Winning Principle 2 All patients should be on defined inpatient Figure 11: Winning Principle 2 - Baseline and potential impact pathways based on their tumour type and reasons 10 Test Trusts for admission. Elective 2006/07 2007/08 2008/09 Baseline Testing Commence Spread Ten trusts defined elective Episodes 52,852 53,149 48,182 pathways and models including the 23 hour for Breast Care Bed days 358,884 344,064 290,931 67,953 Model, enhanced recovery Bed day capacity approaches and shifting inpatient released procedures to an ambulatory setting. Range LOS 7.81 - 5.08 7.36 - 4.97 7.07 - 4.79 The trusts potentially released 67,953 bed days (from the baseline position) (Figure 11). The average length of stay for cancer related elective admissions nationally by PCT is 7.2 elective bed days per new case. The range was from 4.9 days to 11.5 (HES 2008/09). Clinical Models of Care: Breast 23 Hour Care Model The Breast 23 hour care model was significantly successful. It started in one trust with one clinician and spread across the Pan Birmingham Cancer Network. Clinicians engaged with the testing following a visit to Kings College Hospital NHS Foundation Trust where clinicians had tested not inserting wound drains. This practice was incorporated into the 23-hour pathway and formed part of testing with further improvements in clinical decision- making, clinical practice, design of the pathway, pre-assessment, discharge planning and team working.WINNING PRINCIPLE 2
  • 16. Consolidation Report - From testing to spread | 17 Figure 12: 23 Hour Breast Care Model across the Pan Birmingham Cancer Network April to December 2009 (9 months) LENGTH OF STAY (DAYS) HOSPITAL SITE Breast Conserving Surgery (wide local excisions) Mastectomy 11+ 6 to 10 2 to 5 1 0 11+ 6 to 10 2 to 5 1 0 0% 0% 15% 43% 42% 2% 5% 51% 37% 5% 0% 6% 6% 22% 67% 0% 13% 31% 31% 25% 0% 0% 1% 46% 53% 5% 10% 25% 56% 5% 1% 0% 1% 16% 83% 0% 4% 16% 52% 29% 0% 10% 10% 30% 50% 0% 27% 55% 9% 9% 1% 0% 5% 43% 51% 9% 12% 43% 30% 6% 0% 1% 10% 74% 14% 1% 6% 54% 36% 3% 0% 1% 5% 39% 55% 3% 9% 39% 38% 10% City Hospital provides 94% of all breast surgery within 0 to 1 days. The network achieves a combined total of 74% in 0 to 1 days 94% 49%Data taken from CBSA and relates to payments made.Pan Birmingham local data (April - Pan Birmingham Cancer NetworkDecember 2009) demonstrates the overall delivered the 23 hour breastspread and adoption position of the care model (at the time of the review)23 hour breast care model across the to 74% of all breast surgery patientscancer network. Figure 12 shows the (excluding reconstructions).overall delivery of wide local excisionsis 94% with 548 patients The original test site at the Cityexperiencing this pathway approach. Hospital now delivers the 23 hourMastectomies are currently at 49% breast care model to 94% of all(348 patients) and the approach breast surgery patients (excludingcontinues to spread. reconstructions).
  • 17. 18 | Consolidation Report - From testing to spread Potential savings identified Figure 13: 23 Hour Breast Model - Potential Value for Money The realisation of these efficiency Potential cost savings for breast across the Pan Birmingham Cancer Network benefits across the Pan Birmingham Cancer Network was a by-product of Test sites Total number Average Inpatient Day case Potential improving quality. It was locally of episodes length of cost at £200 cost at £250 savings determined how to use the released stay per day per day capacity and capture the efficiency gains (Figure 13). Sandwell & West 473 5.32 503,272 118,250 385,022 Birmingham During testing the figure of £200 per University Hospital 394 4.04 318,352 98,500 219,852 day inpatient bed day is based on the Birmingham lower estimate of costs used to provide a baseline figure and to Birmingham 270 5.19 280,260 67,500 212,760 illustrate the potential. Heartlands Hospital Good Hope 156 5.03 156,936 39,000 117,936 Hospital Walsall Hospital 231 3.95 182,490 57,750 124,740 Network Total 1524 4.70 1,432,560 381,000 1,051,560 Based on local trust data. Across the West Midlands 15 out of Figure 14: Average Length of Stay: Breast Inpatient Admissions 17 PCTs had the lowest average length of inpatient stay for breast 7.5 7 2006 - 2007 2007 - 2008 2008 - 2009 surgery (Figure 14). 6.5 Average Length of Stay (days) 6 The future potential of the 23 5.5 hour Breast Care Model is 5 4.5 significant if spread 4 • National average length of stay for 3.5 breast surgery is 2.8 days (HES 3 2009) 2.5 2 • 34,000* new cases are registered 1.5 per annum in England. 1 • 34,000 x 2.8 days = 95,200 bed 0.5 days. Lower estimate £200 per bed 0 day = £560 per patient. Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Elective Emergency Net cost £19.04m East East of London North North South South East South West Yorkshire & • 23 Hour Breast Model - 34,000 Midlands England SHA SHA SHA East SHA West SHA Central SHA Coast SHA West SHA Midlands the Humber SHA SHA new patients = 34,000 bed days = £6.8m. SHA of Trust/Admission Method *Cancer Registrations in England 2000
  • 18. Consolidation Report - From testing to spread | 19Clinical Models of Care: Enhancedrecovery approaches Figure 15: Colorectal Enhanced Recovery - Winning Principle 2 Average Length of Stay: Elective Inpatients Lower GI Procedures.Enhanced recovery approaches (Lower GI Neoplasm. Procedure L1 = Colectomy, Excision of Rectum)tested in colorectal (Figure 15),gynaecology (Figure 16), and urology, 14reduce length of stay from the 2006 - 2007 2007 - 2008 2008 - 2009baseline position. Average Length of Stay (days) 12 10The learning from this testing hasbeen shared with the Department of 8Health Enhanced Recovery Partnershipprogramme. 6 4 2 0 City Hospital Queen Mary’s Hospital Whipps Cross Sandwell and West South London University Hospital Birmingham Hospitals Healthcare NHS Trust Whipps Cross University NHS Trust Hospital NHS Trust Trust/Hospital Site Figure 16: Gynaecology Enhanced Recovery - Winning Principle 2 Average Length of Stay: Elective Inpatients Gynaecological Procedures. (Gynaecological Neoplasm. Procedure L1 = Procedure on Uterus) 9 2006 - 2007 2007 - 2008 2008 - 2009 8 Average Length of Stay (days) 7 6 5 4 3 1 0 Queen Elizabeth The Queen Mother Hospital East Kent Hospitals University Trust/Hospital Site
  • 19. 20 | Consolidation Report - From testing to spread Model of Care: Shifting care Figure 17: Barking, Havering and Redbridge Hospital NHS Trust - Baseline & progress from an inpatient setting (Elective Day Care and Inpatients Breast. Gynaecology, Haematology, Head & Neck, Shifting care to an alternative setting Lower GI, Thorax, Upper GI, Urology) was tested by Barking Havering and Redbridge Hospital NHS Trust. 700 Day case admission - Barking, Havering and The testing focused on shifting Redbridge Hospitals NHS Trust - Queen’s Hospital 600 procedures traditionally carried out in Ordinary admission - Barking, Havering and haematology and oncology inpatient Redbridge Hospitals NHS Trust - Queen’s Hospital beds to a day case setting (Figure 17). 500 Number of Episodes The local data in figure 18 illustrates 400 the potential investment and the valuing of patients’ time. 300 200 100 0 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 Breast Gynaecology Haematology Head & Neck Tumour Group/Year 700 600 500 Number of Episodes 400 300 200 100 0 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 2006 - 2007 2007 - 2008 2008 -2009 Lower GI Thorax Upper GI Urology Tumour Group/Year Based on local trust data.
  • 20. Consolidation Report - From testing to spread | 21 Fig 18: Quantifying the impact and valuing patients time Procedure Average no. Average no. Average no. Average cost Average cost Number of Released of hours of hours of hours per inpatient per day case patients cost for spent as spent as saved per procedure (audit data through day audit inpatient day case procedure (baseline data based based on £18.75 unit during period (baseline data) (baseline data) on £8.30 per hour) per hour) audit Hickman line insertion 92 4.5 87.5 £763.60 £84.37 5 £3393.15 Blood Transfusion 35 7.5 27.5 £290.50 £140.62 14 £2098.32 Ascitic Drain 76 9 67 £630.80 £168.75 9 £4158.45 CT Guided Biopsy 128 6.5 121.5 £1062.40 £121.87 6 £5643.18 US Guided Biopsy 20 6 14 £166.00 £112.50 3 £160.50 HDR Full Insertion 24 7 17 £199.20 £131.25 9 £611.55 IV Antibiotics 113 7.5 105.5 £937.90 £140.62 2 £1594.56 Total Cost Saving £17,659.71Barking, Havering and Redbridge NHS Model of Care: Parencentesis inTrust is continuing testing and the hospice settingspreading the principles making East Sussex NHS Trust tested avertingimprovements in: inpatient admissions for patients from the local hospice that required a• Direct access for Sickle Cell parencentesis, and tested this being patients. undertaken at the hospice. The• Further reducing wasted patients concept was tested successfully, and time for some procedures in spread to another site, although assessment beds. numbers of patients are small. The• Testing protocols for outpatient outcomes of testing has spread and management of Neutropenic integrated into local emergency Sepsis. improvement work.• Further shifting care to and reducing unnecessary inpatient admissions.• Testing whether assessment beds could be included in the 4-hour bed wait target?
  • 21. 22 | Consolidation Report - From testing to spread Winning Principle 3 Clinical decisions should The Whittington Hospital Brighton and Sussex University be made on a daily basis NHS Trust Hospitals NHS Trust to promote proactive case The local approach was to have the Tested several strategies to maximise management. availability of an acute oncologist and timely clinical decision-making which rapid access clinics. included improved communications between clinical teams, weekly MDT This is not a stand-alone principle Access to daily clinical decision ward discussions, Daily paper review as timely clinical decision-making making has: of inpatients including outliers, is a key component integrated admission priority assessment and within all the principles, • Reduced unnecessary lengths of agreed pathway trigger points to pathways and models of care. stay for new unknown cancers - avoid discharge delays. Two trusts, Brighton and Sussex from 17.1 days to 12.1 days. A University Hospitals NHS Trust reduction of five days for Evidence relating to surgical, medical and The Whittington Hospital previously unknown cancer and haematology daily clinical NHS Trust tested this principle patients who were admitted as decision making appears to be well across oncology. emergencies compared with the established and built into consultant year before adopting Winning job plans. This does not appear to be Principle 3 for acute oncology. the case in oncology. Further • Made a reduction in average evidence may emerge in this area length of stay of 3.7 days for from the National Chemotherapy known cancer patients. Implementation Group. • Significantly decreased the number of unnecessary tests patients would have undergone. This values patients’ time and improves the patient experience.WINNING PRINCIPLE 3
  • 22. Consolidation Report - From testing to spread | 23Winning Principle 4 Patient and carers need to know about their condition and symptoms to encourage self-management and to As part of the testing, all sites were encouraged to engage patients in promoting self-care. Various approaches were used during the “ The patient’s stories in the DVD are very powerful and make much more impact on know who to contact testing including patient education, other patients and carers when needed. information, production of a DVD and about the importance of ” telephone help lines as central contact presenting early. points. The view from the review Lead cancer nurse team was that testing had not demonstrated or captured ‘real self- “ management’ and only a few sites had been able to quantify the impact of the interventions during testing. It This DVD is a good idea. appeared that once implemented or products produced the capture of Verbal information and impact data/audit was discontinued, leaflets don’t really sink in although patient satisfaction audits because it’s such a difficult continue. time. You can’t take it all in, it’s a bit too much, but I think We know that patients are receiving information and that for example, the DVD will stick in people’s ” Blackpool, Fylde and Wyre NHS minds. Foundation Trust has distributed a Husband of a patient DVD to over 500 patients across the cancer network. The DVD is given to patients on chemotherapy, helping them to identify the signs and symptoms of neutropenic sepsis. The DVD has been acknowledged as good practice and has been adopted by other areas. There will be the opportunity to capture more information from the National Patient Survey regarding inpatient care and with the new emergency initiative this will provide the opportunity to focus on some specific areas of self-care management. WINNING PRINCIPLE 4
  • 23. 24 | Consolidation Report - From testing to spread Summary: Consolidation of testing The 25 test sites provided evidence of progress, potential impact and the ongoing implementation of the winning principles and models of care that improve quality of the patient experience and productivity. The progress reported here demonstrates that test trusts have moved from initial testing and that improvement continues. The quantitative figures however should not be judged in isolation of the organisational context and complexities of change involved.
  • 24. Consolidation Report - From testing to spread | 25Beyond testing: Coverage and spreadSince the commencement of the Expansion and coverage beyond the 25 test sitesTransforming Inpatient Care Spread is evident across England, going beyond the 25 test trusts (Figure 19), withProgramme 2007, the learning has 34% of the potential acute secondary providers indicating they are involved inbeen widely shared and disseminated spreading the quality Winning Principles and Models of Care. This provides anationally as part of the spread useful baseline position of coverage.strategy (Transforming Care for CancerInpatient Publications, 2008, 2009.Annual Conference 2008, 2009). Figure 19: Beyond testing - coverage and spread map 155 Potential Acute Secondary 8 Care Provider Trusts* 25 Test Trusts (covering 37 hospital sites) December 2009 - 54 Trusts (covering 72 hospital sites) 2 2 14 4 10 26 3 6 8 2 6 16 1 18 4 6 9 8 12 26 1 2 13 1 9 17 *Does not include Children, Mental Health, Eyes, Orthopaedics, Heart/Chest, and Rheumatic Diseases.
  • 25. 26 | Consolidation Report - From testing to spread Spread activity In some areas, to accelerate the pace of spread, the tested models of care have been identified as a health community priority and brought in as part of local commissioning for quality and innovation framework quality accounts (CQuINS). Figure 20: Spread and adoption activity by SHA SHA Emergency Neutropenic Communication Enhanced 23 Hour Shifting Clinical Decision Self Pathways Sepsis Alerts Recovery Breast Procedures Making Management East Midlands East of England London North West South Central South East Coast South West West Midlands Yorkshire & the Humber North East
  • 26. Consolidation Report - From testing to spread | 27Figure 21 highlights which quality Winning Principle is being adopted and spread. Figure 21: Extent of spread Spread Survey December 2009 - January 2010 Communications Alert Systems - Winning Principle 1 Emergency Pathways - Winning Principle 1 Palliative Care Pathways - Winning Principle 1 23 Hour Breast Care Surgical Model - Winning Principle 2 Enhanced Recovery Pathway - Winning Principle 2 Patient Transfers/Repatriation - Winning Principle 2 Shifting Procedures from Inpatients to Day Care - Winning Principle 2 Carcinoma of Unknown Primary - Winning Principle 2 Clinical Decision Making - Winning Principle 3 Neutropenic Sepsis - Winning Principle 1 & 4 23 Hour Helpline - Winning Principle 4 Acute Oncology Model - Winning Principle 1 & 3 0 5 10 15 20 25 30 Number of Hospital SitesGood ideas and innovations are • 72 hospital sites are activelyspreading and being adopted by spreading the improvements. Someorganisations, clinicians and managers sites are embarking on more thanacross England with quality as the one improvement activity.key driver. • From the evidence reviewed (December 2009) - there are currently 183 improvement activities supporting spread across England.
  • 27. 28 | Consolidation Report - From testing to spread Levers for spread Fig 22: The Transforming Inpatient Figure 23: Sites identifying seven elements of the Framework for Spread Transforming Inpatient Framework for Spread A Vision A Vision for Quality for Quality Improvement Systematic Improvement Systematic Spread Spread Strategy Improvement Strategy Improvement Approach Approach Linked Linked Strategic & Organisational Strategic & Organisational Operational Culture Operational Culture Change and Fit Change and Fit Continuous Spread Spread Spread Spread Continuous Monitoring Simple Monitoring Simple Progress & Making the Principles & Progress & Making the Principles & Impact Connections Messages Impact Connections Messages Collaboration Leadership Collaboration Leadership Partnerships Engagement Partnerships Engagement & Team Accountability & Team Accountability Working Working Alignment Alignment Learning with Learning with & Unlearning Opportunities & Unlearning Opportunities Patient & Levers Patient & Levers Centred Centred (NHS Improvement 2009) The learning from the Transforming Cancer Inpatient Care Programme Figure 24: Reported levers for spread December 2009 remains practically based as it draws on real experiences and the challenges 35 of taking a good idea and spreading it further to benefit more patients. The 30 learning from the test sites has been Number of Patients 25 used to develop a Transforming Inpatient Framework for Spread 20 (2009); Driver (2008); Williamson 15 (2007); (Figure 22). The framework is a tool to help support other 10 organisations and teams in their quest 5 to spread good quality innovations. 0 When comparing the reported levers Implementation Use of Opinion Benchmarking Patient Plan Leaders Groups of spread (Figure 24) against the Communications Shared Commissioning None & Awareness Comparative Data Agreements Transforming Inpatient Framework, seven of the elements have been identified. Figure 23 highlights these elements.
  • 28. Consolidation Report - From testing to spread | 29ConclusionFrom testing to spreadThe review has shown that theTransforming Inpatient CareProgramme continues to makeprogress. Spreading and encouragingadoption and adaption of the winningprinciples and new models of careacross England, but there is still moreto be done and the pace needs to beaccelerated.The new levers supporting spreadsuch as QIPP, GP commissioning and apatient led NHS will support the drivefor change and further adoption ofgood practice.Spread and adoption is not easy andrequires a multi-level of methods,levers and factors to create, inspireand connect to people, organisationsand within the nature of the currenthealth landscape. The programme willcontinue to support spread anddisseminate the practical learningacross the NHS to benefit all patients.
  • 29. 30 | Consolidation Report - From testing to spread Acknowledgements and references Acknowledgements NHS Improvement – Transforming Middlesex University, London Inpatient Case Studies (July 2009) Transforming Inpatient Care Cancer Reform Strategy 2007 Programme Test Sites NHS Cancer Reform Strategy (2009) - Achieving Local Implementation - Excellence in Oncology Awards 2009 - Professor Sir Mike Richards second annual report British Oncology Association National Director for Cancer and End of Life Care, National Cancer NHS Improvement - Meeting the NHS Improvement website Action Team challenge together... delivering care in the most appropriate setting (October Celia Ingham Clark 2008) Krishna K Varadhana, Keith R. Nealb, National Clinical Lead and Chair of Cornelius H.C. Dejongc, Kenneth C.H. Transforming Inpatient Care NHS Improvement - The Winning Fearond, Olle Ljungqviste, Dileep N. Programme Principles: Transforming Inpatient Care Loboa. Programme for Cancer Patients (July NATCANSAT (National Cancer 2008) The enhanced recovery after surgery Services Analysis Team) with a (ERAS) pathway for patients special thanks to Neal Jones Letter from David Nicholson CBE , undergoing major elective open NHS Chief Executive. Implementing colorectal surgery. A meta-analysis of Thank you to the organisations the Next Stage Review visions: the randomised controlled trials. who responded to the spread quality and productivity challenge survey. (Gateway ref: 12396) Key contacts Enhanced Recovery Partnership Department of Health, Enhanced Programme Recovery Partnership Programme: Ann Driver Delivering Enhanced Recovery: Director Helping patients to get better sooner References after surgery (2010) Angie Robinson National Improvement Lead NHS Improvement - Transforming National Chemotherapy Advisory Inpatient Care Programme Group Guidance (August 2009). An integrated approach - The National Cancer Action Team. Marie Tarplee transferability of the Winning National Improvement Lead Principles - Sharing the learning Driver A. (2008). Factors effecting (July 2010) achievement of cancer waiting time Catherine Strong targets in NHS Trusts; an exploratory PA NHS Improvement - Transforming study. Unpublished thesis, Doctorate Inpatient Care Programme Professional Studies in Health; From Testing to Spread - Sharing the Middlesex University, London knowledge and learning from organisations spreading the Winning Williamson J. (2007). The critical Principles (July 2010) factors for whole system change of a clinical specialty identified through the NHS Improvement - Transforming Cancer Services Collaborative Care for Cancer Patients: Spreading ‘Improvement Partnership’. the Winning Principles and Good Unpublished thesis, Doctorate Practice (July 2009) Professional Studies in Health;
  • 30. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 ©NHS Improvement 2010 | All Rights Reserved | July 2010 Delivering tomorrow’s improvement agenda for the NHS