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Meeting the challenge together... delivering care in the most appropriate setting


Meeting the challenge together... delivering care in the most appropriate setting (October 2008). This document has been designed to support the pilot sites (now starting to test new ideas working …

Meeting the challenge together... delivering care in the most appropriate setting (October 2008). This document has been designed to support the pilot sites (now starting to test new ideas working with partners in primary care and social care) but will also be of interest to other organisations attempting to reform inpatient care (Published October 2008).

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  • 1. NHS NHS ImprovementCANCER Transforming Inpatient CareDIAGNOSTICS Programme for Cancer Patients Meeting the challengeHEART together... delivering care in the most appropriate settingSTROKE Supporting delivery...
  • 2. Meeting the challenge together... delivering care in the most appropriate setting 3ContentsForeword 4Introduction: Question: Why focus on cancer inpatients? 5Delivering care in the most appropriate setting 8• National programme overview• New models of care: Transforming Inpatient Cancer Care• The Winning PrinciplesTesting, spreading and sustaining 10Step One: Getting started 10 • Planning and engagement • Base-lining: Cancer Commissioning Toolkit • User involvementStep Two: Measuring quality that is fair, personalised, safe and effective 14Step Three: Capturing the learning of testing, spread and sustainability 17Useful resources 18
  • 3. 4 Meeting the challenge together... delivering care in the most appropriate setting Foreword The Cancer Reform Strategy set out the benefits both for patients and for the NHS of transforming inpatient care for cancer patients. Too many patients are being admitted as emergencies when, with suitable planning, alternative models of care could have been put in place. Once admitted, the length of stay is often unnecessarily prolonged because of failure to define and implement inpatient care pathways and because of delays in decision making. Better education for patients would lead to self management approaches which could also reduce unnecessary admissions. The Transforming Inpatient Care Programme, led by NHS Improvement – Cancer and the National Cancer Action Team, has been established to support local initiatives to improve inpatient care for cancer patients. Pilot sites are now starting to test new ideas working with partners in primary care and social care. ‘Meeting the challenge together... delivering care in the most appropriate setting’ has been designed to support the pilot sites but will also be of interest to other organisations attempting to reform inpatient care. It builds on the ‘four winning principles’ that were identified from previous testing. Key to the success of this phase of the programme will be spread and sustainability to achieve the maximum impact. It is vital that we capture learning from individual pilot sites, both about what does and what does not work, in order that the benefits are optimised as soon as possible. Mike Richards National Cancer
  • 4. Meeting the challenge together... delivering care in the most appropriate setting 5Question: Why focus on cancer inpatients?• Answer: To ensure quality that is fair, personalised, safe and effective• Answer: To promote partnership working, the alignment of systems and combined leverage for improvement• Answer: Because it’s an area that’s had little attention
  • 5. 6 Meeting the challenge together... delivering care in the most appropriate setting‘ My time in hospital was their time, QUESTION: ’ not mine. (User feedback) • Answer: Because it matters Answer: There are some key interfaces to patients with the social care system Firstly, the whole system is acknowledged to be Andy’s reflections currently unsustainable due to the gap between funding and demographic and demand pressures. The My name is Andy Millward. I am a 55 year old man, Green Paper, currently in design phase, will be who was diagnosed in October 2004 with metastatic addressing this. Whatever the answers, it can be prostate cancer, a form of site specific cancer that was assumed that funding will remain very tight. so advanced that I was only given eighteen months to two years to live. I am very fortunate, in that I have thus far been able to defeat that timetable and Secondly, improving the inpatient experience does to prognosis, but the majority of my subsequent some degree depend on social care, especially if there treatment has been successfully managed whilst at are plans to reduce lengths of stay, move care closer home, which is very much where I, along with many to home and support early discharge. Taking this others on similar cancer journeys, wish to be. I have together with funding pressures, it will require whole had two hospital admissions since then, both via the systems solutions involving social care, including emergency pathways at my local hospitals and both ensuring that financial incentives work for social as admissions related primarily to severe pain. The well as primary/community care. process of accessing inpatient care was both difficult and traumatic for both my wife and I and unnecessarily burdensome, as we had to negotiate very Thirdly, the Government’s Putting People First different processes and locations to eventually arrive at (December 2007) transformation programme presents the oncology ward that could attend to my specific the system with the challenge of transforming the difficulties. way in which services are delivered to put control in the hands of service users and carers. By 2011 all I cannot fault the level of care offered as an service users of social care will have the right to use inpatient (and in line with many of the audits that I know have been carried out, some of my time was individual budgets to choose how their care is spent unnecessarily on general medicine wards). arranged, and those who fund their own care will be However, whilst recognising that staff who have offered the same level of advice and support as those responsibility for us have serious considerations of risk receiving state funding. In redesigning pathways, and clinical governance to consider, I think we as account should be taken of how choice and control patients could be given more responsibility and will operate for patients. innovative resources to manage more at home. From experience, I do also believe that I could very easily Fourthly, each region now has coordinated have been discharged sooner, thereby shortening my arrangements for care and support improvement, with length of stay. This is the real challenge for all of us and I therefore warmly welcome the launch of the Joint Improvement Partnerships overseeing national strategy on in-patient care and potential programmes of work, and Regional Improvement and likely alternatives to managing cancer journeys like Efficiency Partnerships allocating what funding there is my own away from hospital. in a coordinated way. It is important that any health We also need to ensure that even if acute admission is systems improvement work is able to link to these absolutely necessary – and not just a default position new arrangements. of the system – that treatment and care in hospital is kept to an absolute minimum. Simon Williams Director of Community and Housing, Andy Millward, National Lead for Urgent Care Nottingham (September 2008)
  • 6. Meeting the challenge together... delivering care in the most appropriate setting 7Why focus on cancer inpatients? Answer: A move from a care delivery chain to a whole care system Why focus on cancer Delivering the next stage of the Cancer Reform inpatients? This is Strategy will require increased levels of integrated working alongside substantial redesign of services to ensure that services are relevant and responsive to no longer a question service users. Commissioners have a vital role in leading thinking on new services whilst supporting but an opportunity providers to work together, innovate and think differently about the scale, scope and style of services for action... which will be required outside of traditional settings. Commissioners will need to set out clear service strategies which focus on supporting an increase in for example self-management. This will undoubtedly create opportunities for new ideas and new providers in the area of cancer care. Andrew Donald Chief Operating Officer, Birmingham East & North PCT (September 2008) Answer: Care being delivered in the most appropriate setting and improving outcomes is a key commissioning role Doing this in a methodical and explicit way to develop new models of care brings acceptability and sustainability into consideration. Extending this work beyond secondary care and involving more stakeholders increases the complexity but the importance and potential benefits of this work make it worthwhile. A challenge faced by a PCT is working with the systems in place and developing new ways of commissioning new models. Philippa Muir Head of Specialist Commissioning and Clinical Networks, Oxfordshire PCT
  • 7. 8 Meeting the challenge together... delivering care in the most appropriate setting Delivering care in the most appropriate setting A programme of work has been established, supported by NHS Improvement and the Cancer Action Team, working with key organisations, users, charities and professional bodies. The overall programme covers six priority workstreams. Lead - (TBC) HES Lead - Cancer Lead - Action Team National Cancer Services Lead - Cancer Analysis Action Team Team Lead - Cancer Action Team Lead - NHS Improvement This document focuses on supporting the delivery of the New Models of Care: Transforming Inpatient
  • 8. Meeting the challenge together... delivering care in the most appropriate setting 9Winning PrinciplesPrevious testing identified four winning principles that can improve length of stay management,avert unnecessary admission, deliver care in the appropriate care settings, improve efficiency,quality, promote value for money and importantly value the patients’ time. 1. Unscheduled (emergency) patients should be assessed The task now is to: prior to the decision to admit. • Ensure that these winning Emergency admission should be the exception not the norm. principles are spread and embedded across the NHS 2. All patients should be on • Test new ideas with new defined inpatient pathways partners such as primary based on their tumour type and social care and reasons for admission. • Sustain proven improvements to achieve maximum impact 3. Clinical decisions should be made on a daily basis to promote proactive case management. winning_principles 4. Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed.
  • 9. 10 Meeting the challenge together... delivering care in the most appropriate setting Testing, spreading and sustaining Step One: Getting Started Tip 1: Create a shared vision – time and effort spent in agreeing high quality and performance indicators at the start will enable the team to stay focussed. Tip 2: Keep the service users and carers central. Tip 3: Create co-production energy – work with an approach that encompasses professional, organisational and functional boundaries to create partnership environments. Tip 4: Define the workstream scope – there are many project initiation documents available but it is worth agreeing which one you are going to adopt to ensure appropriate links are correctly made at the start. Tip 5: Test small step changes - one service user at a time makes the experience safe and controlled. Tip 6: Engage partners early in discussions. Make sure you are not just shifting existing services without the infrastructure to support and adding more unnecessary steps into the process. Tip 7: Use clinicians and leaders as a catalyst to improve care at all stages. Tip 8: Use and involve the local network service improvement team as a resource. Tip 9: Focus on really understanding the problem not jumping to the
  • 10. Meeting the challenge together... delivering care in the most appropriate setting 11Good planning can inspire changethat leads to improvementsPlanningLeadership and • Identify the key people to be involved early on in the workstream.engagement • Who are the key stakeholders? • Clinical and managerial leadership is critical to success. • Have you included data and informatics and finance, primary care and social care?Knowledge and • Establish the steering/working group.skills – the basics • Has the group got the people with the knowledge and skills? Can they make the decisions? • Do they have service improvements skills? • Knowledge of heath and social care processes? • Is there service user Involvement? • Is their agreed local accountability and responsibility for delivery? • Knowledge of commissioning? • Information gathered from all perspectives (service users, staff, commissioners, partnerships etc).Planning the • Identify, understand and define the ‘real’ problem not the solution.improvement • Review data to understand demand, activity and variation in performance.workstream • How are your improvements going to be measured and monitored? Have you included qualitative and quantitative performance indicators? • Match the collection of baseline data with the scope of the problem identified. • Remember that no data will be perfect and beware of analysis paralysis (collecting everything that tells you nothing). • Break the data down into sections of information to help you identify what needs to be collected and analysed. • Look for the 80/20 rule (Pareto principle) this happens to 80% of our users; focus on the 80% first, look for trends in retrospective data. • Keep clinicians, leaders and key people involved. • Identify (visioning) and design the ideas to tested.Engagement with • Seek and build continuous and meaningful engagement with the publicpublic and service and service users, involve them in shaping services.users • Have an understanding of different user engagement options, including the opportunities, strengths, weaknesses and risks. • Routinely invite service users and the public to respond to and comment on issues. • Ensure that users and the public understand how their views will be used, which decisions they will be involved in, when decisions will be made, and how they can influence improvement.Test out your ideas • Communicate widely about ideas being tested. • Test the idea (maybe more than one testing cycle). • Capture results, benefits and measure the impact. Match across to your performance indicators. • Capture the learning (the things that work and those that didn’t documenting reasons why). • Communicate regularly with the whole team and partnerships - keep the message short and snappy. • Ensure identified ownership of action points.Evaluation • Analyse the results and quantify the impact of actual and potential. • Identify benefits- e.g. quality, cost, outcomes. • Identify risks. • Evaluate the alternatives. • Make recommendations. • Build your business case on evidence.Implementation – • Recommendations for implementation (provide the evidence that supports your testing).spread and sustain • Commissioners want to see the evidence. • Celebrate your achievements. • Share the learning - publicise your work. • Prepare your spread/adoption strategy. • Include how you will measure sustainability.
  • 11. 12 Meeting the challenge together... delivering care in the most appropriate setting Use a simple approach: Apply a practical framework for testing, spreading and sustaining YES Analysis Is it the Identify the Visioning Baseline from Testing Cycles right solution to real root of the What are you trying address the real different perspectives problem Test out the idea’s to achieve? problem? NO YES Case for change Evaluate and Implementation Agree the redesign Evaluation Plan the implementation check sustainability Implement the idea & implementation of Evaluate the benefits of the tested idea. Build the improvements What is the difference the case for change Spread/Adoption Strategy Use available resources for gathering The Cancer Commissioning Toolkit will baseline information help you to define who needs to be engaged and define who will drive the The Cancer Commissioning Toolkit (CCT) workstream – commissioning, primary The Cancer Reform Strategy (2007) identified better care, secondary care or social care information and stronger commissioning as two of the key drivers to achieve the goal that cancer services in You will still need to capture England should be amongst the best in the world. The a local baseline CCT is a one stop online library of key cancer To find out locally and to understand what information and data which can be easily accessed for lies beneath the numbers of the CCT. use. The Cancer Commissioning Tool provides the To help you with local baselines a series starting point by providing useful baseline and of questions have been developed into benchmarking information. an inpatient checklist which is available at the back of this document. Most of this information should be available in The Cancer Commissioning Toolkit (CCT) inpatient your local organisations. chapter is divided into three key
  • 12. Meeting the challenge together... delivering care in the most appropriate setting 13Capturing your baseline The involvement of users can result in a number of benefits for the organisation. • Find out why your length of stay is X and bed days Y User involvement • Tip 1: Don’t look at the numbers of the CCT in • Raises your awareness of the issues isolation from the whole improvement picture that impact on service users for the patient • Helps to clarify how health services can • Tip 2: Don’t jump to solutions be improved and redesigned based on the numbers without • Helps to identify issues and support identifying the real their improvements to make the problem biggest impact for service user needs • Tip 3: Think about: • Challenges the professional views and ‘How can you really manage existing approaches to services. length of stay if you do not know what the right length of stay is?’ •Tip 4: Do not get complacent, if User involvement - methods you identify from the CCT data • Questionnaire surveys that you are in the higher or • Satisfaction surveys middle quartile - there is • Interviewing always room for improvement. • Discovery interviews • User diaries • Focus groups • Workshops • Reader panelsGetting the user involved • User panelsUser involvement is increasingly becoming accepted • Citizens’ juriesby planners, service providers and users. The need to • Local 18 week patient experiencelisten and act on the views of users and the public is integral part of improving quality and delivery ofhealthcare.There are many different approaches to user The inpatient test sites used a variety ofinvolvement; start by identifying what already exists these methods, for example, patientacross the health community. satisfaction surveys were developed to ensure that there were no adverse effects on patient experience due to User involvement changes in their pathways. • Patient Advice and Liaison Services (PALS) ‘ • Studying the complaints and compliments • Suggestion boxes and comments slips • Local organisational audit and national audit I much preferred coming to e.g. Health Care Commission Annual Health day care for my antibiotics Check, National Cancer Audit • Study the organisations website for as I was able to have my suggestions/comments. It is also worthwhile exploring what is currently happening in local treatment early enough to areas to gain feedback from patients for allow me to go home and example: ’ • Patient and public involvement forums care for my disabled wife. • Local Involvement Networks (LINKs) (Patient interview) • Patient groups: User groups, carer groups and disease support groups • Expert Patient Programmes • Patient participation groups in primary care. winning_principles
  • 13. 14 Meeting the challenge together... delivering care in the most appropriate setting Step Two: Measuring that quality is fair, personalised, safe and effective Tip 1: To be able to realise benefits - it is important to agree the measures (metrics or indicators) right at the start of the workstream with all partners. Tip 2: Measures (metrics/indicators) should reflect the whole performance spectrum: • Quality and patient experience • Efficiency and value for money • Effectiveness and impact of improvements • Alignment with national indicators across partnerships. Tip 3: Set up a data capture system for continuous monitoring of improvement at the start. Tip 4: Feedback regularly on the improvements made. A true measure captures all the benefits that everyone can
  • 14. Meeting the challenge together... delivering care in the most appropriate setting 15Identifying the potential alignment of national and localindicators with Transforming Inpatient Care‘Vital Signs’ ‘National Indicators’ Cancer ReformIndicators for progress against Local Authority and Local Authority Strategy (CRS)national/local priorities for PCTs Partnerships for adult health and wellbeing New Models Transforming Inpatient CareRates of hospital admissions for Number of social care clients receiving self directed Winning Principle 4ambulatory care support per 100,000 population – designing the care and support package that best suits their specific needsProportion of people with long term The percentage of people with a long-term Winning Principle 4conditions supported to be independent condition supported to be independent and inand in control of their condition control of their conditionPatient experience of access to Timeliness of social care assessments and social Winning Principle 1primary care care packages following assessmentNumber of delayed transfers of care per The average weekly rate of delayed transfers of Winning Principle 1100,000 population (aged 18 and over) care from all NHS hospitals, acute and non-acute, Winning Principle 2 per 100,000 population aged 18 and over Winning Principle 3Timeliness of social care assessment The ability of the whole system to ensure Winning Principle 3and package appropriate discharge from hospitalSelf reported experience of patients Self reported experience of social care users Winning Principle 4and users perceptions of servicesPatients and user reported measures of User reported measures of respect and dignity in Winning Principle 3respect and dignity in treatment their treatmentNumber of emergency bed days per Number of emergency bed days per head of Winning Principle 1head of weighted population weighted populationAmbulance conveyance rate to A&EProportion of all deaths that occur Percentage of all deaths that occur at home - end Winning Principle 4at home of life care, access to appropriate care enabling people to be able to choose to die at homePercentage of patients receiving their Waiting times targets Winning Principle 2first definitive treatment for cancerwithin two months of urgent referralfor suspected cancerPercentage of patients seen within 18 Winning Principle 3weeks for admitted pathways
  • 15. 16 Meeting the challenge together... delivering care in the most appropriate setting Remember, measures provide evidence Transforming Inpatient Care and motivate stakeholders: has the potential of: • Reducing cancer bed days by 25% Providers are motivated to reduce per SHA length of stay and to release capacity. • Ensuring inpatient care for cancer does not exceed 12% of all inpatient bed PCTs are motivated to reduce days (baseline CRS 2007) inappropriate admissions and bed • Ensuring costs do not exceed the 2008 baseline days over trim points. • Reducing emergency admissions by 5%. Patients do not want to be in a hospital Capturing and measuring the quality, unnecessarily - efficiency and impact through the NHS Improvement microsite adding no value to their well being The microsite will be one of a cluster of or treatment. specialised websites linked to the Cancer Commissioning Toolkit and the NHS Improvement website. The microsite is being developed to support the new models workstream. It will present specific information and data relating to the impact of testing, spread Early intervention and the sustainability of the work being undertaken by the provider sites actively by social care. Early involved the workstream. supportive discharge benefit - cost saving in The microsite will be a ‘working web the community - right space’ that will allow organisations to support at the review their historic activity, scenario plan, quantify their assumptions and right time. measure the actual and potential impact of their improvement ideas. The microsite will go live in January 2009 and will continue to evolve and develop during
  • 16. Meeting the challenge together... delivering care in the most appropriate setting 17Step Three: Capturing the learning for testing,spread and sustainabilityTo enable the learning to be collated and shared, 3. Sustainability Checklistthree approaches have been developed, that togethercan enhance the delivery of improvement across the It is important to develop a plan fornew models workstream and build the momentum for sustainability which ensures that wespread. (The learning diary/spread planner and create lasting improvements.sustainability check list can be found in the backpocket of this document). The sustainability check list focuses on some key questions to assist you in1. The Testing Learning Diary developing your strategy.Capturing the elements of the ‘Testing process’ (Aim,Measures, Process and Impact) will help to support alearning framework that will enable the key outcomesof the ‘testing phase’ to be shared with the widerNHS.The Inpatient Learning Diary is a tool which collatesthe learning from the testing, and helps to guidethe sites through the testing approach by a seriesof questions. This is available learn objectively from the whole process, theproject needs to be reviewed in order to establishwhat has been accomplished, and to also learn fromwhat did not go so well. This will enable allorganisations involved to learn from the experienceand to share that learning with others.2. Spread PlannerSuccess is often gauged by how quickly an idea israpidly adopted and spread. Having a spread strategycan eliminate the gap between what is and what canbe. It promotes equity of service delivery in order thatall can gain from the benefits. The spread planner is aguide to spreading the winning principles and otheroutcomes and benefits from testing. It derives fromthe experience of the early test sites, Institute forHealth Improvement (IHI) and the work of EverettRodgers (Diffusion of Innovation 2003).
  • 17. 18 Meeting the challenge together... delivering care in the most appropriate setting Useful resources Service Improvement Information • NHS Improvement, Transforming Inpatient Care, Winning Principles • Gold Standards Framework (GSF) • Liverpool Care Pathway for the Dying Patient (LCP) • Palliative Care Social Care Information • Adult Social Care: The Government’s Green Paper and the LGA’s Campaign • Putting Patients First • High Impact Changes for Health & Social Care • Care Support Independence: Meeting the needs of a changing society Health Information • Our NHS Our Future: High Quality Care for All (Lord Darzi) • Cancer Reform Strategy • Cancer Commissioning Tool • Department of Health • World Class Commissioning • Our Health, Our Care, Our Say • National Planning Guidance ‘Vital Signs’ User and Public Involvement • Department of Health (2004). Choose and Book • Department of Health (2005). Creating a Patient Led NHS - Delivering the NHS Improvement Plan PolicyAndGuidanceArticle/fs/en?CONTENT_ID=4127453&chk=NXIecj • Department of Health (2006). Developing a Stronger Local Voice PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4137040&chk=U6PSmq • Department of Health (2006). Reward & Recognition PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4138523&
  • 18. AcknowledgementsWith our thanks to:• All the Test Sites for their continuingcommitment to this national workstream• Professor Mike Richards• Simon Williams• Andy Millward (User Representative)• Philippa Muir• Dr. Brian Cottier• Andrew Donald• Celia Ingham Clark, National Clinical Lead• Cancer Action Team• NHS Improvement Team: Dr Ann Driver, Angie Robinson, Marie Tarplee, Catherine Strong, Jim Farrell, Wendy GrayFor further information please contact:Dr Ann DriverDirector, NHS ImprovementEmail: ann.driver@improvement.nhs.ukTel: 07900 223142Angie RobinsonNational Improvement Lead, NHS ImprovementEmail: angie.robinson@improvement.nhs.ukTel: 07900 223346Marie TarpleeNational Improvement Lead, NHS ImprovementEmail: marie.tarplee@improvement.nhs.ukTel: 0791 7233248
  • 19. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTSTROKE NHS Improvement Formed in April 2008, NHS Improvement brings together the Cancer Services Collaborative ‘Improvement Partnership’, Diagnostics Service Improvement, NHS Heart Improvement Programme and Stroke Improvement into one improvement programme. With over eight 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 and stroke services. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 ©NHS Improvement 2008 | All Rights Reserved