Whole system pathways and commissioning as a dynamic approach

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  • Part of process requires SOC Strong hospital focus – explain estate But then………… Salford’s health status, etc. etc., Involvement of S&THA and PCGs (at the time) and City Council, etc.
  • The new system has some important features as can be seen on this slide. Firstly the integration of health and social care systems is extremely important to making the new system work, not only to ensure users pass through the new systems unhindered, but mainly to provide users of the service a completely new experience, unobstructed by our traditional organisational boundaries and funding mechanisms. Throughout the system, and particularly within Hope Hospital, we will separate emergency and elective, or unplanned and planned work. This will enable new processes to be developed which streamline our systems, and prevent the interruption of planned care by unplanned activity or pressures. A new intermediate tier will support the improvement of processes, preventing unnecessary admissions and offering increased capacity to manage more cases within the primary/community setting. And finally, we will manage out patients and chronic diseases generally in a different way, which does not require repetitive visits to the hospital, but encourages more local management, backed up by easier access to specialist advice and support. To look at these features in detail:
  • Services will change in many ways, but the principles illustrated on this slide are fundamental to SHIFT. We look to move from unplanned to planned care, through the development and application of care pathways, which have been streamlined to meet patient expectations. One of the ways we expect to provide capacity to meet demand is by developing more comprehensive service outside of typical “office hours”, thereby reducing unnecessary demand on already pressurised emergency services. Hospital services will also be streamed into emergency and elective, overcoming the present situation whereby emergency pressures interrupt elective work, and so on. We look to develop multi-disciplinary teams, empowered by training and the opportunity to work to enhanced roles through agreed protocols and pathways. Finally, we have some excellent early work taking place on patient empowerment, in primary care but supported through call centres, and so on, and we envisage a wide range of chronic diseases will be managed in this manner in the future.
  • Planned care, as can be seen on this slide we expect to streamline planned care substantially. We see a range of clinicians being trained and empowered to manage patients more substantially than at present, and by having direct access to a range of diagnostics, therapies and specialist opinion, to reduce, and in some cases eliminate the need to refer for an out-patient assessment. Planned procedures will take place either in the new Health and Social care centres, or in identified facilities on the Hope site – a 72 hour elective facility. This has emerged from consideration of the fact that 92% of Medical Elective admissions have an LOS of less than 3 days and the pattern is similar for Surgical Elective admissions (84% staying 3 days or under)
  • Whole system pathways and commissioning as a dynamic approach

    1. 1. SHIFT Project – Salford’s Health Investment For Tomorrow Whole system pathways and commissioning as a dynamic approach Janet Roberts, Sylvain Laxade, Janelle Homes, Richard Freeman
    2. 2. What we are going to cover <ul><li>Making it Real </li></ul><ul><li>What have we done? </li></ul><ul><li>Were there problems? </li></ul><ul><li>What are we doing now? </li></ul><ul><li>How will we make change stick? </li></ul>
    3. 3. Where have we come from and what have we done?
    4. 4. History of the Project <ul><li>Strategic Outline Case </li></ul><ul><li>Initial hospital focus </li></ul><ul><li>Victorian ward blocks </li></ul><ul><li>Salford’s health status </li></ul><ul><li>Other organisations </li></ul><ul><li>LIFT </li></ul>
    5. 5. Features of the new systems <ul><li>Integration of health and social care </li></ul><ul><li>Planned or elective care </li></ul><ul><li>Unplanned or emergency care </li></ul><ul><li>New intermediate level services </li></ul><ul><li>New ways of managing out patients and chronic diseases </li></ul>
    6. 6. How services will change….. Acute Intermediate Primary / community Old = organisational focus New = Pathway focus 1 0 2 0
    7. 7. Service Design Groups Emergency Elective Chronic Disease Management Diagnostic & Therapies Intermediate Care Elderly Primary Care Childrens Interface Group
    8. 8. User / public involvement <ul><li>Early principle of project </li></ul><ul><li>Public consultation </li></ul><ul><li>Patient focus </li></ul><ul><li>Get it right! </li></ul><ul><li>Requirement for planning services </li></ul><ul><li>Methodologies </li></ul>
    9. 9. Care Pathways & Service Redesign <ul><li>Integrated Care Pathways are one way of implementing protocols. They express locally agreed, multidisciplinary practice, based on guidelines and evidence, where available, for a specific patient group.They form all or part of the clinical record, document the care given and facilitate evaluation of outcomes for quality improvement purposes ( Modernisation Agency, 2002) </li></ul><ul><li>The first stage of an Integrated Care Pathway development relates to the provision or mapping of the patient’s journey, what is to happen , where, when and by whom.This is often referred to as the ‘High Level Care Pathways’ ( Modernisation Agency 2002) </li></ul>
    10. 10. Accessing the detail <ul><li>Identified a range of diseases / patient presentations & services </li></ul><ul><li>Clinical leads </li></ul><ul><li>Events - Energise </li></ul>
    11. 11. Getting Started <ul><li>Clear methodology for the redesign process </li></ul><ul><li>Identification of the key stakeholders </li></ul><ul><li>Selection of case types based on pre set criteria </li></ul><ul><li>Development of a project plan </li></ul><ul><li>Inclusion and exclusion criteria </li></ul><ul><li>Strategies for managing the redesign process </li></ul><ul><li>Reporting mechanisms </li></ul>
    12. 12. A Sample Project Plan <ul><li>Part 1: Process Map of current patient’s journey and SWOT analysis against NHS PAF </li></ul><ul><li>Part 2: Process Map of future journey, Key proposals and the resource implications </li></ul><ul><li>Part 3: Potential Opportunities and Health Impact- access, outcomes, efficiency, effectiveness, patient’s experience. Key protocols and guidelines supporting the new journey </li></ul><ul><li>Part 4: Health and Social interventions and goals along the patient’s journey and manpower/skill mix identification </li></ul>
    13. 14. Primary Care Model A&E Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model OBC Model Health Care Service Models Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    14. 15. <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Care Continuum in a Whole System Approach Fractured Neck of Femur Management Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    15. 16. INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Continuum of Dependence Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    16. 17. Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Essential Supporting Activities Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    17. 18. Procurement <ul><li>Commissioning, LDPs </li></ul><ul><li>Modernisation Development Agenda </li></ul>Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum The Links with LDPs & Modernisation Agenda Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    18. 19. Technology Development <ul><li>PACS – Remote Health Management – ICRS – telemedicine & telemonitoring- Diagnostics & Lab </li></ul>Procurement <ul><li>Commissioning, LDPs </li></ul><ul><li>Modernisation & Development Agenda </li></ul>Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum The IM&T Contribution Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    19. 20. Human Resource Management <ul><li>Recruiting, rewarding, retaining </li></ul><ul><li>New roles, new ways of working, whole system working </li></ul>Technology Development <ul><li>Integrated patient record, PACS – Remote Health </li></ul><ul><li>Management – ICRS – telemedicine & telemonitoring </li></ul>Procurement <ul><li>Commissioning, LDPs </li></ul><ul><li>Modernisation Development Agenda </li></ul>Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum New Roles & Functions Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    20. 21. Health Care Infrastructure Human Resource Management <ul><li>Recruiting, rewarding, retaining </li></ul><ul><li>New roles, new ways of working, whole system working </li></ul>Technology Development <ul><li>Integrated patient record, PACS – Remote Health </li></ul><ul><li>Management – ICRS – telemedicine & telemonitoring </li></ul><ul><li>SHIFT / LIFT / Health & Social Care Partnership </li></ul>Procurement <ul><li>Commissioning, LDPs </li></ul><ul><li>Modernisation Development Agenda </li></ul>Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>Social Services City Council Life Events Life Event & Life Cycle <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Social Model Support Activities The Health & Social Partnership Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    21. 22. Health Care Infrastructure Human Resource Management <ul><li>Recruiting, rewarding, retaining </li></ul><ul><li>New roles, new ways of working, whole system working </li></ul>Technology Development <ul><li>Integrated patient record, PACS – Remote Health </li></ul><ul><li>Management – ICRS – telemedicine & telemonitoring </li></ul><ul><li>SHIFT / LIFT / Health & Social Care Partnership </li></ul>Procurement <ul><li>Commissioning, LDPs </li></ul><ul><li>Modernisation Development Agenda </li></ul>Management Systems <ul><li>Systems of planning, finance, quality control, etc. </li></ul><ul><li>Scheduling, access, outcomes, user experience, efficiency, effectiveness </li></ul>INDEPENDENCE DEPENDENCE DEPENDENCE INDEPENDENCE SEMI - DEPENDENCE <ul><li>Primary prevention </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Falls management </li></ul><ul><li>Early recognition </li></ul><ul><li>call for help </li></ul><ul><li>initial management </li></ul>Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Quality & Cost - effective care Access Efficiency Patient / User Experience Outcomes Effectiveness Equity Care Continuum OBC Model Dependence Continuum Support Activities Achieving Quality Cost-Effective Care Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system
    22. 23. START Patient consults General Practitioner GP assesses needs Hernia diagnosed / suspected GP sends referral letter to hospital Consultant triages patient and informs appointments Hospital sends appointment to patient Initial outpatient consultation. Consent given. Patient put on waiting list Hospital pre-operative assessment … six, nine, twelve months later Patient attends Day Case Unit - Operation - Home on day of surgery unless clinically contra indicated Review in outpatient 4-6 weeks later, discharge to GP. Audit completed END Current Patient Pathway for Day Case Hernia Repair Current Patients Journey YES Refer to appropriate agency NO
    23. 24. START <ul><li>Patient consults GP with hernia </li></ul><ul><li>GP assesses condition and suitability for day case hernia according to anaesthetic and surgical protocol </li></ul><ul><li>Investigations and test if necessary </li></ul><ul><li>GP books patient into Day Case Unit operating list via direct booking on line according to the patients preference </li></ul><ul><li>GP emails referral letter and Day Case suitability pro forma to hospital- Consent in principle </li></ul><ul><li>Patient attends Day Case Unit Seen by Surgeon and Anaesthetist </li></ul><ul><li>Written consent </li></ul><ul><li>Operation if appropriate and fit- Same day discharge </li></ul><ul><li>Review appointment with GP / a Nurse in Primary Care </li></ul><ul><li>On line audit form completed and emailed to hospital </li></ul>END Proposed Journey following redesign
    24. 25. Goal achieved GP level. Patient presents with hip pain GP assessment using joint protocol Serious pathology suspected Refer to orthopaedic consultant immediately END Refer to appropriate agency END Hip problem suspected NO YES YES Refer to PCT Central Booking System for physio triage. Commence pain management Triage in primary / secondary care Patient <50 years Vascular necrosis suspected,significant hip pain Refer to orthopaedic surgeon Identify cause Treat accordingly Patient appropriate for surgery P1 Refer to orthopaedic consultant Outpatient appointment within 4 weeks Listed for surgery via booking system Outpatient appointment via central booking system PC Stage 1 Pre-operative assessment within 2/52 of listing New Zealand score. Priority assessment/ Health Management Hip assessment. Wish for surgery YES MDT assessment Goal setting Identify address All home alterations/ modifications Surgical consent Back to primary care for goal management Admit on day of surgery, subject to anaesthetic criteria. Surgery 3/12 NO Hospitalisation. Length of stay 3/5 days unless clinically indicated Hospitalisation goals achieved Discharge home 6 weeks review ? P Care 12 weeks review YES NO YES 2nd pre-op assessment + Anaesthetic assessment Treat as P3 The future management of Hip Pain - The Elements at Work in Red
    25. 26. Intermediate Care needed YES Identify package of care setting, etc. Options Transitional home/ Intermediate Care/ Hospital Intermediate Care Goals met 1 year review Indefinite review via THR system Discharge Go to review system Chronic D Mang END Outcome of New Zealand Hip Score Patient improving Review management Treat as P3 Priority classification. Care for all Refer to community physio and OT via booking system Pain management according to pain guidelines Review New Zealand hip score in primary care 3/12 P3 Manage according to P2 Refer to Orthopaedic Surgeon Continue P3 programme Outpatient physio GP management Review 3 to 6 months Pain management if required New Zealand Score P3 P2 NO P3 P1 P2 Remain at P2 Continue programme Review in 3/12 Refer to Orthopaedic Surgeon P1 Surgical management DISCHARGE Review system END
    26. 27. Future underpinning of Elective Care Application of the 72 hour principle An amalgam of service models as identified in OBC Focus on length of Stay underpinned by outcomes and coordination Use of a range Intermediate Care facilities Dependence on IM&T Supported by new roles and functions High S Care acuity and turnover leading to quicker access Redefinition of purpose of Secondary and Primary Care Clinical Governance across whole system Post-op review in Primary Care Linked to Social Services and City Council Life Event Model
    27. 28. Planned Care……………. Key Change Principles emerging from the Redesign Primary Prevention and Early Detection Strategy Management in Primary Care via Joint Protocol Development and Clinical Network Informal access to Surgeons and Physicians if required Referral according to pre set criteria via Central Booking System Not all Patents need to go to Outpatient Investigations and Diagnostics in Primary Care prior to referral Surgery in an appropriate location based on Risk criteria Pre-op location based on Anaesthetic Risk Admission on day of Surgery
    28. 29. Integrating the Redesign into the Commissioning Process The Logical Steps Process map of current service SWOT Analysis/NHS PAF Future Design Resource Implications and Economic Model Clinical Governance - Guidelines/Protocols Medicine Management Committee Professional Executive Committee Integration into LDPs/Financial Flows Directorate’s agenda Monitoring by Exception
    29. 30. Resource Implications <ul><li>People </li></ul><ul><li>Time </li></ul><ul><li>User Involvement </li></ul><ul><li>Support </li></ul><ul><li>Planning </li></ul><ul><li>Specific Needs client / patient groups </li></ul>
    30. 31. Barriers <ul><li>Time </li></ul><ul><ul><ul><ul><ul><li>Right people – right time </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Short term delivery targets v long term improvements </li></ul></ul></ul></ul></ul><ul><li>Culture </li></ul><ul><ul><ul><ul><ul><li>Bureaucracy & Institutional loyalties </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Adversarial approach between primary & secondary care </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Silo thinking & working </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Risk aversion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Professional & inter professional tension & rivalry </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Limited ownership locally of overall strategy </li></ul></ul></ul></ul></ul><ul><li>People </li></ul><ul><ul><ul><ul><ul><li>Resistance to change – suspicion, fatigue, cynicism, apathy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Self preservation, empire building </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fear – involving patients & carers </li></ul></ul></ul></ul></ul><ul><li>Information </li></ul><ul><ul><ul><ul><ul><li>Lack of good quality / whole system information & data </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lack of shared information </li></ul></ul></ul></ul></ul>
    31. 32. Overcoming barriers <ul><li>Skills </li></ul><ul><ul><li>Energiser </li></ul></ul><ul><ul><li>Barometer </li></ul></ul><ul><ul><li>Programme Manager </li></ul></ul><ul><ul><li>Facilitator </li></ul></ul><ul><ul><li>Translator </li></ul></ul><ul><ul><li>Communicator </li></ul></ul>
    32. 33. Strengths of the process <ul><li>Relationship changes </li></ul><ul><li>Energy & Enthusiasm </li></ul><ul><li>Mutual understanding and agreements </li></ul><ul><li>Communication & networking </li></ul>
    33. 34. What are we doing now? How will we make the change stick? <ul><li>Created SHIFT vision, service principles and sample care pathways </li></ul><ul><li>Directorate / service level planning </li></ul><ul><li>Core organisational focus </li></ul><ul><li>Early wins </li></ul><ul><li>Tier 2 / Collaboratives / NSFs / etc. </li></ul>
    34. 35. The challenge for commissioning How can commissioning make service redesign work?
    35. 36. How can commissioning help? <ul><li>Costs & activity </li></ul><ul><li>Financial flows </li></ul><ul><li>Local Delivery Plans </li></ul><ul><li>Ongoing quality & activity monitoring </li></ul>
    36. 37. Pathways & commissioning <ul><li>Translate pathways into separate elements with: </li></ul><ul><ul><li>Costs </li></ul></ul><ul><ul><li>Locations </li></ul></ul><ul><ul><li>Expected activity </li></ul></ul><ul><ul><li>Quality measures </li></ul></ul><ul><ul><li>Quantified impact on existing services </li></ul></ul><ul><li>This will be the basis for commissioning redesigned services </li></ul>
    37. 38. Financial flows <ul><li>Payments linked to activity </li></ul><ul><li>National tariff price for each HRG </li></ul><ul><li>Full cost implications of activity changes </li></ul><ul><li>Regime is still developing </li></ul><ul><li>Issue of currency & tariff for: </li></ul><ul><ul><li>Mental health services </li></ul></ul><ul><ul><li>Community services </li></ul></ul>
    38. 39. Using financial flows <ul><li>Financial flows means </li></ul><ul><li>Moving activity at full cost </li></ul><ul><li>Patient choice is reflected in payments </li></ul><ul><li>But… </li></ul><ul><li>Need to develop mechanisms for pathways to cross between primary & secondary care </li></ul>
    39. 40. Local Delivery Planning <ul><li>Sets out actions to meet key deliverables </li></ul><ul><li>Prioritisation process for schemes </li></ul><ul><li>So… </li></ul><ul><li>Actions arising from service design must be reflected in the LDP </li></ul><ul><li>Service design resource requirement must be subject to appropriate scrutiny and prioritisation </li></ul>
    40. 41. Ongoing monitoring <ul><li>Develop mechanisms and indicators to monitor: </li></ul><ul><ul><li>Quality of service provided </li></ul></ul><ul><ul><li>Activity delivered </li></ul></ul><ul><ul><li>Access to services </li></ul></ul><ul><li>The above will be required for each part of the pathway </li></ul>

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