This presentation by Karen Middleton CBE, Chief Allied Health Professions Officer, explores the narrative for the NHS reforms, the key structures that clinicians need to be aware of and some of the main challenges and opportunities they present for MS care. It was presented at the MS Trust Annual Conference in November 2013.

1. NHS reforms –
opportunities and
challenges for MS Care
Karen Middleton CBE
Chief Allied Health
Professions Officer

2. Summary
• Context - the narrative for the reforms
• The key structures that clinicians need to be
aware of
• Key messages
• Challenges
• Opportunities
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3. Some NHS facts and figures
• 1.3 million staff
• £109 billion annual budget
• Over 1 million patients treated every 36 hours
• 15 million hospital admissions per year
• 88 million outpatient attendances
• C.12 billion spent on medicines
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4. Context
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5. Context – Quality (safe, effective, good experience)
‘In the next room you could hear the buzzers sounding. After
about 20 minutes you could hear the men shouting for the
nurse, ‘nurse, nurse’ and it just went on and on. And then very
often you would hear them crying, like shouting ‘nurse’
louder, and then you would hear them crying, just
sobbing, they would just sob and you presumed that they had
had to wet the bed. And then after they would sob, they
seemed to then shout again for the nurse, and then it would
go quiet…’
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6. 6

7. Commissioning of services
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8. First Mandate for NHS England
• First Mandate published on 13th November
2012
• Sets out what the Government expects in
return for handing over £95bn of tax payers
money to NHS England
• The NHS Outcomes Framework sits at the
heart of this Mandate and the Board is
expected to demonstrate progress across the
entire framework
• In turn, the NHS Outcomes Framework sits at
the heart of NHS England’s planning
guidance ‘Everyone Counts’, published in
December 2012
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9. NHS Mandate
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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127193/mandate.pdf.pdf

10. Tools and levers of the Quality Framework
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11. NHS ENGLAND
Our focus – delivering improved outcomes
Domain 1
The NHS
Outcomes
Framework
Domain 2
Domain 3
Preventing
people from
dying
prematurely
Enhancing
quality of life
for people
with longterm
conditions
Helping
people to
recover from
episodes of ill
health or
following
injury
Domain 4
Domain 5
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Ensuring people have a positive
experience of care
Treating and caring for people in a safe
environment and protecting them from avoidable
harm
Effectiveness
Experience
Safety

12. How we align these tools and levers will be key to
success
NHS OUTCOMES FRAMEWORK
Domain 2
Domain 3
Domain 4
Domain 5
Preventing
people from
dying
prematurely
Enhancing
the quality
of life for
people with
LTCs
Recovery
from
episodes of
ill health /
injury
Ensuring a
positive
patient
experience
Safe
environment
free from
avoidable
harm
Duty of quality
Duty of quality
Domain 1
NICE Quality Standards
(Building a library of approx 150 over 5 years)
Commissioning
Outcomes
Framework
Provider payment mechanisms
Commissioning
Guidance
tariff
standard
contract
CQUIN
Commissioning / Contracting
NHS Commissioning Board – certain specialist services and primary care
GP Consortia – all other services
Duty of quality
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QOF

13. NHS Outcomes Framework ‘At a Glance’
1
Preventing people from dying prematurely
Overarching indicators
1a Potential Years of Life Lost (PYLL) from causes considered amenable to
healthcare
i Adults ii Children and young people
1b Life expectancy at 75
i Males ii Females
Improvement areas
Reducing premature mortality from the major causes of death
1.1 Under 75 mortality rate from cardiovascular disease* (PHOF 4.4)
1.2 Under 75 mortality rate from respiratory disease* (PHOF 4.7)
1.3 Under 75 mortality rate from liver disease* (PHOF 4.6)
1.4 Under 75 mortality rate from cancer* (PHOF 4.5)
i One- and ii Five-year survival from all cancers
iii One- and iv Five-year survival from breast, lung and colorectal cancer
Reducing premature death in people with serious mental illness
1.5 Excess under 75 mortality rate in adults with serious mental illness* (PHOF 4.9)
Reducing deaths in babies and young children
1.6 i Infant mortality* (PHOF 4.1)
ii Neonatal mortality and stillbirths
iii Five year survival from all cancers in children
Reducing premature death in people with a learning disability
1.7 Excess under 60 mortality rate in adults with a learning disability
2
Enhancing quality of life for people with long-term
conditions
3
Helping people to recover from episodes of ill health or
following injury
Overarching indicators
4
Ensuring that people have a positive experience of care
Overarching indicators
3a Emergency admissions for acute conditions that should not usually require
hospital admission
3b Emergency readmissions within 30 days of discharge from hospital* (PHOF 4.11)
Improvement areas
Improving outcomes from planned treatments
3.1 Total health gain as assessed by patients for elective procedures
i Hip replacement ii Knee replacement iii Groin hernia iv Varicose veins
v Psychological therapies
Preventing lower respiratory tract infections (LRTI) in children from becoming
serious
3.2 Emergency admissions for children with LRTI
4a Patient experience of primary care
i GP services
ii GP Out of Hours services
iii NHS Dental Services
4b Patient experience of hospital care
4c Friends and family test
Improvement areas
Improving people’s experience of outpatient care
4.1 Patient experience of outpatient services
Improving hospitals’ responsiveness to personal needs
4.2 Responsiveness to in-patients’ personal needs
Improving people’s experience of accident and emergency services
4.3 Patient experience of A&E services
Improving recovery from injuries and trauma
3.3 Proportion of people who recover from major trauma
Improving recovery from stroke
3.4 Proportion of stroke patients reporting an improvement in activity/lifestyle on the
Modified Rankin Scale at 6 months
Improving recovery from fragility fractures
3.5 Proportion of patients recovering to their previous levels of mobility/walking ability
at i 30 and ii 120 days
Helping older people to recover their independence after illness or injury
3.6 i Proportion of older people (65 and over) who were still at home 91 days
after discharge from hospital into reablement/ rehabilitation service***
(ASCOF 2B)
ii Proportion offered rehabilitation following discharge from acute or
community hospital
Improving access to primary care services
4.4 Access to i GP services and ii NHS dental services
Improving women and their families’ experience of maternity services
4.5 Women’s experience of maternity services
Improving the experience of care for people at the end of their lives
4.6 Bereaved carers’ views on the quality of care in the last 3 months of life
Improving experience of healthcare for people with mental illness
4.7 Patient experience of community mental health services
Improving children and young people’s experience of healthcare
4.8 An indicator is under development
Improving people’s experience of integrated care
4.9 An indicator is under development *** (ASCOF 3E)
Overarching indicator
2 Health-related quality of life for people with long-term conditions** (ASCOF 1A)
NHS Outcomes
Framework 2013/14
Improvement areas
Ensuring people feel supported to manage their condition
2.1 Proportion of people feeling supported to manage their condition**
Improving functional ability in people with long-term conditions
2.2 Employment of people with long-term conditions** * (ASCOF 1E PHOF 1.8)
at a glance
Reducing time spent in hospital by people with long-term conditions
2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive
conditions (adults)
ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under
19s
Enhancing quality of life for people with mental illness
2.5 Employment of people with mental illness **** (ASCOF 1F & PHOF 1.8)
Enhancing quality of life for
13i Estimated diagnosis rate people with dementia (PHOF 4.16)
2.6
for people with dementia*
ii A measure of the effectiveness of post-diagnosis care in sustaining
independence and improving quality of life*** (ASCOF 2F)
Treating and caring for people in a safe environment and
protect them from avoidable harm
Overarching indicators
5a Patient safety incidents reported
5b Safety incidents involving severe harm or death
5c Hospital deaths attributable to problems in care
Improvement areas
Alignment across the Health and Social Care System
Enhancing quality of life for carers
2.4 Health-related quality of life for carers** (ASCOF 1D)
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*
**
Indicator shared with Public Health Outcomes Framework (PHOF)
Indicator complementary with Adult Social Care Outcomes
Framework (ASCOF)
*** Indicator shared with Adult Social Care Outcomes Framework
**** Indicator complementary with Adult Social Care Outcomes
Framework and Public Health Outcomes Framework
Indicators in italics are placeholders, pending development or identification
Reducing the incidence of avoidable harm
5.1 Incidence of hospital-related venous thromboembolism (VTE)
5.2 Incidence of healthcare associated infection (HCAI)
i MRSA
ii C. difficile
5.3 Incidence of newly-acquired category 2, 3 and 4 pressure ulcers
5.4 Incidence of medication errors causing serious harm
Improving the safety of maternity services
5.5 Admission of full-term babies to neonatal care
Delivering safe care to children in acute settings
5.6 Incidence of harm to children due to ‘failure to monitor’

14. Key work programmes
1.
2.
3.
4.
5.
6.
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Prevention, early diagnosis and intelligence
Community services
Acute services
Integrated care and support
Patients in control
Parity of esteem

15. Clinical Senates
Clinical senates will help Clinical Commissioning Groups (CCGs), Health and
Wellbeing Boards (HWBs) and the NHS CB to make the best decisions about
healthcare for the populations they represent by providing advice and leadership at a
strategic level.
• Engage with commissioners to identify areas with potential to
improve outcomes
• Mediating with their population about how to implement best
practice
Purpose • A source of clinical leadership
• Proactive role in promoting major service change
• Link clinical expertise and local knowledge i.e. on patient pathways
• Engage with clinical networks
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16. 12 Clinical Senates
North East, north
Cumbria, and the Hambleton
& Richmondshire districts of
North Yorks
Yorkshire &
The Humber
Greater
Manchester, La
ncashire and
south Cumbria
East
Midlands
Cheshire &
Mersey
East of
England
West
Midlands
Thames
Valley
London
South West
South East
Coast
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Wessex

17. Strategic Clinical Networks (SCNs)
Established within 12 geographical areas covered by Clinical Senates
Help local
commissioners
to:
First SCNs
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•
•
•
•
•
•
•
•
•
Reduce variation in services
Encourage innovation
Define evidence-based best practice pathways
Operate as engines of change across complex systems of care
To maintain and/or improve quality and outcomes
Cancer
Cardiovascular disease
Maternity and children’s services
Mental health, dementia and neurological conditions

18. Innovation
‘An idea, service or
product, new to the NHS
or applied in a way
that is new to the NHS,
which significantly improves
the quality of
health and care
wherever it is applied.’
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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131299

19. Academic Health Science Networks
• 15 – designated and licensed
• 5 year contracts
• Systematic delivery mechanism for diffusion of innovation
and best practice and collaboration between partners
including industry
• Align education, clinical research, informatics, training and
healthcare delivery
• Improving patient and population health by translating
research into practice and developing and implementing
integrated health care systems
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20. AHSNs
Academia
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Industry
Oxford
Eastern
Wessex
UCL Partners
South London
East Midlands
West Midlands
West of England
North West Coast
Greater Manchester
Yorkshire and Humber
South West Peninsula
Kent, Surrey and Sussex
North East and North Cumbria
Imperial College Health Partners
NHS

21. Health Education England
• National
• Local – 13 Local Education training Boards (LETBs or
HEELs)
Purpose:
To support the delivery of excellent healthcare and health
improvement by ensuring that our workforce has the right
numbers, skills ,values and behaviours, at the right time in the
right place.
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22. HEE advisory arrangement
HEE Board
MPAB
PAF
HEEAGs
Exec
Subgroups, National Advisory Groups, Task/Finish Groups, National Programmes
Primary Decision Making Body/ Overarching Governance
HEE Advisory & Decision Making Support Bodies
Sub Groups, Special Projects & National Advisory Groups
Board Recommendations & decision under scheme of
delegation
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* SLT = HEE Exec & LETB MD’s

23. Key messages
• Stop looking up for direction and guidance
• It really is a commissioning-led system
• Understand patient power
• You have to be bi-lingual
• Clinical care has to be paramount
• Clinical LEADERSHIP is critical
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24. Challenges
• Doing more for less – or doing different for less
• Transformational rather than transactional change
• Generalists versus specialists
• Education and training numbers
• Reactive versus proactive
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• Exerting influence – more later!

25. Opportunities
• The focus on outcomes
• Rehab, rehab, rehab!
• Multi-disciplinary approach
• Patient voice
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26. Exerting influence
• Put yourself in the shoes of the other person
• Avoid perception of self-interest
• Respect
• Prepare
• Build alliances
• Tell a story
• Private persuasion over public passion
• Resilience
• Wild Cards - Evidence; humour: sprinkling stardust
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27. A final great thought from a great inspiration…
”When you are done
changing, you are done”
Benjamin Franklin
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28. Thank you
Karen.middleton1@nhs.net
karen@chpo
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