FLS case study: service improvement with additional funding

1. Fracture Liaison Service Case Study:
Service improvement with additional
funding
The Haywood Hospital
Zoe Paskins @zpaskins
Senior Lecturer and Honorary Consultant Rheumatologist
Haywood Rheumatology Centre, Stoke on Trent
Keele University

2. Overview: a story of 2 parts
• Service expansion: our ‘journey’
• Other service improvement initiatives

3. Stoke-on Trent

4. Our FLS:
Nurse-led one-
stop clinic
Catchment (acute
Trust) 500,000

5. Fracture Liaison Service first commissioned by SoT PCT
2009

6. Physical presence in fracture clinic
to identify patients – mornings only
One stop clinic for DXA,
assessment, lifestyle
advice, bloods
Treatment
recommendations
to GP
£
Letter to GP
recommending referral
in to clinic
££
Rheumatology tariff, WL
Bad for
• Patients
• GPs
• Commissioners

7. Lessons learnt:
Number 1
Be prepared with all the
arguments for
commissioners – ‘moral’
and financial

8. 2012-3
Fracture liaison Service first
commissioned by SoT PCT
2009
2012/13
Business case first submitted
to NS PCT

9. 2013-4
Fracture liaison
Service first
commissioned by
SoT
2009
2012/13
1st Business case
submitted to NS PCT
1st Business case
approved in
principle
…Commissioners left
2013/14
June 2014
Clinical Lead of
service changed

10. 2014
Fracture liaison
Service first
commissioned by
SoT
2009
2012/13
Business case first
submitted to NS
PCT
Business case
approved in
principle
Commissioners left
2013/14
June 2014
Clinical Lead of
service changed
Peer review of
osteoporosis
service
Oct 2014

11. NOS involvement
Peer review
Commissioning workshop
Face to face - help sort priorities
By e-mail - draft documents – service spec,
business case v 2.0, cost analysis

13. Lessons learnt:
Number 2
Attendance at these
meetings is really
important!

14. NOS involvement
Peer review
Commissioning workshop
Face to face - help sort priorities
By e-mail - draft documents – service spec,
business case v 2.0, cost analysis
Meeting with commissioners - moral support

15. Fracture liaison
Service first
commissioned
by SoT
2009
2012/13
Business case
first submitted
to NS PCT
Business case
approved in
principle
Commissioners
left
2013/14
June 2014
Clinical Lead of
service changed
Peer review of
osteoporosis
service
Oct 2014
Jan 2015
Business case
re-visited
Verbal
agreement to
commission
Jan 2015

17. Fracture liaison
Service first
commissioned
by SoT
2009
2012/13
Business case
first submitted
to NS PCT
Business case
approved in
principle
Commissioners
left
2013/14
June 2014
Clinical Lead of
service
changed
Peer review of
osteoporosis
service
Oct 2014
Jan 2015
Business case
re-visited
Verbal
agreement to
commission
Jan 2015
No contract
July 2015

18. • No written confirmation of approval received (or
money, or contract) despite chasing ++
• We started tentatively to clear waiting list
(overtime)
• New staff posts not approved without contracts
• Morale of existing staff suffering
• Then.. An email about something else, to
someone else

19. (part of) my reply
“……………….This is also particularly embarrassing
given that the National osteoporosis Society
have highlighted our FLS unit in a recent high
profile journal article and cited the case of Stoke
as a commissioning success. They are in
constant contact with me about the progress on
this venture and I should not like to have to tell
them that the CCG are only prepared to fund a
partial service.”

20. Lessons learnt:
Numbers 3,4 & 5
Follow up all meetings
with something in writing
Keep staff informed all
the way
Using clout of NOS?

21. f
Peer review of
osteoporosis
service
Oct 2014
Jan 2015
Business case
re-visited
Verbal
agreement to
commission
Jan 2015
No contract
July 2015
August
September
2015 –
commissioned

24. er review of
steoporosis
service
Oct 2014
Jan 2015
Business case
re-visited
Verbal
agreement to
commission
Jan 2015
No contract
July 2015
August
September 2015
– commissioned
Our next
mission: South
Staffs 2017

26. Email to someone else, about
something else… June 2015
“We therefore request that you provide a
response outlining how you will deliver the FLS
within the identified cost envelope including a
trajectory for the management of the backlog as
unfortunately there will be no additional money
to fund this.”

27. End of part 1!

28. Other service developments: peer
review driven
“Opportunity to refine the FLS-DXA-OP clinic
pathway cutting out the GP step”
Solution: LMC not CCG!

29. “Review roles – including .. job plan review, line
management”
One of the solutions:

30. “There is little evidence of integrated and
seamless care across secondary, community and
primary care”.

31. Solutions?

33. • 72 responses!
• >10 GPs gave emails for future contact
• Lots of helpful suggestions
 Reduced length of report
 Changed policy on blood results

34. Service away (half) day
• The task:
How do we demonstrate our
excellence?
What are our key outcomes?
How can we deliver better
value/ be more efficient?
How do we deal with
increasing referral rates?
How can we be more patient
centred?
• (Some) actions/outcomes:
 Evaluation of our helpline
 Patient feedback on all
elements of service
 Changed follow up policy for
DXA
 Invite patients to our service
meetings/ future away days

35. Summary
• Importance of maintaining follow up with
commissioners after initial agreements
• The value of NOS peer review
• But.. You don’t need a peer review to improve
your service!