The Map of Medicine in the North West Update August 2009

1. The Map of Medicine in the North West Update August 2009 James Walker Map of Medicine Programme Lead NW SHA Chief Information & Knowledge Office

2. The Map of Medicine GP2GP The Map is a Core Component of NPfIT: NHS Care Record Service Choose and Book New National Network Picture Archiving &Communications Systems Electronic Transmission of Prescriptions

3. The Case for Change in Healthcare! • The requirement to deliver World Class Commissioning • NHS Operating Framework - working in a ‘cash constrained’ environment PCTs judged by results • Developing patient centric services, more personalised care - services closer to home, money following the patient • More choice of providers including independent sector • More information / knowledge about what choices to make • Greater emphasis on quality of services and outcomes – PROMS – Commissioning for Quality (CQINS) • Reconfiguration & Modernisation of Healthcare • Patient Safety issues – Need to reduce medico-litigation

4. Closing the Gap US data collated by Professor Bill Runciman, President, Australian Patient Safety Foundation from McGlynn et al; NEJM 2006 Vol 348; p2635-45

5. Semmelweis, Vienna 1847 • High rates of death due to puerperal fever (childbed fever) • Women delivered by physicians or students mortality rate (13–18%) • Women delivered by midwives or trainees (2%) Prof. Klein: Inadequate hospital ventilation Prof. Semmelweis: Handling cadavers prior to delivery Instituted mandatory hand washing Mortality plummeted to 2% Best, M et al. Qual Saf Health Care 2004;13:233-234

6. 150 years later...Marshall and Warren – Helicobacter pylori • Published seminal paper in the Lancet in 1983 • NICE guidance 2000; Regimens to eradicate Helicobacter pylori • 17 years to become standard best-practice • How many unnecessary gastrectomies and selective vagotomies? c10,000 Drugs like Thalidomide, Cox-2 inhibitors Overuse of antibiotics - MRSA and antibiotic resistance Drug-drug interactions Others yet to be identified

7. Highest rates for heart disease and stroke Nearly a quarter of children live in poverty 16% people on benefits 23% of adults binge drinkers The Case for Change in the NW Average life expectancy 3 years less than the UK best Highest rate for long term mental health problems 60% of adults overweight or obese 2nd highest rates - deaths from cancer and smoking related illnesses

9. Feeling lucky? Which Pathway should I take?

10. The Problem Diabetes Guidelines Chronic Heart Disease NSF SUS Data Population profile Draft Service Review Prescribing data Internal memorandum My Documents Business Objects Reports Public Health Team Trust Board Report

11. NWSHA Map of Medicine RAG Status January 2008 Map Views H O I G C B R K E D P A Q N T J L U V M S X F W

12. NWSHA Map of Medicine RAG Status April 2008 Map Views H O I G C B R K E D P A Q N T J L U V M S X F W

13. NWSHA Map of Medicine RAG Status September 2008 H O I = LHCs with Live view on CSC instance G C B R K E D P A Q N T J L U V M S X F W

14. NHS NW Map of Medicine RAG Status July 2009 H O I = LHCs with Live view on CSC instance All 24 PCT Led Local Health Communities have their own ‘view’ of the Map of Medicine G C B R K E D P A Q N T J L U V M S X F W

15. NHS NW Objectives for the Map • To make the Map of Medicine available to all NHS & Social Care organisations • To inculcate Clinical Ownership & uptake of MoM • To exploit the potential of the Map to support improved care outcomes to support WCC & Healthy Horizons • To facilitate improved Clinical Governance • To implement an ‘evidence based’ knowledge tool • To implement a sustainable MoM Programme • To make the Map of Medicine a single point of reference for patient-centric care, regardless of where care is delivered: Primary, Secondary or Tertiary Care • Developing a vision for the Map to support improved care outcomes in NHS NW

16. Context - Current Status • Sponsor - Alan Spours the NHS NW Chief Information & Knowledge Officer (CIO) is driving the national NHS CIO network for MoM adoption • SRO Dr Andy Coley’s NHS NW Chief Clinical Officer & Co-Founder of Clinical Leads Network www.cln.nhs.uk • SHA resources in place to implement MoM & raise awareness • 100% Technical enablement of MoM in the NW • Utilisation of MoM in 22/24 PCT Led Local Health Communities • Strong clinical engagement • Utilising MoM to improve & standardise health care provision • Utilising the Map to support enhanced quality of care in NW • Striving to win ‘hearts & minds’ of clinicians • At the early stage of a move towards BAU for MoM

17. Facilitate Redesign & Delivery of Health Services: Delivering Patient Centred Services Empowering Patients & Clinicians Improving Quality of Health Care Delivering Seamless Services Making Better Use of Resources Objectives of Map Roll Out in NHS NW - What Are We Aiming to Achieve ?

18. The Map of Medicine is developed In partnership with clinicians and….

19. What is the Map of Medicine?

20. Localisable benchmark for clinical processes Framework for sharing clinical knowledge across care settings Evidence based care pathways available in any setting

21. Saves re-inventing the content wheel locally

22. How do I access the Map? Access is via Smartcard and from within N3 Patient Access via NHS Choices website http://healthguides.mapofmedicine.com

23. Users NASP and LSPapplications Registration Authority – Process • Registration Authority – process by which users will gain access to NHS Spine applications:e.g. MoM, Choose & Book, ETP & Summary Care Record Service etc • Access to services by smart card • Single sign-on process described during procurement Local Network / N3 Smart Card Plus PIN Trust PC

24. SmartCards – Will Look Like This..Chip & PIN - Only a lot better looking! James Walker Modernisation Programme Manager E&N Herts NHS Acute Trust

25. There is a clear need for improving knowledge management • “The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.” • J A Muir Gray, Director of Clinical Knowledge, Process and Safety - Connecting for Health, NHS Improved knowledge management can help prevent and minimise: • Errors and mistakes • Poor quality healthcare • Waste • Variations in policy and practice • Poor patient experience • Overenthusiastic adoption of interventions of low value • Failure to get new evidence into practice

26. Localising the Map of Medicine

27. Localising the Map Local Administrative Information • Adding administrative detail • e.g. contact details, clinic information, opening times etc. • links to websites or intranet sites • Simple process Clinical Localisation • Changes to the national care pathways • adding, changing or deleting information • More complex involving stringent local clinical governance

28. Rationale for localising the Map • Improve communication of local information and local patient pathways • Increase relevance as a knowledge, governance and communication tool • Gain local ownership, adoption and support • Knowledge sharing of international evidence & best practice • Opportunity to map current practice • Undertaking service redesign to: • meet government targets e.g. 18 week RTT • support Practice-Based Commissioning • Improve transparency and communication across: • care settings (community/primary care/secondary care) • related departments • sectors

29. Supporting the Independent Sector ‘IS CATS Provider Care UK Provide Clinical Services to 10 Greater Manchester PCTs The use of the Map will improve the quality of referrals into GM NHS CATS as well as secondary care AND improve the quality of discharge summaries IS CATS manages patients in the top 6 specialties: musco-skeletal medicine including orthopaedics & rheumatology, ENT, Urology, General Surgery and Gynaecology for 30% of these referrals for the 3rd largest city in the UK IS CATS Provide services for part of the Pt journey The Map Pathways are visible across the GM Region in Primary & Acute Sector Provides transparency for referral criteria & the Pt journey Clinicians from primary and secondary care clinicians agreed that the management of such patients on 50 Pathways should be based on the pathways in the Map of Medicine to ensure quality

30. Commissioning – Modernisation Developments communicated via Map of Medicine in the Wirral AMD Pathway Modernisation Quantitative Benefits Qualitative Benefits Patients were waiting 10 weeks for appointments, this has been reduced to 3 weeks. A real risk of patients losing their sight has been addressed. Data from 2008 is showing a saving of around £500 per patient for 30 patients per month This single pathway development will save approximately £180,000 There are 100 pathways in development on the Wirral. Potential savings can be assessed from all of these:

31. Map Supporting Reconfiguration • Cumbria PCT reconfiguration programme ‘Closer To Home’ • Referral Management based on the Map of Medicine Care Pathways. • Referral Criteria reviewed with clinicians and published on the Map • In 2007/08, Cumbria PCT spent £12.5M on first referrals which was £406k above expected (based on the England average). Potential savings can be assessed: • £1M could have been saved if the 22 most extreme performing practices reduced their referrals to match the England average. • £624k could have been saved if 10 practices reduced their referrals to match the England average. • If this benefits work were applied to other workstreams the return could be huge, they need to be quantified and realised in one or two areas and then cascaded across the organisation and quantified. • Date source NHS Comparators data, https://nww.nhscomparators.nhs.uk/NHSComparators/Login.aspx

32. Map Supports World Class Commissioning World class commissioning will deliver better health and well-being for all: People will live healthier and longer lives Health inequalities will be dramatically reduced. It will deliver better care for all: Services will be evidence-based and of the best quality People will have choice and control over the services that they use, so they become more personalised. It will deliver better value for all: Investment decisions will be made in an informed and considered way, ensuring that improvements are delivered within available resources PCTs will work with others to optimise effective care. The Map supports WCC Objective 5 – Provide ‘evidenced based care’

33. The Operating Framework signalled that incentives and interventions will be directly linked with Commissioning Assurance “PCTs …be held to account for, and rewarded for, their development towards world-class commissioning through one national assurance system that will focus on commissioning outcomes, competencies and governance” Operating Framework 2008/09, page 46

34. Map Supports Advancing Quality • Supporting ‘Advancing Quality’ (AQ) • AQ a NW SHA World Class Quality Programme • AQ incentivises Acute Trusts to consistently deliver Quality • AQ Indicators to be embedded in the Map of Medicine • Primary Care see Referral Criteria • Acute Trusts are rewarded to ‘Quality Care’

35. Advancing Quality Focus • 5 Clinical Conditions - Acute myocardial infarction (AMI) - Heart failure - Community Acquired pneumonia - Coronary artery by-pass graft (CABG) - Hip/Knee replacement surgery • 105 Clinical measures • 3 year project evaluated Oct 2003- Sept 2006 • Hospitals in top 2 deciles rewarded for quality scores

36. Advancing Quality Indicators tobe embedded in the Map of Medicine • Evidence based consensus clinical measures • Examples – Aspirin at arrival (AMI) Prophylactic antibiotic 1 hour prior to surgical incision (H&K) Smoking cessation advice /counselling (CHF) Blood culture collected prior to 1st antibiotic administration (P) In patient mortality rate (CABG)

37. Map Pathways are end to end Acute Hospital  Diagnostic & Treatment Centre  Community Hospital  Community Pharmacy Mental Health Trust  Social Service  Primary Care Trust  NHS Direct  GP Practice  Integrated Working  Ambulance Trust  Patients cross organisational boundaries 

38. 407 Pathways Available to patients via NHS Choices website http://healthguides.mapofmedicine.com

39. The Map supports Quality Measures • Supports PROMS • Supports CQUINS • Supports PALS • Supports Darzi Quality Indicators

40. Culture v Technology “The significant problems we have cannot be solved at the same level of thinking with which we created them! – Albert Einstein

41. Increasing Clinical Workload!

42. Programme Impact Summary – Map of Medicine Programme overview / objectives • The Map of Medicine offers high quality clinical information visualised in over 400 patient pathways. It serves as a single healthcare knowledge source that will speed the delivery of evidence based best practice across healthcare organisations; this evidence is continually monitored, reviewed and updated. The Map of Medicine is endorsed by the NHS and the NHS National Library for Health (NLH) and is developing initiatives in partnership with the NHS Institute they work closely with the Royal Colleges, including the Royal College of Physicians & the Royal College of GPs . The Map also work with NICE and the National Patient Safety Agency • The Map of Medicine is working with EMIS & TPP to develop integration, they are also working with InPSand iSoft, and engaging with Out of Hours plus Acute suppliers i.e.Lorenzo & Cerner, it is anticipated that integration will be incremental from 2009 onwards. Benefit summary Primary impact on Key dependencies • Patients • 407 Pathways available to patients on www.nhs.uk or http://healthguides.mapofmedicine.com Patient pathways online. • Increased patient confidence as pathways are evidence based • Improved communication across organisational boundaries • Increased patient safety through access to information • NHS staff • Easier access to up-to-date information, 24 hours/day • Supports healthcare planning, PbC reconfiguration, modernisation • Enables demand management – Appropriate referral information • Facilitates coordination between Health & Social Care • Supports 18 Week RTT targets • Provides knowledge support • Supports Clinical Governance • GP practices • • Timely access to information to support patient care • Clinical Governance updates • Improved communication (Information Governance) • Improved Pt safety, onlineaccess to BNF/NLH specialist libraries • Supports Continuous Professional Development (CPD) • Out-of-Hours patient care will be based on up to date pathways • GP practices: Awareness of changes to core business processes. • Information Governance • Clinical Governance Communication NICE, NSF Data Set Change Notice changes • Integral to Modernisation • Supports PBC • Acute Care • Improved communication • Improved Pt safety • End to End Pt pathways • Unscheduled care settings: A&E, OOH awareness oflocal business process redesign. • PCTs: Reconfiguration, Planning resources; Management of clinical & patient information • Supports PBC • Internal • Clinical ownership • CEO ownership across LHC • LHC Governance arrangements • LHC resources • Practice based Commissioning • Advancing Quality Programme • Smartcard access • Stakeholder engagement • World Class Commissioning • External • Map of Medicine • Acute ownership/engagement • GP practice sign up • Urgent and emergency care resources • Local Service Provider – Key Supplier of NHS systems as hosts for HW • Integration in strategic clinical solutions: GPSoC, CaB, Lorenzo, Cerner, Out of Hours • .

43. NHS NW Vision for the Map

44. Darzi & the Map in the NW

45. Map Logins 2007/08

46. Map Logins 2008/09 12.5 % 12.5% 12.5 % 12.5 % 12.5 % 12.5 % 12.5 % 12.5 %

47. The Map of Medicine in the North West a significant Change Management Programme A programme that will only succeed with clinical ownership www.cln.nhs.uk Thanks….. NW SHA Map of Medicine lead James.walker@northwest.nhs.uk