GETTING IT RIGHT FIRST TIME – reducing variation, improving patient outcomes

1. Getting It Right First TimeSeamless Surgery Connect - 23 March 2018 Michael Horrocks, GIRFT Clinical Lead Vascular Surgery & Clinical Ambassador SW HubLiz Lingard, GIRFT Hub Director, North East, North Cumbria & Yorkshire

2. GIRFT First principles GETTING IT RIGHT FIRST TIME – reducing variation, improving patient outcomes Aiming to deliver operational productivity improvements that translate into resource savings of £240-420m in 2017-18 and c.£1.4bn p.a. by 2020-21 (c.£3-4bn cumulative 2017-21). • Programme is led by frontline clinicians who are expert in the areas they are reviewing • Supported by Secretary of State for Health, Royal Colleges and professional societies • Peer to peer engagement helping clinicians and managers identify and deliver changes that will improve care and deliver efficiencies. • Innovative use of data sets to identify unwarranted variations in the way services are delivered • Regional hubs will support trusts, CCGs and STPs to drive locally designed improvements

3. Unwarranted Variations Identified England average £1398 Significant unwarranted variations seen in practice and outcomes, but scope identified to tackle many of these variations, and great appetite found among clinicians and managers to do so. 0.19% - 4.49% Lower back pain surgery costs >£100m per annum with little evidence of efficacy Variation in hip & knee deep infection rate within one city. If all trusts got to 0.19% this could save the NHS up to £2-300m p.a, enough for 60,000 replacements Cemented: £650 Uncemented: £5,300 No evidence that hip on right provides better outcome for over 70s • Litigation: huge variation between trusts in averages: • General surgery: £17 - £477 • Urology: £4 - £117 • Vascular: £1 - £6,353 • Obs & Gynae: £55 - £6,896

4. GIRFT Orthopaedics Pilot: impact to date c.£50m 50,000 75% £4.4m estimated savings p.a, from increased use of cemented hip replacements for patients aged over 65 – reducing readmissions of trusts have renegotiated the costs of implant stock and reduced use of expensive ‘loan kit’ estimated savings over two years and improved quality of care estimated beds freed up annually by reduced length of stay for hip & knee operations Pricing Letter A pricing letter provides transparency of procurement costs to all trusts BOA used GIRFT principles in best practice guidance Litigation costs have reduced by 36% in 3 years

6. From pilot to national programme 1000+ Clinical work streams are already underway Clinical Lead visits already completed Remaining work streams will all start by summer 2018 7 28 • Delivery strategy agreed and governance in place • Collaboration agreements with national and local partners being delivered • Regional implementation support network in place • Benefits measurement & tracking approach in place • 3 national reports published, with 9 more to come in 2018 • Implementation until March 2021 with more specialties (oncology, paediatric medicine) to be added

7. Cross-cuttingclinical projects • GIRFT is delivering a number of cross cutting projects: • GIRFT Clinical Leads are coming together to work in clinical service lines when beneficial for exploiting opportunities or joining up services across specialty boundaries: Procurement & Technology Patient Safety Strategic Service Change Medicines Optimisation Frailty Coding Litigation Pathology services Anaesthetics Perioperative Diagnostic services Outpatients Brain conditions ED & Acute Admissions Critical & Intensive Care

8. General Surgery National Report (August 2017) General Surgery National Report (published in August 2017) identified: • The need to overhaul quality and capture of clinical data and overcome barriers to addressing variation. • That consultant-led assessments in Emergency Departments (EDs)could cut admissions by 30%, improving EDs’ sustainability and freeing up bed capacity. • Cost savings of 59% for a basket of typical surgical supplies. • A total opportunity for £160m savings annually including £32m from improving enhanced recovery to shorten length of stay 8

9. Vascular Surgery National Report (February 2018) • 70 trusts in England conduct vascular surgery and many of these already collaborate within a local network. However, there is no standard model. • A nationwide, vascular surgery “hub and spoke” network of specialist units treating every vascular surgery case as “urgent” could stop over 100 deaths and reduce disability by substantially reducing the risks associated with blocked arteries such as sudden death, strokes, restricted movement, and amputations. • Regional specialist vascular surgery hubs within networks would ensure round-the-clock availability of early diagnostics & specialist interventions to improve surgical outcomes. • Improved NHS productivity resulting from fewer strokes, and reduced emergency readmissions, returns to theatre, and length of stay would save between £7.6m (€8.58m; $10.5m) and £16m, and there would be an opportunity to save a further £6.5m through improved procurement. 9

10. GIRFT implementation model is up and running • The responsibility for designing and implementing any changes derived from GIRFT recommendations lies with trusts and their partners in each local health economy. • Each trust has a board-level GIRFT clinical champion (normally Medical Director), and each clinical workstream will have a designated GIRFT lead. • Over 80% of GIRFT staff are trust facing. Nearly 40% are clinicians. They support each trust and their local partners to improve clinical outcomes by: Clinical Leads, as national leaders in their field, advise trusts on how to reduce any unwarranted variations seen in their GIRFT data packs and help to benchmark their performance against their peers. Clinical Leads drive improvement nationally by writing a GIRFT National Report on their specialty, through working closely with NHSE Clinical Directors, and by feeding into wider national improvement initiatives. • Regional Hubs support trusts in delivering the Clinical Leads’ recommendations by: • Helping them to assess and overcome the local and national barriers to delivery including in mitigating unintended negative consequences. • Working closely with NHSI regions to ensure prioritisation of GIRFT delivery takes account of the wider context within each trust and is joined up with local and regional improvement initiatives. • Working closely with Op Prod teams to ensure a joined up approach to trusts on clinical quality and productivity improvements. • Joining up with RightCare/NHSE to ensure joined up support to STP level improvements

11. GIRFT-NHSI Regions Collaboration • GIRFT Hubs working alongside NHSI regions and Op Prod on NHSI Top 15 trusts • Joined up planning beginning on GIRFT national report delivery • GIRFT ‘Trust on a page’ dashboard available from late spring 2018 • GIRFT Analytics Portal training for NHSI staff from April • Hubs have fed opportunities into trust CIP planning • Joint trust meetings already happening in the North

12. GIRFT Implementation: regional hubs 7 GIRFT Hubs with clinical and project delivery leads who will support trusts, commissioners, STPs and ACCs to: and disseminate best practice Provide concentrated additional resources Build and deliver implementation plans reflecting: • The variations highlighted in trusts’ data packs • The improvement priorities discussed in Clinical Lead visits • The recommendations set out in each National Report

13. North East, North Cumbria & Yorkshire Hub Implementation Team Clinical Ambassador Dr Jean Macleod (88 days) 27/02/2018 Clinical Ambassador Mr Mark Lansdowne (88 days) March 2018 TBC Hub Director Liz Lingard 3/10/2017 Implementation Managers Jennifer Wilkie 8/01/2018 Aimee Robson 05/03/2018 Terese Phillips 05/03/2018 Jacqueline Calydon 16/04/2018 Helen Biggs 16/04/2018 Helen Ridley 16/04/2018 Michael Lydon 30/4/2018 NENCY Hub Base Waterfront 4, Newburn, Riverside Newcastle upon Tyne, NE15 8NY Communications Manager Vacant Business Intelligence Manager Vacant Hub Administrator Paula Kew 15/01/2018

14. Being a GIRFT clinical Lead Michael Horrocks

15. Themes to be investigated by GIRFT • Organisation of the service • Staffing/ Activity levels (lists, outpatients etc.) • Time from Referral, Assessment to Surgery (definitive treatment) • Lengths of stay and delayed discharge • Complications: Mortality, Return to theatre, complications (infection) • Readmissions, particularly within 30 days • Skills/Deskilling • Post surgery destination • Friends and Family Test • Data • Procurement • Litigation costs

16. Reported numbers of Vascular Surgeons and Interventional Radiologists by provider - Oct-2015

17. Provision of weekend elective vascular surgery reported by providers and provider type Oct-2015

18. Proportion of all AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015

19. Proportion of Aneurysms repaired by EVAR Proportion of all unruptured (elective) AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015 (x2 variation) Proportion of all ruptured (emergency) AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015 (x10 variation)

20. Proportion of patients readmitted in an emergency within 30 days for any reason following an AAA procedure by provider and provider type: initial admission 01-Apr-2012 to 31-Dec-2014 Open procedure EVAR procedure

21. In-hospital  mortality following any AAA repair procedure by provider and provider type 01-Jan-2015 to 31-Dec-2015 (x10 variation)

22. Proportion of patients receiving a CEA procedure of any type within 7 days of referral to a Vascular service by provider and provider type 01-Jan-2014 to 31-Dec-2014 (x6 variation)

23. Median days from assessment to surgery for CEA repair by provider and provider type 01-Jan-2014 to 31-Dec-2014 (5-30 days variation)

24. Proportions of post-surgical destination ward type post CEA procedure by provider 01-Jan-2014 to 31-Dec-2014

25. Adjusted in-hospital mortality or stroke rate of patients undergoing a CEA procedure during the inpatient spell of the procedure by provider and provider type 01-Jan-2014 to 31-Dec-2014 (x10 variation)

26. Activity counts of lower limb revascularisation procedures by procedure type, provider and provider type 01-Apr-2014 to 31-Mar-2015

27. Average length of stay for elective lower limb bypass procedures by provider and provider type 01-Apr-2014 to 31-Mar-2015 Diabetic Non-diabetic

28. Average length of stay for elective lower limb bypass procedures by provider and provider type 01-Apr-2014 to 31-Mar-2015 -twice as long if admitted as an emergency Non-diabetic Diabetic

29. Recommendations • Engage of profession with management • Fully develop the Network Structure (for Vascular) • Develop as an Urgent Specialty with fast through flow • Engage with Spoke hospitals, clinicians and managers • Ensure all patients have same priorities • Share pathways and timelines with other teams • Adequate staffing and facilities • Consider 7 day operating with cases fed into facilities • Arrange angioplasties to reflect the urgency and facilities

30. Continued • Full pre-admission work-up • Prehabilitation where possible • Early discharge planning • Identify likely re-admitters (frailty score) • Early medical contact post-op • Phone contact for worried patients • Review your litigation cases and learn from them

31. Local Issues • Hubs, how many and where • Combining teams • Particular geographical problems • Ensuring spokes are on board • Shared pre-op work-up • Accept post-op transfers • Ensure links for referrals and MDT’s • Regular reviews of data and outcomes

32. Questions Mike Horrocks GIRFT Vascular Clinical Lead GIRFT Clinical Ambassador for South West Hub  E M Liz Lingard North East, North Cumbria & Yorkshire Hub Director  E Liz.Lingard@nhs.net M 07730374650