Strategic Clinical Networks The holy grail of integrated care

1. Strategic Clinical NetworksThe holy grail of integrated care • DEBateman NCDNeurology Date September 17

2. 12 SCNs in England • 4 million people per SCN • 700k per SCN with a neurological condition • What are they for? • What can they do? • How can they do it?

3. Strategic Clinical Networks • Large geographical area • Connect the network & join up care • Coordinate complex care pathways • Designed around patients’ needs • Unique opportunity to do this with support • Permanent structures for continued improvement • Never achieved previously

4. Why is this so important? • Current spend 5.3 billion! • No more money! • Service redesign • Change of roles • Permanent structures for continued improvement • Neurology conditions ideally suited to this approach

5. Problems with neurology services • Poor care • Poor access to care • Poor value for money • Lack of expert staff • Lack of clear pathways of care

6. What are neurological conditions? • Common disorders • Headache & migraine 90% life time prevalence in women • Life threatening • Meningitis, encephalitis, SAH, GBS, status epilepticus • Rarebut difficult • MND,myasthenia, mitochondrial disease • Long term conditions • Parkinson’s disease 1 :1000 • Multiple sclerosis 1:800 • Epilepsy 1:250

7. Where & how ? • Access to care? • 3 ways • Acute emergency • Scheduled care OP dept • Long term care

8. What is commissioned? • Neuroscience specialist commissioning e.g. rare neuromuscular disorders • Tertiary rehabilitation in some areas NSC • OP scheduled care CCG • What about acute and long term neurology conditions?

9. What do patients want?Neurological Alliance • Local service • Quick & accurate diagnosis • Rapid access to expert support & Rx • Support to self manage their condition • Reduced admissions & LOS

10. Acute neurology servicesunder the radar! • 1 : 10 admissions - Neurological • 3rd most frequent speciality after cardiology & respiratory • Current process : triage to general physician • inappropriate care due to unavailability of local neurologist • Delay in referral & misdiagnosis • Increased LOS • Inappropriate use of investigations • Great concern but no champion! (charity or GP)

11. NASH • 41% DGH no policy for acute seizure care • 35% DGH no policy for status epilepticus 10% mortality • 48% DGH no policy of further referral • 66% known epilepsy • 3.5% admitted to a neurology ward • % admitted greater than for COPD • 52% access to epilepsy nurse

12. Can this be done better? • Liaison neurology • 75% seen within 24 hours • Halves LOS • 30% change in diagnosis • Management change 80% Epilepsy patients • Reduced costs saving 150K in typical DGH

13. Leeds model (Dunn) • Daily consultation service to Acute Medicine • 3 Liaison Rounds on Acute Medical Unit • 2 Acute Clinics, direct access for Acute Medicine • Training in Acute Neurology

14. Leeds model • LOS 8 days to 2 days over nearly 10 years • For 200 patients this is a Saving of about 500k

15. Inequity • Why should the standard of care be different to : • Acute stroke? • Gastroenterological emergencies etc.? • Epilepsy deaths and admissions static past 10 years

16. How? • Modify neurology DGH job plans to include liaison work • Appoint acute neurologists • Emergency clinics to prevent admission • Reduce scheduled care- see later ! • CCGs to commission and DGHs to provide acute care from neurologists

17. Neurology OP clinics (scheduled care) • ↑by 10 % per year • 1 : 125 adult population see a neurologist in OP • In some areas majority seen in the centre (40%)

18. Who is seen in the routine OPD?Is this good value use of neurology? • 20 % headache • 70% migraine & tension headache • 30 % no neurological diagnosis • Functional & psychological 16% • Epilepsy 14%

19. How can this be improved? • Intermediate H/A & Epilepsy clinics • more economical • better patient satisfaction • GPwSI to filter referrals for a group of CCGs • E mail triage of referrals • ↓ by 40% patients seen • NeuroMail/telephone clinics • Remove chronic neurology- see next!

20. What are long term neurological conditions? • Life time prevalence Ep,MS,PD & others • 6 per 1000 • 3000 patients in 500K population • 25 % never seen a PD nurse • 60 % trusts have no epilepsy nurse • PD nurses reduce consultant time by 40% • Admission rates ↓ by 50 % • Self funding !

21. Who should look after them & how?! • Key worker NOT neurologist! • NeuroCare teams i.e. stroke care • Led by GPwSI supported by local neurologist • MND,epilepsy,MS,PD & other LTC • Specialist nurses & AHPs • Continuing health care teams • Social care integration

22. Suggestion 1NeuroCare teams • Develop local generic neurology networks for long term conditions alongside stroke on a 500k population basis • GPwSI, specialist nurse, AHPS etcMND,PD,MS etc • Improve care, more cost effective

23. Suggestion 2 • Measures to reduce acute neurology admissions- Savings! • Improve access to neurology opinion in DGH for acute admissions • urgent clinics, liaison neurology sessions, ED protocols • The Dunn model • On a 500 k basis achieved for CVA • 7day working (NCEPOD&NASH)

24. Suggestion 3 • Modernise OP (scheduled) care • GPwSI headache, epilepsy, general, NeuroMail • GP education programmes • CCG integration in SCN planning

25. Outcomes • Domain 1 preventing acute illness & dying prematurely • Domain 2 improving QUAL for LTC • Domain 3 helping recovery • Better outcomes & value

26. Measuring success? • Patient experience surveys • Clinical audit tools • Disease registry • Neuro navigator : • web based tool for patients carers health staff • Accountability, responsibility • PAC committee