SHIFT Project – Salford’s Health Investment For Tomorrow

1. SHIFT Project – Salford’s Health Investment For Tomorrow Whole system pathways and commissioning as a dynamic approach Janet Roberts, Sylvain Laxade, Janelle Homes, Richard Freeman

2. What we are going to cover • Making it Real • What have we done? • Were there problems? • What are we doing now? • How will we make change stick?

3. Where have we come from and what have we done?

4. History of the Project • Strategic Outline Case • Initial hospital focus • Victorian ward blocks • Salford’s health status • Other organisations • LIFT

5. Features of the new systems • Integration of health and social care • Planned or elective care • Unplanned or emergency care • New intermediate level services • New ways of managing out patients and chronic diseases

6. How services will change….. Old = organisational focus New = Pathway focus Acute 10 20 Intermediate Primary / community

7. Service Design Groups Elective Chronic Disease Management Emergency Diagnostic & Therapies Elderly Primary Care Childrens Interface Group Intermediate Care

8. User / public involvement • Early principle of project • Public consultation • Patient focus • Get it right! • Requirement for planning services • Methodologies

9. Care Pathways & Service Redesign • Integrated Care Pathways are one way of implementing protocols. They express locally agreed, multidisciplinary practice, based on guidelines and evidence, where available, for a specific patient group.They form all or part of the clinical record, document the care given and facilitate evaluation of outcomes for quality improvement purposes(Modernisation Agency, 2002) • The first stage of an Integrated Care Pathway development relates to the provision or mapping of the patient’s journey, what is to happen , where, when and by whom.This is often referred to as the ‘High Level Care Pathways’ (Modernisation Agency 2002)

10. Accessing the detail • Identified a range of diseases / patient presentations & services • Clinical leads • Events - Energise

11. Getting Started • Clear methodology for the redesign process • Identification of the key stakeholders • Selection of case types based on pre set criteria • Development of a project plan • Inclusion and exclusion criteria • Strategies for managing the redesign process • Reporting mechanisms

12. A Sample Project Plan • Part 1: Process Map of current patient’s journey and SWOT analysis against NHS PAF • Part 2: Process Map of future journey, Key proposals and the resource implications • Part 3: Potential Opportunities and Health Impact- access, outcomes, efficiency, effectiveness, patient’s experience. Key protocols and guidelines supporting the new journey • Part 4: Health and Social interventions and goals along the patient’s journey and manpower/skill mix identification

14. Health Care Service Models OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

15. Care Continuum in a Whole System Approach Fractured Neck of Femur Management OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

16. Continuum of Dependence Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

17. Essential Supporting Activities • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

18. The Links with LDPs & Modernisation Agenda • Commissioning, LDPs • Modernisation Development Agenda Procurement • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

19. The IM&T Contribution • PACS – Remote Health Management – ICRS – telemedicine & telemonitoring- Diagnostics & Lab Technology Development • Commissioning, LDPs • Modernisation & Development Agenda Procurement • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

20. New Roles & Functions • Recruiting, rewarding, retaining • New roles, new ways of working, whole system working Human Resource Management • Integrated patient record, PACS – Remote Health • Management – ICRS – telemedicine & telemonitoring Technology Development • Commissioning, LDPs • Modernisation Development Agenda Procurement • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

21. The Health & Social Partnership Health Care Infrastructure • SHIFT / LIFT / Health & Social Care Partnership • Recruiting, rewarding, retaining • New roles, new ways of working, whole system working Human Resource Management Support Activities • Integrated patient record, PACS – Remote Health • Management – ICRS – telemedicine & telemonitoring Technology Development • Commissioning, LDPs • Modernisation Development Agenda Procurement • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Social Model Social Services City Council Life Events Life Event & Life Cycle OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

22. Achieving Quality Cost-Effective Care Health Care Infrastructure • SHIFT / LIFT / Health & Social Care Partnership • Recruiting, rewarding, retaining • New roles, new ways of working, whole system working Human Resource Management Access Efficiency Patient / User Experience Support Activities • Integrated patient record, PACS – Remote Health • Management – ICRS – telemedicine & telemonitoring Technology Development • Commissioning, LDPs • Modernisation Development Agenda Quality & Cost - Procurement • Systems of planning, finance, quality control, etc. • Scheduling, access, outcomes, user experience, efficiency, effectiveness Management Systems Dependence Continuum INDEPENDENCE DEPENDENCE DEPENDENCE SEMI - DEPENDENCE INDEPENDENCE OBC Model Primary Care Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model A&E Model effective care Outcomes Effectiveness Equity A&E management RCP guidelines Fast track Emergency model management 72hr stay Operation time according to condition Specialty bed Length of stay < 6 days Intermediate Care e.g. virtual, transitional, therapy beds • Primary prevention • Osteoporosis • Falls management Secondary prevention & chronic disease management Care Continuum • Early recognition • call for help • initial management Recovery Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

23. Current Patient Pathway for Day Case Hernia Repair Current Patients Journey Patient consults General Practitioner START GP assesses needs Hernia diagnosed / suspected Refer to appropriate agency NO YES GP sends referral letter to hospital Consultant triages patient and informs appointments Hospital sends appointment to patient Initial outpatient consultation. Consent given. Patient put on waiting list Hospital pre-operative assessment … six, nine, twelve months later Patient attends Day Case Unit - Operation - Home on day of surgery unless clinically contra indicated Review in outpatient 4-6 weeks later, discharge to GP. Audit completed END

24. Proposed Journey following redesign START • Patient consults GP with hernia • GP assesses condition and suitability for day case hernia according to anaesthetic and surgical protocol • Investigations and test if necessary • GP books patient into Day Case Unit operating list via direct booking on line according to the patients preference • GP emails referral letter and Day Case suitability pro forma to hospital- Consent in principle • Patient attends Day Case Unit Seen by Surgeon and Anaesthetist • Written consent • Operation if appropriate and fit- Same day discharge • Review appointment with GP / a Nurse in Primary Care • On line audit form completed and emailed to hospital END

25. The future management of Hip Pain - The Elements at Work in Red GP level. Patient presents with hip pain GP assessment using joint protocol Serious pathology suspected Refer to orthopaedic consultant immediately END New Zealand score. Priority assessment/ Health Management Hip assessment. Wish for surgery Refer to PCT Central Booking System for physio triage. Commence pain management Refer to appropriate agency YES Hip problem suspected Triage in primary / secondary care NO YES Patient <50 years Vascular necrosis suspected,significant hip pain Refer to orthopaedic surgeon Identify cause Treat accordingly END PC Stage 1 Pre-operative assessment within 2/52 of listing Listed for surgery via booking system Outpatient appointment within 4 weeks Outpatient appointment via central booking system Refer to orthopaedic consultant Patient appropriate for surgery P1 YES NO Treat as P3 NO Identify address All home alterations/ modifications 2nd pre-op assessment + Anaesthetic assessment MDT assessment Goal setting Back to primary care for goal management Admit on day of surgery, subject to anaesthetic criteria. Surgery 3/12 Surgical consent Goal achieved YES Hospitalisation. Length of stay 3/5 days unless clinically indicated YES Hospitalisation goals achieved 12 weeks review 6 weeks review ? P Care Discharge home

26. NO Options Transitional home/ Intermediate Care/ Hospital Intermediate Care Indefinite review via THR system Identify package of care setting, etc. 1 year review YES Intermediate Care needed Goals met Go to review system Chronic D Mang END Discharge P3 Patient improving Review management Treat as P3 Review New Zealand hip score in primary care 3/12 Refer to community physio and OT via booking system P2 Priority classification. Care for all Outcome of New Zealand Hip Score Pain management according to pain guidelines Remain at P2 Continue programme Review in 3/12 P1 Refer to Orthopaedic Surgeon Surgical management Review system DISCHARGE END P3 Continue P3 programme P1 Refer to Orthopaedic Surgeon New Zealand Score Outpatient physio GP management Pain management if required P3 Review 3 to 6 months P2 Manage according to P2

27. Future underpinning of Elective Care Application of the 72 hour principle An amalgam of service models as identified in OBC Focus on length of Stay underpinned by outcomes and coordination Use of a range Intermediate Care facilities Dependence on IM&T Supported by new roles and functions High S Care acuity and turnover leading to quicker access Redefinition of purpose of Secondary and Primary Care Clinical Governance across whole system Post-op review in Primary Care Linked to Social Services and City Council Life Event Model

28. Planned Care……………. Key Change Principles emerging from the Redesign Primary Prevention and Early Detection Strategy Management in Primary Care via Joint Protocol Development and Clinical Network Informal access to Surgeons and Physicians if required Referral according to pre set criteria via Central Booking System Not all Patents need to go to Outpatient Investigations and Diagnostics in Primary Care prior to referral Surgery in an appropriate location based on Risk criteria Pre-op location based on Anaesthetic Risk Admission on day of Surgery

29. Integrating the Redesign into the Commissioning ProcessThe Logical StepsProcess map of current serviceSWOT Analysis/NHS PAFFuture DesignResource Implications and Economic ModelClinical Governance - Guidelines/ProtocolsMedicine Management CommitteeProfessional Executive CommitteeIntegration into LDPs/Financial FlowsDirectorate’s agendaMonitoring by Exception

30. Resource Implications • People • Time • User Involvement • Support • Planning • Specific Needs client / patient groups

31. Barriers • Time • Right people – right time • Short term delivery targets v long term improvements • Culture • Bureaucracy & Institutional loyalties • Adversarial approach between primary & secondary care • Silo thinking & working • Risk aversion • Professional & inter professional tension & rivalry • Limited ownership locally of overall strategy • People • Resistance to change – suspicion, fatigue, cynicism, apathy • Self preservation, empire building • Fear – involving patients & carers • Information • Lack of good quality / whole system information & data • Lack of shared information

32. Overcoming barriers • Skills • Energiser • Barometer • Programme Manager • Facilitator • Translator • Communicator

33. Strengths of the process • Relationship changes • Energy & Enthusiasm • Mutual understanding and agreements • Communication & networking

34. What are we doing now? How will we make the change stick? • Created SHIFT vision, service principles and sample care pathways • Directorate / service level planning • Core organisational focus • Early wins • Tier 2 / Collaboratives / NSFs / etc.

35. The challenge for commissioning How can commissioning makeservice redesign work?

36. How can commissioning help? • Costs & activity • Financial flows • Local Delivery Plans • Ongoing quality & activity monitoring

37. Pathways & commissioning • Translate pathways into separate elements with: • Costs • Locations • Expected activity • Quality measures • Quantified impact on existing services • This will be the basis for commissioning redesigned services

38. Financial flows • Payments linked to activity • National tariff price for each HRG • Full cost implications of activity changes • Regime is still developing • Issue of currency & tariff for: • Mental health services • Community services

39. Using financial flows Financial flows means • Moving activity at full cost • Patient choice is reflected in payments But… • Need to develop mechanisms for pathways to cross between primary & secondary care

40. Local Delivery Planning • Sets out actions to meet key deliverables • Prioritisation process for schemes So… • Actions arising from service design must be reflected in the LDP • Service design resource requirement must be subject to appropriate scrutiny and prioritisation

41. Ongoing monitoring • Develop mechanisms and indicators to monitor: • Quality of service provided • Activity delivered • Access to services • The above will be required for each part of the pathway