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North West Community Provider Alliance Clinical Pathway Workshop 2009 2
CONTENTS
Introduction p 3
Pathway Review Summary p 4
Long Term Conditions p 7
End of Life Care p 23
Urgent Care p 39
Planned Care p 50
Staying Healthy p 54
Health Improvement p 61
Mental Health p 66
Child Health p 75
Maternity and Newborn Care p 88
Acknowledgements
North West Community Provider Alliance Clinical Pathway Workshop 2009 3
North West Community NHS Services Clinical Pathway Workshop
Introduction
Across the North West, the NHS Providers of Community Services are working together as an Alliance to support collaboration in the promotion and
development of high quality and innovative community services.
Transforming Community Services has recognised the crucial role that community services have to play in the delivery of Quality, Innovation,
Productivity and Prevention (QIPP) and that an essential element of the transformation process is the effective engagement of community clinicians
and practitioners in shaping community services that are fit for the future delivery of high quality productive care.
This report is the output of a half day workshop attended by over 100 community expert clinicians and practitioners from across the North West. They
met to debate and agree a consensus view of the high impact changes that could be made by community services to enable service, pathway and
partnership reform, and contribute to the wider system delivery of Healthier Horizons and QIPP.
The event involved practitioners working in PCT provider services. However, it was recognised that it is vital for similar pathway discussions to be
extended to include a range of stakeholders (including NHS, social care, third sector and independent sector providers, as well health and social care
commissioners) if any of these proposals are to be taken forward and the anticipated QIPP benefits realised.
We hope that this summary report provides the basis for these new conversations at service, health and social care economy, and regional levels.
Dr Barbara Green on behalf of the North West Provider Alliance
October 2009
North West Community Provider Alliance Clinical Pathway Workshop 2009 4
Pathway Review Summary
Process
The reviews brought together clinical experts, from all disciplines, to offer high level evidence based and clinically supported proposals of the key
community service changes that could be commissioned to deliver the aspirations of the Darzi vision, Transforming Community Services and the
implementation of Healthier Horizons.
Eight expert multidisciplinary panels met, each focussing on a specific clinical pathway: Long term conditions, End of Life Care, Planned Care, Urgent
Care, Health Improvement, Staying Healthy, Child Health and Maternity and New Born Care.
Each panel was asked to:
a) Provide a consensus of the top three to five high impact changes for community services, with reference to the evidence base and best practice
examples where possible
b) Identify the benefits of each, from the perspectives of the patient/client; the commissioner; and system reform agenda
c) Consider the enablers and barriers to delivery
The outputs from each panel are reproduced within this report including a summary of the relevant recommendations from Healthier Horizons and
Transforming Community Services Best Practice Guides. As can be seen, there is considerable synergy between all three.
Summary of the themes across the pathways
• Community Services were seen as crucial levers for positive change in terms of improving the health and well being of the population of the North West
and in enabling radical system reform.
• There was unequivocal support for the ambitions contained within High Quality Care for All, Transforming Community Services and Healthier Horizons
and a clear commitment that community staff – whether directly or indirectly providing care – would actively participate in the transformation process.
North West Community Provider Alliance Clinical Pathway Workshop 2009 5
• There was a realistic understanding of the scale of the challenge and that leadership at all levels was needed to successfully deliver the pace of
change that is required.
• Practitioners were excited by the prospect of working collaboratively at service and system levels to improve quality and productivity. They also
identified significant opportunities for the co-production and adoption of innovative practices for improvement.
• It was hoped that there would be wider recognition of the expertise that already exists within community services and that commissioners would
actively support existing examples of excellent practice, delivered in some areas of the North West, being spread and adopted by all.
• The engagement of communities and patients and the whole community service workforce was seen to be fundamental to the success of the
transformation process. Community services are very close to the needs of the communities they serve. They are part of the stories that families and
individuals share and can offer a valuable insight into the real experiences of people of their lives, health and health care.
• Community service practitioners have a strong ethos and commitment to empowerment and enablement. They have extensive experience of the co-
production of interventions with clients and communities to improve health outcomes and address health inequalities. The importance of building on
existing community insights and relationships was highlighted and all panels emphasised the importance of strengthening universal services and
prevention, health improvement and early intervention functions.
• There was consistent support for integrated clinical pathways to be jointly commissioned by health and social care with clearly defined outcomes and
benefits. It was proposed that the design and delivery of the pathway should then be determined by providers working together to co-design and re-
design effective integrated practice throughout the patient or client journey.
• There was strong support for the development of collaborative clinical networks and integrated care pathways, with a balance between a standardised
approach and the flexibility to respond to individual choice and needs.
• Collaboration and competition were major themes with both being seen as providing the potential for improvement. It was suggested that
commissioners might incentivise horizontal and vertical co-operation across a number of the pathways.
• Integration was offered as a philosophy to clinical practice enabling improved client experience and outcomes, as opposed to a focus on financial
alignment or organisational form. Integrated practice and co-operation with a wide range of providers was seen as offering significant opportunities to
improve access and quality.
North West Community Provider Alliance Clinical Pathway Workshop 2009 6
• Most community services are commissioned to operate during a typical 9am – 5pm weekday period. It was suggested that a simple and rapid
improvement to patient experience, access and choice could be made if many community services were commissioned to deliver over more extended
or flexible hours.
• Many of the panels identified workforce development and redesign to be essential for successful transformation. The general view was that this was
recognised by the community services workforce who would welcome the opportunity for greater engagement in service and system reform.
• It was felt that there was a need for clinical leadership within community services to be specifically commissioned and the further development of
generalist, specialist and expert practitioner roles.
• Knowledge management and the lack of reliable and comparable data were frequently seen as barriers to improved service delivery. Clinicians were
keen to co-produce a range of meaningful metrics with commissioners so that energy and effort is focussed on measures that are valued and enable
transformation.
• The panels identified significant variation in the scale and range of community service provision across the North West. There was no apparent
rationale for this variation and very few standard service models.
• There were concerns expressed about the emerging tension of collaboration and competition between NHS community providers within the new
market, and a worry that colleagues may become less willing and open to sharing their innovative practices.
• There has been an absence of a forum for community staff to meet and share best practice and therefore limited cross-fertilisation of knowledge and
innovation between community services.
• The participants were very positive about the workshop and wish to develop the work further. They were keen for clinicians and practitioners to
continue to work together in multidisciplinary pathway groups.
North West Community Provider Alliance Clinical Pathway Workshop 2009 7
LONG TERM CONDITIONS
North West Community Provider Alliance Clinical Pathway Workshop 2009 8
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Continue with
health and
social care
integration
Health and social care
integration means less
duplication/number of
assessments and number of
handoffs, which produces
seamless care and links to
care pathways. A single
point of contact improves
quality and the number of
acute episodes. This means
holistic needs are met. A
single number to access
services means increased
satisfaction with a decreased
‘scatter gun’ effect. Right
treatment first time for
patients.
Able to efficiently
manage economic
markets, therefore,
opens up markets.
Brings increasing
value for money and
improves productivity
by reducing
duplication.
Encourages
integrated
commissioning by
Health & Social
Care. Developing
‘care bundles’
reduces costs and
increases quality
control. Right
treatment first time
and so reduced
waiting times.
Encourages a
community tariff.
Integrated commissioning by
Health & Social Care with
improved market
management. Patient
involvement will give a more
definite view of what patients
want and need from a
service. Breakdown of roles
and boundaries. Encourages
professionals to ensure that
services are person led not
service led. Lean.
Streamlined. Empowers
patients to use Choose and
Book. Links to other
pathways e.g. urgent care,
end of life. Embedded Single
Assessment Process.
Integrated teams co-
located with shared
reporting systems and
pooled budgets and IT
systems.
Shared priorities/
protocols/information.
Commitment from
organisations, staff and
GPs.
Common
understanding of
‘integration’ as practice
rather than
organisational form.
Clear pathways linked
to electronic Directory
of Services.
Staff training.
Inadequate IT
systems.
Financial barriers and
freedom to act.
Terms and conditions
of Service Level
Agreements.
Systems/policies.
Different remits e.g.
free at point of
care/subject to
eligibility.
Respect for decision
making.
North West Community Provider Alliance Clinical Pathway Workshop 2009 9
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Develop personalised care plans using joint care planning, integrated
assessments and joined up multidisciplinary working along the care pathway.
Intermediate care and rehabilitation services should form part of the long
term conditions pathway preventing inappropriate admissions to the acute
trusts, facilitating early discharge and enabling people to achieve the
optimum level of independence for their long term future.
• Ensure that community teams and matrons make close linkage with
continuing healthcare services so that, where appropriate, packages of care
can be set up effectively and efficiently with no time delay for patients. Work
closely with community mental health teams to develop referral pathways to
improving services such as: improving access to psychological therapies
(IAPT) or cognitive behavioural therapy (CBT) for patients who require
specialist advice, support and treatment.
• Extend the hours of service according to patients needs. This may include
telephone access for on-call and out-of-hours home visits. Offer services in
local and convenient venues to reach patients who may not engage in
traditional ways. This may include church halls, supermarkets, and train
stations.
• Use technology to implement shared care planning, so that all involved in the
patient’s care including the emergency services, such as the ambulance trust
or out-of-hours provider, have an understanding of the patients needs and
treatment plan.
• Use technology as a form of documentation. This may include remote access
devices such as palm tops and tablets which can be synchronised easily with
IT systems, avoiding unnecessary travel or time wastage;
• A new model of care should be commissioned that
enables integration of health and social care, with the roles
of professionals changing to meet patients' needs. There
needs to be a clear description of what primary care
should be like to incorporate social care, community care
and specialists.
• A designated care co-ordinator will have responsibility for
ensuring that a plan is developed and agreed.
• The role of primary care should be strengthened and
developed with new skills and ways of working to deliver
more personalised care around patients.
• The development of a virtual care campus to deliver health
and social care provision within primary care for
specialised problems.
• Greater use of technology to enable patients to be
maintained /monitored in primary care.
North West Community Provider Alliance Clinical Pathway Workshop 2009 10
2.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Integrated
discharge
planning,
continuity
across primary
and secondary
care
This approach
will increase
safety and
provide
seamless
crossover care
to community
services. There
will be fewer
complaints,
reduced re-
admissions,
reduced length
of stay as a
result of positive
care planning
There will be
fewer
complaints,
reduced re-
admissions,
therefore,
reduction of cost
of emergency
admissions.
Improved
delivery of A & E
4 hour standard
and 18 week
pathways.
Increased health and well being
outcomes.
Improved quality and efficiency
subject to genuine investment in
community services to deliver
tangible benefits of care closer to
home.
Shared commissioned
services with shared priorities
for staff and patients.
Shared IT systems means
more efficient ways of
working.
Creation of new roles to
enhance the service.
PbR/block contracts –
restriction of the
development of local
integrated care pathways.
‘Blame culture’ in the NHS.
Organisational boundaries.
Lack of shared knowledge
North West Community Provider Alliance Clinical Pathway Workshop 2009 11
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Intermediate care and rehabilitation services should form part of the
long term conditions pathway preventing inappropriate admissions to
the acute trust, facilitating early discharge and enabling people to
achieve the optimum level of independence for their long term future.
• Ensure that community teams and matrons make close linkage with
continuing healthcare services so that, where appropriate, packages of
care can be set up effectively and efficiently with no time delay for
patients.
• A new model of care should be commissioned that enables
integration of health and social care, with the roles of
professionals changing to meet patients' needs. There needs to
be a clear description of what primary care should be like to
incorporate social care, community care and specialists.
• A designated care co-ordinator will have responsibility for
ensuring that a plan is developed and agreed.
• The role of primary care should be strengthened and developed
with new skills and ways of working to deliver more
personalised care around patients. The development of a
virtual care campus to deliver health and social care provision
within primary care on specialised problems.
• Greater use of technology to enable patients to be maintained
/monitored in primary care.
North West Community Provider Alliance Clinical Pathway Workshop 2009 12
3.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Self care
management -
tele-health,
personalisation,
empowerment
Patients have
greater autonomy,
choice and
improved access.
This enables them
to stay well, at
home and gives
them reassurance
and increased
confidence, which
empowers them.
Therefore, they are
in control and
independent. This
would be a patient
led pathway which
enables choice and
involvement,
improvements in
waiting times and
is a timely
intervention, i.e.
choice of where
and when for the
patient.
This will reduce the need
for professional
interventions and need for
services. Produces a
healthier population who
have choice. Self
monitoring reduces
exacerbations, hence,
decreased GP
visits/admissions. A good
opportunity for looking at
new
developments/innovation
through re-investment with
a prevention and education
agenda.
Re-investment
opportunities across the
pathways which supports
a shift from illness to
wellness.
Patients in control of their
own health which reduces
the burden of Long Term
Conditions.
Financial benefit across
economy - with a return to
work.
Enhances Choice and the
self care agenda with a
consistent message and
approach to patients.
Individualised budgets.
Reduced burden of care.
Technology to be available
with the possibility of using
Expert Patients who can
and wish to self care. This
would reduce system
costs.
Condition specific
programmes.
Quality and Outcomes
Framework for Pathways
eg. COPD, so that
quality/data can be
collected for evidence.
Partnership working with
Voluntary sector e.g.
MIND.
Reliability of technology.
Patients - culture.
Financial investment.
Trust /confidence.
Programmes are
condition specific.
Knowledge of how to
access.
Engagement.
Safeguarding issues.
Capacity for services to
address real demand.
Today's business - what
about tomorrows -
double running.
Priorities.
North West Community Provider Alliance Clinical Pathway Workshop 2009 13
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Support and enable people to manage their own health.
• Invest in tele-health and tele-care to empower patients to take, maintain
and maximise their own health potential.
• Develop personalised care planning using joint or integrated
assessments.
• Use a ‘buddy system’ to support patients.
• Teach patients and carers to recognise the signs of deterioration/acute
exacerbation and how to take action.
• Provide staff with appropriate training. This may include non-medical
prescribing, advanced assessment, motivational interviewing or
cognitive behavioural therapy skills.
• Replace where appropriate visits with a telephone contact. This may be
useful to monitor a patient’s condition remotely.
• Offer choice through personalisation. Work with local authority to
support patients wishing to make use of ‘self directed budgets’.
Maximise the opportunity for patients to participate in the Expert Patient
Programme.
• Place individuals with LTC and /or their carers in charge,
enabling them to live well with their condition.
• Greater use of current technology to enable patients to access
their health records and test results remotely, for example,
kidney care: MySpace.
• Address the skills gap of health 'educators' for LTC within a
primary care setting.
• Consider the person's social, cultural and family circumstances
- not just clinical.
• Develop and apply the social care model for personalised
budgets and payments.
• Increased support for patients, their families and carers in
managing LTC, including from voluntary groups.
• A named patient advocate and care co-ordinator for all patients
with a LTC.
• Exploit the use of technology to maximum effect by providing
support to dedicated staff on how to introduce new technology
and how to measure its effectiveness.
North West Community Provider Alliance Clinical Pathway Workshop 2009 14
4.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Improve
transitional care
for children with
long term
conditions.
Improved quality of care
and reduced anxiety of
patients, carers and
professionals, which in
turn improves
independence.
Reduction in long term
complications with
increased life
expectancy/opportunities.
Long term cost
benefits which
address inequalities
and increase
reported mental
health and wellbeing.
Increased mortality
rates and reduced
admissions.
Invest to move
forward and
improve health.
Re-engineer
pathways as
patients have
improved
wellbeing and
chronic illness.
Open to new ideas/ways of
working -
Technology/communications and
transitional care can be caught
electronically.
Making the agenda personalised.
Specialist commissioning with
integrated care pathways.
Commissioning across adult and
children's services. Use of NSF
for Long Term Conditions to move
this forward.
Different models of care
for children/adults.
Episodic nature of adult
services /children's more
preventative/ maintaining.
Lack of knowledge in
adult services.
Paternalistic services.
Lack of flows on
neurological Long Term
Conditions
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Practitioners closest to patients to lead change themselves and realise their own high ambitions for the care that they provide.
• Provider Organisations to align high quality care to organisational vision and strategy.
• Commissioners to understand the constituents of high quality care and enable world class commissioning decisions to be made that are clinically led and focus on achievements.
• Strengthen partnership working across health and social care.
• Start discharge planning as soon as possible, make sure all practitioners are
• Place individuals with Long Term Conditions and /or
their carers in charge, enabling them to live well with
their condition.
• Greater use of current technology to enable patients to
access their health records and test results remotely,
for example, kidney care: MySpace.
• Address the skills gap of health 'educators' for Long
Term Conditions within a primary care setting.
North West Community Provider Alliance Clinical Pathway Workshop 2009 15
involved in this process, care is co-co-ordinated, and discharge summaries provided for all key services involved in the patients care.
• Addressing variability, working efficiently, demonstrating high levels of productivity and achievement of ambitions for quality.
• Support teams to develop creative approaches to service provision.
• Support and empower practitioners.
• Ensure that there are robust systems in place.
• Develop personalised care plans using joint care planning/integrated assessment and joined up multidisciplinary working along the care pathways.
• Intermediate care and rehabilitation services should form part of the Long Term Conditions
• Maximise the potential for modern targeted, community services to improve efficiency and effectiveness of the wider health and social care system. This may include joint health and social care team development. Extend the hours of service according to patients needs.
• Use case managers as key workers.
• Use technology as a virtual means of asking advice or a second opinion from a specialist, Allied Health Professional or GP.
• Use a 'buddy' system to support patients.
• Consider the person's social, cultural and family
circumstances - not just clinical.
• Develop and apply the social care model for
personalised budgets and payments.
• Increased support for patients, their families and carers
in managing Long Term Conditions, including from
voluntary groups.
• A named patient advocate and care co-ordinator for all
patients with an Long Term Conditions. Exploit the
use of technology to maximum effect by providing
support to dedicated staff on how to introduce new
technology and how to measure its effectiveness.
North West Community Provider Alliance Clinical Pathway Workshop 2009 16
5.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Improve
Primary Care
Improved primary care will
ultimately improve access for
patients and reduce the need
for Out Of Hours care.
Ultimately this will improve
quality of care and reduce
complications.
Enables care closer to home
giving patients seamless care,
continuity, good relationships
with their carers and
professionals.
Medicine Management is more
effective and efficient with a
choice for patients.
Reduced acute
admissions and
interventions.
Reduced need for
services.
Increased self care
and quality of life.
Reduction in
medication costs.
Opportunities for re-
investment -
illness/wellness with
increased evidence for
quality assurance.
Improved community
health and wellbeing.
Improved and better co-
ordinated working
relationships between
GPs/community services.
Use of shared IT
systems.
Improved effectiveness
and efficiency. i.e.
Choose and Book.
GPs/QOF.
Organisational
boundaries.
Relationships between
GPs/Community
Services.
Shared IT Systems.
Lack of
awareness/knowledge of
services available.
Referral criteria.
Access to services.
North West Community Provider Alliance Clinical Pathway Workshop 2009 17
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Know about local health needs and plan services accordingly.
• Work with Commissioners to agree outcome data that needs to be
collected to demonstrate effective intervention.
• Develop systems and processes, which encourage constant patient,
service user and carer feedback. Audit changes which have been
made as a result of feedback on user experience
• Create effective health and care partnerships.
• Implement new services approach - addressing viability, working
efficiently, demonstrating high levels of productivity and
achievement of ambitions for quality.
• Provide local health information about your services, access,
availability and choices for patients, the public and professionals.
• Provide clear information about OOH service provision to patients,
public and practitioners.
• Provide the right resource, in the right place, at the appropriate time
in accordance with need.
• For people with LTC or complex health care needs - provide a
personalised care plan and, where appropriate, use joint care
planning or integrated assessments such as the single assessment
process or CAF.
• Use technology to implement shared care planning.
• Further development of practice based registers to target screening
- developing appropriate pathways for preventing further
progression of disease.
• Commissioners (PCTs and Social Care) should jointly develop 'care
passports'.
• PCTs should maximise the defined role of pharmacists in self care
of long term conditions.
• The role of primary care should be strengthened and developed
with new skills and ways of working to deliver more personalised
care around patients.
North West Community Provider Alliance Clinical Pathway Workshop 2009 18
6.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Joint working
and integrated
access to care
pathway.
Joint working/single
assessment
process/planning means
that patients only have to
tell their story once which
reduces duplication.
Increased continuity and
co-ordination of care.
Joint working so there is
always a professional
knowledge base if unable
to communicate with
patients or other
colleagues.
Improved treatment and
outcomes.
Timely and efficient
service.
Improved efficiency of
care packages.
Improved quality and
outcomes.
Measurement of
outcomes and
benefits.
Improved
safeguarding.
Hits government
targets.
Agencies committed
to use of Single
Assessment Process.
Progressive way to make
systems lean - spend to
save.
Funding is linear and
therefore able to support
timely and efficient pathway
response to patients needs.
More patients cared
for/maintained in the
community.
Reduced demand for
hospital services.
Joint commissioning
arrangement for efficiency
and effectiveness and links
to Mental Health and
Physical Health agenda.
Promote local specialist
networks/peer support.
Peer support with
increased knowledge
base for sharing =
shared core skills.
Sharper focus at
interfaces between
services and agencies
through improved
collaboration which
breaks down 'silos'.
Location.
Co-location a benefit?
Healthcare
professionals to charge
for services?
Differences in NHS and
Social Care legislation.
Culture.
Protection of existing
roles.
North West Community Provider Alliance Clinical Pathway Workshop 2009 19
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Invest in telehealth and telecare to empower patients to take control of
their health needs, under the guidance and support of the case
manager.
• Develop personalised care plans using joint care planning/integrated
assessment and joint up multidisciplinary working along the care
pathway.
• Engage service users and carers as a means of offering choice and
personalisation. Include encouragement to participate in expert patient
programmes with personalised budgets.
• Intermediate care and rehabilitation services should form part of the
LTC.
• Work closely with the Mental Health teams to develop referral
pathways.
• Extend the hours of service according to patients needs.
• Use case managers as key workers.
• Use technology to implement shared care planning.
• Use technology as a virtual means of asking advice or a second
opinion from a specialist, AHP or GP.
• Use a 'buddy' system to support patients.
• Place individuals with LTC and /or their carers in charge,
enabling them to live well with their condition.
• Greater use of current technology to enable patients to access
their health records and test results remotely, for example, kidney
care: MySpace.
• Address the skills gap of health 'educators' for LTC within a
primary care setting.
• Commissioners (PCTs and Social Care) should jointly develop
'care passports'.
• Develop and apply the social care model for personalised
budgets and payments.
• Increased support for patients, their families and carers in
managing LTC, including from voluntary groups.
• A named patient advocate and care co-ordinator for all patients
with an LTC.
North West Community Provider Alliance Clinical Pathway Workshop 2009 20
7.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Intermediate
Care as a
philosophy
rather than
separate team
plus priority for
local systems
to implement.
Care does not
need to fit into a
‘box’, there
should be no
criteria for
exclusion.
Services to be
needs led, not
criteria driven.
Open access
across a range
of services.
Underpinned by
NSF which is
measurable.
Improves and
increases
accessibility with
equality of
access.
Patient
pathways should
include
intermediate
care as part of
package of care
rather than
separate care.
Links nicely to urgent care reform,
self-care, end of life care.
Links with mental and physical
health agenda.
Provides care closer to home.
Reduces hospital admissions.
Enables development of
the rehabilitation agenda
with increased clarity for
the efficient use of
resources.
Less specialism and more
joint working promoted.
Links to clinical/medical
support i.e. Geriatrician.
Cultural change.
North West Community Provider Alliance Clinical Pathway Workshop 2009 21
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Intermediate care and rehabilitation services should form part of the LTC pathway.
• Work closely with the Mental Health teams to develop referral pathways.
• Extend the hours of service according to patients needs.
• Use case managers as key workers.
• Use technology to implement shared care planning.
• Use technology as a virtual means of asking advice or a second opinion from a
specialist, AHP or GP.
• Use a 'buddy' system to support patients.
• Create effective health and care partnerships.
• Provide the right resource, in the right place, at the appropriate time in accordance with
need.
• For people with LTC or complex health care needs - provide a personalised care plan
and, where appropriate, use joint care planning or integrated assessments such as the
single assessment process or CAF.
• Invest in telehealth and telecare to empower patients to take control of their health
needs, under the guidance and support of the case manager.
• Develop personalised care plans using joint care planning/integrated assessments and
join up multidisciplinary working along the care pathway.
• A new model of care should be commissioned
that enables integration of health and social
care, with the roles of professionals changing to
meet patients' needs.
• There needs to be a clear description of what
primary care should be like to incorporate social
care, community care and specialists.
• A designated care co-ordinator will have
responsibility for ensuring that a plan is
developed and agreed.
• The role of primary care should be strengthened
and developed with new skills and ways of
working to deliver more personalised care
around patients.
North West Community Provider Alliance Clinical Pathway Workshop 2009 22
8.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners Benefits for System Reform
Enablers to Delivery
Barriers to Delivery
Improve staff
skills in
generalist and
expert roles
and develop
advanced
practitioners.
Right skills, in
the right place,
at the right time,
which ensures
minimum
intervention,
with maximum
quality and
effectiveness..
Less input but the same
productivity with a flexible
workforce.
Uses a flexible approach with one
person rather than numerous
professionals.
Commissioning pathways
increases efficiency and
effectiveness
Extended career
opportunities as
professionals
become multi-
skilled.
Uses modernised
training to gain
skilled
professionals.
Trans-disciplinary.
More modern
training is required
with defined roles to
reflect this. Most of
this can be work
based
learning/competency
based on KSF
Training not up-to-date.
Job descriptions/roles not fit for
purpose.
Staff confidence.
Professional bodies.
Culture.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Provide staff with appropriate training. This may include non-medical
prescribing, advanced assessment, motivational interviewing or cognitive
behavioural therapy skills.
• Entrepreneurial practitioners maximising opportunities and demonstrating the
ability to lead and develop effective and productive nurse and AHP services.
• Seeking out business opportunities to develop care closer to home initiatives.
• Display expert leadership skills ensuring that the attributes become embedded
within work. Display influencing skills and ability to implement change. Work
with commissioners, managers and others to redesign care pathways which
will address all the elements of LTC management.
• A review of the capacity and skills mix needed in primary
care to support LTC.
• A new model of care should be commissioned that
enables integration of health and social care, with the
roles of professionals changing to meet patients' needs.
There needs to be a clear description of what primary
care should be like to incorporate social care, community
care and specialists.
North West Community Provider Alliance Clinical Pathway Workshop 2009 23
END OF LIFE CARE
North West Community Provider Alliance Clinical Pathway Workshop 2009 24
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Standardised care
pathway for end of
life care to enable
equitable access,
regardless of
clinical diagnosis.
Standardisation of
care pathways
promotes equity,
quality, experience,
support, and
advanced care
planning.
Clinical Pathways
set out clearly
defined expectations
which promote
consistency.
Integrated Care
Pathway is well
evidenced.
Clinical pathways are
clearly commissioned as
an integrated and
complete service. They
are cost effective and
enable advanced
planning which supports
World Class
Commissioning.
Benchmarking of quality
and efficiency.
Care delivered closer to
home, which promotes
patient choice.
Develops Integrated
Care Pathways for
efficient service delivery.
The North West End of life
pathway is already in
place with some evidence
locally about using this to
meet local needs/map
service.
The pathway is well
evidenced. It promotes a
high profile of end of life
care nationally.
Some areas of the North
West already have
baseline measures of
available resources.
Ambiguity - where is
the patient on the
pathway?
Personalisation of care.
Change process for
staff groups – ie. move
from established roles
and functions,
competencies.
Getting partners to
agree to work
collaboratively.
Unknown resource
issues.
Gaps in knowledge/
gaps in service
provision.
North West Community Provider Alliance Clinical Pathway Workshop 2009 25
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Ensure early identification of patients and have sensitive conversations about death, dying, choice
and personalisation with patients, carers and families
• Ensure that care for those approaching end of life is accessible, responsive and available 24 hours
a day. All patients should have a case manager and documentation (where appropriate) on
advanced care wishes and preferences for care.
• Work in partnership with other practitioners to co-ordinate interventions at all stages of the
patient pathway. Ensure GPs, ambulance trusts, out-of-hours providers, specialist palliative
teams, district nursing teams, acute sector, hospices, care homes, social care and all other
practitioners who have a contribution help devise care plans and agree roles, responsibilities and
communication channels.
• Ensure that all providers who support end of life care within the home, and proactively work to
prevent admissions into an acute trust, work together to understand their role in clinical care and
prevention.
• Familiarise yourself with your SHA and PCT end of life care strategic plans which encompass
patients with all diagnoses, care provided in any setting by a collective of organisations and
providers, and covers each step of the end of life care pathway.
• Ensure that all end of life care teams make close linkage with continuing healthcare services so
that, where appropriate, packages of care can be set up effectively and efficiently with no time
delay for patients.
• Identify all local agencies and third sector organisations who provide end of life care provision and
support, including those offering emotional and bereavement support for children and adults.
Develop collaborative relationships to complement and co-ordinate care.
• Integrated pathways are a widely accepted model to improving standardisation, continuity /
collaboration among multi-disciplinary teams.
• The pathway should be underpinned
by strategic partnerships with co-
ordination across all organisations
and at operational level between
services delivered by hospitals,
PCTs, social care, ambulance
services and the voluntary sector to
provide seamless service.
• It is vital to have a robust, integrated
commissioning framework, based on
the North West end of life care
model across health, social care,
voluntary, charitable and
independent sectors, with strategic
leadership. This will ensure
consistency of approach,
personalised care and choice,
facilitating timely and appropriate
access to services for patients and
their families.
• A joint health and social care
commissioning framework should be
in place for the end of life care
services.
• A financial investment programme
should be identified to support the
delivery of the health and social care
commissioning strategy.
North West Community Provider Alliance Clinical Pathway Workshop 2009 26
2.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Ring fenced funding
with robust tiered
access to support
people in their last
days/weeks of life.
Ring fencing means the
money is available,
therefore there will not be
time delays to access this
service for patients.
There will be speedier
discharge home which
helps patients make the
right choice.
Ring fencing means that
organisation and forward
planning is easier, hence,
freeing up precious time
for care of patients.
Promotes fair access. An
example is Stoke on
Trent PCT - who ring
fenced their equipment
service.
Management of
costs are more
predictable.
Allows speedier
safe discharges -
which are relevant
to
economy/finance
as care at home
may be cheaper.
Avoids
acute/emergency
admission as care
is managed.
Time is freed up
through
management of
patients,
therefore, it is
better use of
resources - more
time to care and
not chase up
equipment etc.
Enables patients and
professionals to make
choices.
Rapid discharge
through pathways.
Admission avoidance.
Examples from other areas
can be replicated.
Predictable costs may be
attractive.
Preferred priorities for care (PPC) audit demonstrates where people have not had access to resources to enable their choice.
By definition, limited
resources.
Access criteria,
equity across other
client groups.
How much is
enough?
What are the right
criteria for access:
open to misuse?
North West Community Provider Alliance Clinical Pathway Workshop 2009 27
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Know about local health needs and plan services accordingly.
• Work with commissioners to agree the outcome data that needs to be collected for a specific service area to demonstrate effective intervention.
• Create effective and health and care partnerships.
• Implement new service approaches.
• Provide the right resources, in the right place, at the appropriate time in accordance with need Benefits realisation: demonstrate that the benefits envisaged are actually derived. Actions to create the change and the delivery of outcomes should be monitored through a plan to track the implementation and the service improvements.
• Advanced care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .
• A financial investment programme should be identified to support the delivery of the health and social care commissioning strategy.
• Protocols for continuing healthcare funding are consistently and equitably applied and accessible in a timely manner (fast tracked).
North West Community Provider Alliance Clinical Pathway Workshop 2009 28
3.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Access to
appropriate
knowledgeable
generalist care 24/7,
supported by
specialist
practitioners (Multi
Disciplinary Team) -
to include sitting
service respite for
carers.
Provides continuation
of care and increases
quality of life.
Patients and carers
have an improved
experience of
palliative care and
support. This relieves
burden and supports
positive grieving with
psychological support.
Preferred Priorities for
Care (PPC) gives
patients and carers
the confidence to stay
at home.
Crises are managed
more effectively.
Decreased pressure on
the system overall as it
is managing more
specialist care in the
community.
Decreased pressure on
bereavement services
as patients and carers
are supported at home.
Fewer emergency
admissions.
Enables speedier
discharge.
Promotes engagement
with charitable
agencies and other
partners.
Promotes reliable
community service
provision and increases
staff morale.
NICE promotes a more
positive end of life
strategy.
A change in working
practices is needed in
line with World Class
Commissioning,
NICE promotes a
more positive end of
life strategy.
Patients able to
exercise more choice.
Skill mix, of integrated
working and
professionals
supports patients and
carers better at home.
Admission avoidance
relieves pressure on
the whole system e.g.
hospices.
At the moment good practice is
available, but in pockets - this
can be replicated as the
infrastructure is already
commissioned. This just needs
strengthening and building.
This will provide a good
evidence base.
Reluctance of staff to
change.
Short term costs -
long term gains.
How to measure
success?
Guidelines support
development of
specialist roles but
these don't have
capacity to deliver - or
have the capacity to
build.
North West Community Provider Alliance Clinical Pathway Workshop 2009 29
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Use an established framework such as the gold standards framework or Liverpool care pathway to optimise care delivery.
• Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway. Make sure GPs, ambulance trusts, out-of-hours providers, specialist palliative teams, district nursing teams, acute sector, hospices, care homes, social care and all other practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels.
• Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients.
• Identify all local agencies and third sector organisations who can provide end of life care provision and support, including those offering emotional and bereavement support for children and adults. Develop collaborative relationships to complement ad co-ordinate care.
• Ensure that all providers who support end of life care within the home, and proactively work to prevent admissions into an acute trust, work together to understand their role in clinical care and prevention.
• Advance care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .
• Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61) .
• All GP practices have a supportive register in place for patients who are known to be in their last year of life.
• End of life services need to be comprehensive and available to all 24/7.
• A single point of access for individuals and their carers also needs to be put in place and would include access for carers and family during the bereavement phase, ensuring the provision of appropriate support.
• To ensure a comprehensive, co-ordinated and seamless approach, it is crucial that professionals and organisations work together so that when people need to use the service it is a 'one service' that is clear and easy to access.
North West Community Provider Alliance Clinical Pathway Workshop 2009 30
4.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Commission
clinical
leadership in
community
services in End
of Life care -
moving to drive,
quality, access,
innovation
Clinical leadership will
drive the service,
therefore, access/quality
of care systematically
improves. Innovations
are delivered, profile is
raised, infrastructure is
developed, leading to a
happier and more
productive workforce so
enabling increased
service delivery.
There are long
term gains plus
quick wins for
patients, with
increased quality
assurance.
As this is service driven then
access/quality of care
systematically improves.
Innovations are delivered,
profile is raised as
infrastructure is developed.
A happier and more
productive workforce will
increase service delivery.
Patients have long term
gains plus quick wins.
Quality assurance
Using evidence of good
practice gives existing
practitioners a good base to
deliver a robust and quality
service.
Expensive resource
undervalued by
commissioners.
Avoid commissioners
over-managing.
Is it for the provider to
deliver from whole
pathways costs?
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Support teams to develop creative approaches to service
provision, which will improve choice, personalisation, efficiency.
• Support and empower practitioners to develop multidisciplinary
teams using approaches such as transformational attributes
• Create effective health and care partnerships
• Use technology to support shared care, joint care planning.
• Joint working between specialist hospital care teams and
community services can be particularly beneficial.
• Commissioners and Providers work together to ensure that
where good evidence exists this is implemented within local
services.
• NHS North West should work closely with all services to determine and meet workforce requirements and to ensure education and training programmes are available for all health and social care staff (NICE,2004:13).
• The North West will work closely with all education providers including the hospices and third sector in particular to develop a more strategic approach to education and training for end of life care.
• Individual practitioners should ensure they have the knowledge and skills required for the roles they undertake within the spectrum of end of life care (NICE, 2004:14).
• All provider organisations should identify the end of life training needs of
staff and should facilitate their participation in training and ongoing
development.
North West Community Provider Alliance Clinical Pathway Workshop 2009 31
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Use of Primary Care
Local Enhanced
Service (LES) to
improve GP case
management in the
community
More people will die
at home, well
supported in the
community.
Provide a working
model of case
management. This
way of working
enables patient
and professional
choice and co-
ordination of care.
Work towards the
Gold standards
framework where
there is evidence of
GP change of
behaviour with QoF
incentive.
The use of
Preferred Priorities
for Care (PPC)
allow patients
wishes.
Better
communication in
multidisciplinary
team.
Outcomes are
commissioned which
decrease inpatient
costs.
This enables care closer
to home giving patient
choice. All services are
integrated.
There will be a financial
reward for GPs who are the
most likely people to have
awareness of client base.
Local Enhanced Service
(LES) is used positively
elsewhere as an enabler of
change.
Improving case
management will release
capacity in secondary care.
GP competencies in end
of life care.
GP compliance with
system and best practice
(culture).
Competing priorities for
GPs.
5.
North West Community Provider Alliance Clinical Pathway Workshop 2009 32
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Create effective health and care partnerships - strengthen partnership
working across health and social care.
• Implement new service approaches.
• Provide the right resource, in the right place, at the appropriate time in
accordance with need.
• Ensure that all patients who are approaching end of life are identified
early and sensitive conversations are had about death and dying, choice
and personalisation with patients, carers and families.
• Ensure that a local practice register is kept and available for all health
and social care practitioners involved in palliative and end of life care.
The register should hold information regarding advance care plans and
the do not attempt resuscitation (DNAR) status of the individual subject
to their consent.
• All GP practices have a supportive register in place for patients
who are known to be in their last year of life.
• End of life services need to be comprehensive and available to
all 24/7.
• A single point of access for individuals and their carers also
needs to be put in place and would include access for carers and
family during the bereavement phase, ensuring the provision of
appropriate support.
• To ensure a comprehensive, co-ordinated and seamless
approach, it is crucial that they work together across professions
and organisations so that when people need to use the service it
is a 'one service' that is clear and easy to access.
• Advanced care planning (ACP) and all three end of life tools are
used in all care settings (NICE,2004:11) .
• A financial investment programme should be identified to support
the delivery of the health and social care commissioning strategy.
North West Community Provider Alliance Clinical Pathway Workshop 2009 33
6.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery
Barriers to Delivery
Advanced care
planning - level 4
Gold Standards
Framework (GSF)
Integrated Care
Planning (ICP)
Preferred Priorities for
Care (PPC)
Advance planning will
help with medicine
management by
allowing anticipatory
prescribing.
Developing pro-active
care planning across
End of Life Care and
into bereavement
means that patients
and carers receive a
seamless service.
Quality care = improved
patient pathway, patient
choice with better care
experience, which
reduces inappropriate
admissions to hospital.
Advance planning
enables rapid
discharge.
By using advance
care planning there
will be increased
home deaths,
therefore, a 10%
reduction in
hospital deaths -
saving money in
the acute sector.
Prescribing costs
will be reduced as
they are managed
better = Value for
money.
Better, managed
care will achieve
quality markers -
increasing patient
and carer
experience
because of
reduced hospital
stays.
Care management will help
to streamlined services and
by using integrated services
duplication reduced.
By using three
tools, fully
implemented in all
care settings.
GSF - level 4 – in
all care settings.
Substantive End of
Life Care facilitator.
Extend principles
of End of Life Care
to all end of life
threatening
illnesses.
Use peer review -
against quality
markers.
Optional not compulsory.
Lack of
awareness/confidence.
Cost/ funding.
North West Community Provider Alliance Clinical Pathway Workshop 2009 34
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Implement new service approaches
• Provide a personalised care plan and, where appropriate, use joint care
planning or integrated assessments such as the single assessment
process or common assessment process (CAF).
• Provide patients and carers with a named key worker or case manager,
with a care plan, to ensure high quality, safe and effective continuity of
care.
• Use and develop evidence based practice and validated research to
improve clinical practice. Ensure that care for those approaching the end
of life is accessible, responsive and available twenty four hours a day.
• Offer all patients approaching the end of life the opportunity to express
their preferences and wishes for care, death and dying.
• Patients should have access to 24hr emergency medicines
• Care should be avail 24hrs a day to enable people to live and die at the
place of their choice.
• Advance care planning (ACP) and all three end of life tools are
used in all care settings (NICE,2004:11) .
• Where ACP is in place, it needs to be timely and regularly
reviewed (Henry C & Seymour 2007:61) .
• All GP practices have a supportive register in place for patients
who are known to be in their last year of life.
• End of life services need to be comprehensive and available to
all 24/7.
• A single point of access for individuals and their carers also
needs to be put in place and would include access for carers and
family during the bereavement phase, ensuring the provision of
appropriate support .
• To ensure a comprehensive, co-ordinated and seamless
approach, it is crucial that they work together across professions
and organisations so that when people need to use the service it
is a 'one service' that is clear and easy to access.
North West Community Provider Alliance Clinical Pathway Workshop 2009 35
7.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Education,
training including
communication
skills and non
malignancy care.
Improved care for
patients will be further
enhanced by up-to-
date training for all
staff.
This will increase
patient, carer and staff
confidence and help
staff deliver choice for
patients and carer,
therefore, more likely to
achieve Preferred
Priorities for Care
(PPC)
Achieves better patient
and carer experience
There is likely to be a
reduction in
complaints/clinical
incidents as there are
the right skills in
teams
It is cost effective
Improved quality of
end of life care
Recruitment and
retention will be
improved as training is
part of their job
description, hence,
better and more
rewarding job
satisfaction and
productivity
Enables succession
planning where staff are
aware of service
development
There needs to be an
established, robust
education and training
strategy to develop the
provider workforce and
strategic development
plans.
Key worker scheme and
development.
Seen solely as a nursing
responsibility.
Education takes away
from face to face contact.
Costly/staff not released.
Difficult to sustain in care
homes (staff turn-over)
North West Community Provider Alliance Clinical Pathway Workshop 2009 36
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Commissioner and provider management teams must be responsible for developing a competent workforce that will deliver sufficient current and future services safely, effectively and which have a positive impact on service user experience.
• Practitioners and clinical teams need to review best practice and prioritise development plans for service delivery
• Provide access to robust training and education, clinical supervision and improved clinical leadership, managerial and business skills to improve health outcomes
• Use and develop evidence based practice and validated research to improve clinical practice
• Ensure practitioners are trained in assessment and care planning, symptom management and advance care planning relating to end of life
• NHS North West should work closely with all services to determine and
meet workforce requirements and to ensure education and training
programmes are available for all health and social care staff
(NICE,2004:13).
• The North West will work closely with all education providers including the
hospices and third sector in particular to develop a more strategic approach
to education and training for end of life care.
• Individual practitioners should ensure they have the knowledge and skills
required for the roles they undertake within the spectrum of end of life care
(NICE, 2004:14).
• All provider organisations should identify the end of life training needs of
staff and should facilitate their participation in training and ongoing
development.
• The development of competencies for end of life care, particularly
communication skills, are identified and used to inform learning and
practice.
North West Community Provider Alliance Clinical Pathway Workshop 2009 37
8.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Access to 24hr
Specialist Palliative
Care ( SPC) advice
including 7 day face to
face core hours
contact 9-5
Improved access helps
to keep patients at home
with better pain and
symptom control,
therefore achieving
Preferred Priorities for
Care (PPC).
Patients and carers
have increased
confidence in their end
of life team.
Reduction in
complaints/critical
incidents.
Reduction in
prescribing costs.
Improves patient and
carers experience.
Reduction in length of
stay
Increased support for
generalist staff.
Opportunity for system
reform and service re-
design through
collaboration between
provider partners.
Review existing team and
skill mix.
HR and staff side
engagement.
Commissioning intent.
Robust partnerships.
Single point of
access.Information on
services (in SPC Packs)
Funding,
Fragmented
approach.
Patient and carers
not accessing
services.
Reduced core
service.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Use an established framework such as the Gold Standards Framework.
• Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway.
• Make sure all practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels
• Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients
• Develop collaborative relationship with all local agencies and third sector
organisations who can provide end of life care provision and support.
• Advance care planning (ACP) and all three end of life tools are used in all care settings.
• Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61).
• All GP practices have a supportive register in place for patients known to be in their last year of .
• End of life services need to be comprehensive and available to all 24/7.
• A single point of access for individuals and their carers
needs to be put in place.
North West Community Provider Alliance Clinical Pathway Workshop 2009 38
9.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Rapid Response
type services
(24 hr)
Increases
patient choice
with reduced
hospital
admission at
end of life.
Rapid response
also supports
carers
Rapid response
type service can
contribute to
10% reduction in
hospital death
and also
improves patient
and carer
experience.
Opportunity
for integrated
service
delivery
Encourages partnership working across pathway
with engagement from commissioners. Helps to
develop robust contracts, equipment etc with
other providers. Procurement is across
partnerships.
Define and develop robust service model and
service spec to develop quicker response times.
Supports the provider/commissioner
relationship.
Commissioner awareness of
what provider services can
deliver. No clarity around
definition of rapid response for
End of Life Care.
Workforce resource issues
Funding. Public expectations.
Media message re: Macmillan
Marie Curie
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Provide local information about your services: the access, availability, choices, for patients, the public and
professionals.
• Check against the experience of those using your services to ensure understanding. Provide the right resources,
in the right place, at the appropriate time in accordance with need. Ensure that all providers who support end of
life care within the home, and proactively work to prevent admissions into an acute trust, work together to
understand their role in clinical care and prevention.
• Implement new services approaches and expand end of life care. This should include developing end of life
services for patients with long term conditions and older people with co-morbidities. This should also include
supporting the delivery of services in settings such as care homes, hostels and prisons.
• Care should be available 24hrs a day to enable people to live and die at the place of their choice, this may also
include partnership working, joint systems planning with those who already provide a 24hr service e.g. ambulance
services, Out of Hours.
The pathway should be
underpinned by strategic
partnerships with co-ordination
across all organisations and at
operational level between
services delivered by hospitals,
PCTs, social care, ambulance
services and the voluntary
sector to provide seamless
service (DH,2006.)
North West Community Provider Alliance Clinical Pathway Workshop 2009 39
URGENT CARE
North West Community Provider Alliance Clinical Pathway Workshop 2009 40
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Rapid Clinical
Assessment
and treatment
in the
community.
Patient Based/Centric
Patients prioritised
Reduced cross Infection
Increased Rehabilitation
Reduced Health Inequalities
Improved Medicines
Management
Reduced hospital admission
Care close/in the home
Holistic/ seamless service
Joined up/signposting
One person assessing
coordinating
Rapid assessment of
clinical/social need
Reduced Waiting time
Increased Carer/family benefits
Value for money –
quality outcomes.
Reduced Health
inequalities.
Reduced hospital
admission.
Improved Medicines
Management
Population focused
Workforce
development and
transformation.
Integrated health and
social care.
Improved quality and
outcomes
Innovative use of
technology
Transformed
community function
Appropriate avoidance
of hospital admissions
Business principles
applied by community
services.
Integrated health and social
care
Access to diagnostics
Common IT System
Integrated Budgets
Integrated Governance
Single point of access
Marketing
Resistance to
change
Clinical Ownership
Lack of care
pathways
IT not fit for purpose
Nobody owns the
patient
Community
infrastructure
Lack of engagement
of GP’s and primary
care.
North West Community Provider Alliance Clinical Pathway Workshop 2009 41
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Rapid Clinical Assessment/ admissions avoidance
• Identify common reasons for hospital admission or attendance.
• Work in partnership with other organisations to provide creative solutions to joined up care. Identify new
service solutions to hospital admission or attendance such as community matron facilitated discharge or
nurse practitioner triage in A & E. More complex wound care provided in a community setting aligned to the
dermatology care pathway, all clinicians must be skilled and competent in providing high quality, safe and
competent wound care
• Use technology as a virtual means of getting specialist advice or a second opinion from a specialist nurse,
allied health professional, GP or consultant.
• Deliver new and innovative services in the community such as drug therapies or outpatient services
Ensure that community teams and matrons make close linkage with continuing healthcare services so that,
where appropriate, packages of care can be set up effectively and efficiently with no time delay or hospital
wait for patients.
Implement 'new service approach' - Services have to be seen to be cost effective and deliver the right care, in
the right place, at the right time. Community staff should be knowledgeable about the cost benefit involved in
hospital admission tariffs and facilitated discharge. This should be balanced against the cost benefit of
developing new services in the community
• Identify solutions to unplanned hospital admissions and attendance at A & E. Community matron facilitated
discharge, nurse practitioners and occupational therapists in A & E
• Be clear about the access points for service: a single point of access, triage or referral system
• Work with primary care, the out-of-hours provider, adult services, ambulance trust and the acute sector to
develop shared care records. This will ensure the most vulnerable, or those at risk of health deterioration are
known to all services along the clinical care pathway.
• Develop three multi-
professional, clinical urgent
care networks in the North
West, which will be
responsible for driving the
implementation of change,
auditing the effectiveness of
change through clinical
outcomes and horizon
scanning for innovation.
• Regionally, commission the
five levels of care
recommended by the
College of Emergency
Medicine.
• Shared IT between care
providers must be
implemented as a priority.
• Develop an inter-
professional workforce with
a culture of joint teaching
and learning.
• Mental health, alcohol and
drug services and social
care to be fully integrated
into urgent care response.
North West Community Provider Alliance Clinical Pathway Workshop 2009 42
2.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
7 Day Working
Continuity of care
Reduced Admissions
Increased speed of discharge
Access to equipment
Timely care
General Benefits to patients
Reduced cross infection.
Care close/in the home
Holistic/ seamless service
joined up/signposting
One person assessing
coordinating – ACM
Rapid assessment –
clinical/social need
Reduced Waiting time
Increased rehabilitation
Increased Carer/family
benefits
Continuity of care
Reduced
Admissions
Increased
discharge
Access to
equipment
Timely care
Population focused
Workforce
development and
transformation
Value for money
Integrated health
and social care
Improved quality
and better
outcomes
Innovative
Community services
applying business
principles
Use of technology
Funding/resources
Appropriate clinical priority
Flexible workforce
Staff Side
Agenda for change
Change fatigue
Integrated working with other
organisations
Equipment users
North West Community Provider Alliance Clinical Pathway Workshop 2009 43
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Extend the hours of service according to patient need. This may
include telephone access for on-call and out-of-hours home visits
making the best use of in-house provision or co-ordinating this through
partnership working with the ambulance trust and out-of-hours
provider.
• Be clear about the access points for service. This may mean
developing a single point of access, triage or referral system.
• Work with primary care, the out-of-hours provider, adult services,
ambulance trust and the acute sector to develop shared care records.
• Use technology to expand access to diagnostics and to seek advice.
This may include access to PACS (digital imaging x-ray) in the
community. This may also include the development of liaison and care
planning systems so that the ambulance trust can admit appropriate
patients direct to community services.
• Use technology as a virtual means of asking for advice or a second
opinion from a specialist nurse, allied health professional, GP or
consultant.
• Replace visits, where appropriate, with a telephone or videophone
contact - (monitoring acute illness or LTC).
• Use technology to empower patients to monitor their own condition.
• Use technology as a form of documentation i.e. remote access
devices - palm tops, tablets which can be synchronised easily with IT
systems avoiding unnecessary travel or time wastage.
• Any required service configuration will be evidence based, follow
audit of patient outcomes and take account of the geography of our
region to ensure best outcomes for the public wherever they live.
• Develop and support the regional clinical network, working with
commissioners to develop and maintain high quality service
delivery.
• Standardisation of out of hours service delivery and access to acute
care and diagnostic services across the North West.
• The national number should allow a locally integrated telephone
access and triage system and facilitate the development of
integrated urgent care and community service access
people get the right treatment in the appropriate setting is the
provision of integrated urgent care services, available if required 24
hours a day, seven days a week (24/7) .
North West Community Provider Alliance Clinical Pathway Workshop 2009 44
3.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Assisted
Technology
Continuous, automatic and remote
monitoring of real time emergencies and
lifestyle changes
Reduced unnecessary hospital admission,
and visits by GP, Community
Matron/Active Case Manager, District
Nurse
Increase patient independence - patients
can take control of their condition
Reduced cross infection
Care close/in the home
Holistic/seamless service joined
up/signposting
One person assessing coordinating
Rapid assessment – clinical/social need
Reduced Waiting time
Increased rehabilitation
Increased Carer/family benefits
Value for money
Population
focused
Reduction in
health
inequalities
Workforce
redesign
Integrated health and
social care
Improved quality and
outcomes
Innovative use of
technology
Transformed community
services more business
minded
Funding the system
changes
Training for staff
Systems monitored by
the company and
maintained
Audit effectiveness
Fear of technology
taking over clinical
roles
Patient fear/resistance
choosing the right
company to provide
cost effective support
and training
Lack of funding
North West Community Provider Alliance Clinical Pathway Workshop 2009 45
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Make sure services have the right skills in the right place to treat
patients safely and competently. Train staff to recognise, assess,
diagnose and treat those who unexpectedly fall ill and require care.
Practitioners may have to have advanced level knowledge, including
physical assessment and non-medical prescribing.
• Develop new roles such as the assistant practitioner role of foundation
degree practitioner at NVQ 4 level, working in partnership with other
organisations to integrate roles.
• Use technology to expand access to diagnostics and to seek advice.
This may include access to PACS (digital imaging x-ray) in the
community. This may also include the development of liaison and care
planning systems so that the ambulance trust can admit appropriate
patients direct to community services. Use technology to expand
access to diagnostics and seek advice.
• Use technology as a virtual means of asking for advice or a second
opinion from a specialist nurse, allied health professional, GP or
consultant .
• Replace visits, where appropriate, with a telephone or videophone
contact - (monitoring acute illness or LTC).
• Use technology to empower patients to monitor their own condition,
e.g. telehealth.
• Use technology as a form of documentation i.e. remote access
devices - palm tops, tablets which can be synchronised easily with IT
systems avoiding unnecessary travel or time wastage.
• Review the role of telemedicine for CT scan interpretation and
trauma resuscitation review, given the geographical constraints of
distance and access in parts of the region.
• The national number should allow a locally integrated telephone
access and triage system and facilitate the development of
integrated urgent care and community service access.
• Shared IT between care providers must be implemented as a
priority.
North West Community Provider Alliance Clinical Pathway Workshop 2009 46
4.
Top 3-5 Improvements
Benefits for patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
IV Therapy
Holistic/Seamless Care
Less disruption and care closer to
home
Value for money
General Benefits to patients
Reduced cross infection
Care close/in the home
Holistic/seamless service
One person assessing coordinating
– Active Case Manager
Rapid assessment – clinical/social
need
Reduced Waiting time
Increased rehabilitation
Increased Carer/family benefits
Value for money
Population
focused
Reduction in
health inequalities
Workforce
Integrated
health and social
care
Improved quality
and outcomes
Innovative use of
technology
Transformed
community
services more
business minded
Skilled workforce
Resources
Marketing
24/7 Workforce
Secondary care `buy in’
Clear clinical pathway
Lack of commissioning
Lack of engagement from GP’s
Lack of resources
Lack of buy in/engagement by
secondary care
Public Perception
North West Community Provider Alliance Clinical Pathway Workshop 2009 47
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Make sure services have the right skills in the right place to treat
patients safely and competently.
• Train staff to recognise, assess, diagnose and treat those who
unexpectedly fall ill and require care.
• Practitioners may have to have advanced level knowledge, including
physical assessment and non-medical prescribing.
• Develop new roles such as the assistant practitioner role of foundation
degree practitioner at NVQ 4 level, working in partnership with other
organisations to integrate roles. This will require commissioning
changes in education pathways
• Develop three multi-professional, clinical urgent care networks in
the North West, which will be responsible for driving the
implementation of change, auditing the effectiveness of change
through clinical outcomes and horizon scanning for innovation.
• Regionally, commission a piece of work together to further refine
the five levels of care recommended by the College of
Emergency Medicine.
• Develop an inter-professional workforce with a culture of joint
teaching and learning.
• Shared IT between care providers must be implemented as a
priority.
North West Community Provider Alliance Clinical Pathway Workshop 2009 48
5
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Integration of
social services and
health care
services
Agencies working in
partnership to promote
health
Patients needs prioritised
and quicker response
promotes improved high
quality service
Reduced depression,
anxiety which causes
distress in Long Term
Conditions which has major
impact on health as causes
distress and deterioration of
physical health and
increase in hospital
admission and mortality
rates
Continuous, automatic and
remote monitoring of real
time emergencies and
lifestyle changes over time
in order to manage the risks
associated with
independent living
Reduction in unnecessary
hospital admission; improve
care home standards
Continuity of care
Working in partnership with
Agencies working in
partnership to promote
health
Patients needs prioritised
and quicker response
promotes improved high
quality service
Reduce depression
anxiety which causes
distress in Long Term
Conditions which has
major impact on health as
causes distress and
deterioration of physical
health and increase in
hospital admission and
mortality rates
Continuous, automatic
and remote monitoring of
real time emergencies
and lifestyle changes
over time in order to
manage the risks
associated with
independent living
Reduction in
unnecessary hospital
admission; improve care
home standards
Integrated health
& social care
Quality and
better outcomes
Innovative
Community
services
applying
business
principles
Use of
technology
Combining social and
healthcare budgets
Employing
social/health workers
in social or health
teams
Common IT systems
Use of Hospital
Anxiety and
Depression measures
Develop clinical
pathway for Advanced
Practitioners or
specialist nurses to
refer to mental health
services
Improve Single
Assessment Point
Funding
System in place to
identify the right
patients
GP Support
Use of available
evidence base
Resistance to change Services being protective of their role Poor referral system at present. SAP documentation not appropriate Fear of technology taking over clinical role. Patient resistance choosing the right company to provide support and training ‘possible’ Lack of funding Lack of training Lack of GP Support
North West Community Provider Alliance Clinical Pathway Workshop 2009 49
GP, care home staff,
families and the patient and
other agencies.
Reduced cross infection
Care close/in the home
Holistic/ seamless service
joined up/signposting
One person assessing
coordinating
Rapid assessment –
clinical/social need
Reduced Waiting time
Increased rehabilitation
Continuity of care
Working in partnership
with GP, care home
staff, families and the
patient and other
agencies
Value for money
Population focused
Reduced health
inequalities
Workforce development
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Work in partnership with other organisations to provide creative
solutions to joined up care.
• Extend the hours of service according to patient need. This may
include telephone access for on-call and out-of-hours home visits
making the best use of in-house provision or co-ordinating this through
partnership working.
• Work with primary care, the out-of-hours provider, adult services,
ambulance trust and the acute sector to develop shared care records.
This will ensure the most vulnerable, or those at risk of health
deterioration are known to all services along the clinical care pathway.
• Use technology as a virtual means of asking for advice/second opinion
from a specialist nurse, allied health professional, GP or consultant .
• PCTs should commission intermediate care that is needs led, not
restricted by age.
• Nationally, social and healthcare should be funded as a single
service line. Shared IT between care providers must be
implemented as a priority.
• Develop an inter-professional workforce with a culture of joint
teaching and learning
• Urgent care services should be integrated and barriers between
primary, secondary and social care should be removed. The key
to ensuring that people get the right treatment in the appropriate
setting is the provision of integrated urgent care services,
available if required 24 hours a day, seven days a week.
North West Community Provider Alliance Clinical Pathway Workshop 2009 50
PLANNED CARE
North West Community Provider Alliance Clinical Pathway Workshop 2009 51
1. Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers To Delivery
Barriers to Delivery
Single point of
access
Single Point of Access
means less confusion
for patients as it
simplifies the patient
journey. This means
that patients are seeing
the right person, in the
right place, at the
appropriate time.
Patients gain good pain
management
Commissioners know what
they are paying for as they
have access to the right
Business Intelligence
There are benefits for providers i.e.
they can forecast demand and make
arrangements to manage this. This
helps to avoid bottlenecks into the
system and supports the
development of standardised
measures of quality and the
capturing and use of patient
experience.
Modern IT drives
efficiencies and so
becoming more
effective.
Modern staff training
enables professionals to
give a more efficient and
effective service to
patients
IT Culture Organisational boundaries
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Build and develop multidisciplinary and interagency teams to
deliver person centred rehabilitation.
• Invest in services that maximise a return to work.
• Use evidence based care pathways as a tool to provide shared
vision.
• Ensure that care is provided by a provider best able to meet the needs of
the patient, and deliver high quality evidence based care which is valued by
the public.
• Care should be provided by the provider best able to meet the needs of the
patient irrespective of whether they are an NHS organisation, as long as
NHS values are maintained.
North West Community Provider Alliance Clinical Pathway Workshop 2009 52
2.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Integrated IT
systems that
`talk’ to each
other and
enable rapid
communication
and the use of
real time
information.
Supports single assessment process and
promotes patient choice.
Reduces duplication and improves access for
patients. Patients understand the process which
in turn reduces complaints.
Healthcare records are updated and supported,
therefore, the most current information is
available.
Reduces waiting times.
Business
Intelligence is up-
to-date.
Change in
behaviour
and culture
for a
modernised
workforce.
Able to target finance to
ensure care in the right
place and at the right
time.
Modernised staff training.
IT support for data
sharing.
Costs.
National agreements.
Sharing information
across organisations.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Use assistive technology including telecare to optimise
health and wellbeing including maintenance.
• Use technology such as telehealth to enable and empower
people to monitor their own conditions.
• Use regular telephone support/video linkage as part of the
rehabilitation programme
• Shared IT between care providers must be implemented as a priority
North West Community Provider Alliance Clinical Pathway Workshop 2009 53
3.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Increased business acumen/ business relationships by community services
This approach
offers value for
money to
taxpayers and
provides
efficient &
accessible
services. There
are more
opportunities to
be involved.
By using
Business Models
other providers
can be brought
into the market
place.
Using the World Class
Commissioning guidelines to
identify and incentivise
outcomes.
Increased collaboration between
providers for effective pathway
delivery.
Transforming Community
Services - providing services in
a community setting in line with
Department of Health Policy
using the market place to
tender for and obtain the best
services possible. This will
involve competition from other
providers and opportunities for
collaboration.
Challenges of Transforming
Community Services.
NHS Culture.
Economic climate.
Change of Government.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Maximise opportunities and demonstrating the ability to lead and further develop
effective productive services which promote self-referral wherever appropriate
and multidisciplinary ordering of investigations and onward referrals.
• Seeking out business opportunities to develop new ways of delivering
rehabilitation services either with existing providers or through new service
development. This may include thinking about social enterprise or integrated care
organisations.
• Developing positive risk opportunities when delivering rehabilitation.
• Understand the business process, impact of the economic downturn and
productivity /efficiency measures and how to put together a business case which
can evidence value for money whilst ensuring high quality care and patient
safety.
• Deliver Advancing Quality programme to ensure that the
payment mechanism rewards the delivery of quality
outcomes including the patient's experience of the health
service.
North West Community Provider Alliance Clinical Pathway Workshop 2009 54
STAYING HEALTHY
North West Community Provider Alliance Clinical Pathway Workshop 2009 55
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers To Delivery
Barriers to Delivery
Proactive
Health Care
Screening for
vulnerable
groups,
learning
disabilities and
older people.
This is
everyone's
responsibility.
Staying healthy
for longer
increases health
and well being
(physical &
mental). This in
turn increases
economic
independence,
therefore,
reduces ill health
payments by the
government.
Patients gain
knowledge,
empowerment,
confidence
which increases
their choice of
services as they
are able to
navigate around
the NHS system
Earlier
intervention to
prevent
specialised
service
requirements i.e.
long term
conditions.
Reduced hospital
admissions.
Creates
independence.
Maximises the
input of current
services.
Focus on health care screening in
community services decreases demand
for acute care and increases enablement
of self care. It also enhances the skills
knowledge of community staff to deliver
inclusive, comprehensive services.
Productivity/ capacity gains in the
community from co-location and
coordination which enables innovation in
the long term which could reverse the
increase in lifestyle related illness reliant
on professional care. Increases co-
ordination of services which reduces
duplication and inappropriate referrals
and multiple staff visits. This also
reduces DNA's and increases
safeguarding of vulnerable adults.
Supports common data sets, quality
indicators, and measured improved
health outcomes through the effective
commissioning of health and well being
services. This is part of tiered/stratified
services targeting vulnerable groups who
may be excluded or not available from
the current services.
Develop the evidence of
needs through partnership
working through the
political/cultural/will/policy
context. It should focus on
inequalities.
Training for the workforce will
increase system capacity
and capability for prevention.
Focusing on value for money
makes radical change
possible.
Through demonstrator sites
contestability can be tested.
Professionals can work with
patients to re-design
services.
Greater use of technology.
Commissioners will
have to decommission
secondary services to
invest in pro-active
care.
Professionals may
protect their own
service area and not
engage fully.
Balance between
quality & value for
money.
Shared insight vs buy
in.
Clinical pathway
design, people do not
follow single pathways
neither do services.
Productivity vs
personalised services
North West Community Provider Alliance Clinical Pathway Workshop 2009 56
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Change is inevitable. There is more in common between services than
Embraces a philosophy that health, wellbeing and reducing
inequalities is every practitioner’s role.
• Know the range of intervention which promote positive behaviour
Extend their impact of health outcomes through joint working with local
partners.
• All practitioners can maximise their role in promoting health and
wellbeing.
• Make good use of ‘teachable’ moments.
• Educate teams in accessing and understanding information, initiating
an d managing difficult conversations and delivery of health messages
in ways that are culturally appropriate.
• Services are planned and delivered in ways that actively seek to
reduce health inequalities.
• Provide the right resources at the appropriate time in the right place in
accordance with need. Overnight/ weekend care/24 hr care. May
mean working with other partners to ensure that systems are in place
to access care. This may include capacity management systems,
access points, and telephone triage.
• Partners should include the out of hours provider and Ambulance
Trusts.
____________________________
North West Community Provider Alliance Clinical Pathway Workshop 2009 57
2.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Coordination/ co-location of wellbeing services/ lifestyle advice (sensitive/ responsive to vulnerable groups) including links to acute care and mental health to enable opportunistic advice.
Increased expectation of own health (breaking negative cycles in communities and families). Experience of co-ordinated care. Easy access to services which are responsive to vulnerable groups. Holistic/ responding to your health needs which are person centred.
Increase in the
uptake of
services.
Improved
outcomes.
Increased
uptake from
vulnerable
groups,
therefore,
reducing health
inequalities.
Efficiency and
productivity
gains.
Opportunity to
innovate across
services.
Focus on health care screening in community services, therefore, decreases acute care and increases enablement of self care. It also enhances the skills knowledge of community staff to deliver inclusive, comprehensive services. Productivity/capacity gains in the community from co-location coordination which enables innovation in the long term which could reverse the increase in lifestyle related illness reliant on professional care. Increases co-ordination of services which reduces duplication and inappropriate referrals = multiple staff visits, This also reduces DNA's and increases safeguarding of vulnerable adults. Supports common data sets, quality indicators, and measured improved health outcomes through the effective commissioning of health and well being services. This is part of tiered/stratified services targeting vulnerable groups who may be excluded or not available from the current services
Develop the evidence of
needs through partnership
working through the
political/cultural/will/policy
context. It should focus on
inequalities.
Training for the workforce will
increase system capacity
and capability for prevention.
Focusing on value for money
makes radical change
possible.
Through demonstrator sites
contestability can be tested.
Professionals can work with
patients to re-design
services.
Greater use of technology.
Commissioners will have
to decommission
secondary services to
invest in pro-active care.
Professionals may protect
their own service area and
not engage fully.
Balance between quality &
value for money.
Shared insight vs buy in.
Clinical pathway design,
people do not follow single
pathways neither do
services.
Productivity vs
personalised services
North West Community Provider Alliance Clinical Pathway Workshop 2009 58
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Embrace philosophy that ‘promoting health and wellbeing and
reducing inequality’ is every practitioners role.
• Provide a personalised care plan, and where appropriate, use joint
care planning or integrated assessments such as the single
assessment process.
• Provide patients and carers with a named key worker or case
manager to ensure high quality, safe and effective continuity of care.
• Ensure that you are familiar with your PCT’s local carers strategy,
providing all carers with a holistic assessment in their own right and
giving appropriate information, support and advise for them to remain
healthy and within their own home.
• Commissioners and provider management teams must be responsible
for developing a competent workforce that will deliver current and
future services safely, effectively and which have a positive impact on
service user experience.
• Practitioners and clinical teams need to review best practice and
prioritise development plans for service delivery.
• Provide access to robust training and education, clinical supervision
and improved clinical leadership, managerial and business skills to
improve health outcomes.
• Work with Care Services Improvement Partnership to ensure that all
relevant partners develop their workforces to deliver health
improvements and reduce health inequalities.
• Identify and increase preventative health spend in PCTs, ensuring
that health improvement activity is commissioned as part of service
level agreements and new prevention services are developed and
delivered by a range of providers.
• Work with the North West Regional Development Agency to support
the development of workforce capacity and capability to deliver the
Staying Healthy agenda through sustainable public sector
procurement and the Good Corporate Citizen Group.
• Develop a new regional, cross sector system that offers regional
funding streams, stronger regional accountability frameworks and
more space for local services to be tailored to individual need.
North West Community Provider Alliance Clinical Pathway Workshop 2009 59
3.
Top 3-5 Improvements
Benefits for Patients
Benefits fo Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Awareness
training to
respond to the
needs of
vulnerable
people. (Linked
to no 1.)
All health
professionals
trained to be
responsive to
the patients
health needs.
Increased
flexibility of how
services/advice
is provided.
Consistent
advice/support.
Essential
enabler to
realise the
benefits of 1 & 2.
Increased
quality of care.
Patient safety
benefits and
reduces risk of
complaints and
adverse
incidents
(reputation of
commissioners).
Focus on community services,
therefore, decreases acute care and
increases enablement.
Tiered services targeting vulnerable
groups who may be excluded or not
available from the current services.
Enhances the skills knowledge of
community staff to deliver inclusive,
comprehensive services.
Productivity/capacity gains in the
community from co-location and
coordination which enable innovation in
the long term which could reverse the
increase in lifestyle related
illness/reliance on professional care.
Increased co-ordination which reduces
duplication/inappropriate referrals -
multiple staff visits, DNA's.
Improved safeguarding.
Supports common data sets, quality
indicators. Measured/improved health
outcomes through the effective
commissioning of health and well being
services.
Develop the evidence
of needs through
partnership working
through the
political/cultural/will/p
olicy context. It should
focus on inequalities.
Training for the
workforce will
increase system
capacity and
capability for
prevention.
Focusing on value for
money makes radical
change possible.
Through
demonstrator sites
contestability can be
tested.
Professionals can
work with patients to
re-design services.
Commissioners will have to
decommission secondary
services to invest in pro-active
care.
Professionals may protect their
own service area and not
engage fully.
Balance between quality & value
for money.
Shared insight vs buy in.
Clinical pathway design, people
do not follow single pathways
neither do services.
Productivity vs personalised
services.
North West Community Provider Alliance Clinical Pathway Workshop 2009 60
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Make full use of ‘teachable’ moments – opportunities to tackle lifestyle
factors when people are receptive.
• Explore opportunities for joint working with local services that promote
health and wellbeing to maximise the health impact, for example
working with health trainers and health and wellbeing partnerships i.e.
local councils.
• Agree joint goals with local partners and monitor whether they are
being achieved and the impact. This should include how, together, you
are impacting on local health inequalities.
• Make best use of service users: using this resource in the promotion
of health, wellbeing and reducing health inequalities. Use programmes
such as peer education, peer-led services, buddying and mentoring.
________________________________
North West Community Provider Alliance Clinical Pathway Workshop 2009 61
Health Improvement
HEALTH IMPROVEMENT
North West Community Provider Alliance Clinical Pathway Workshop 2009 62
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Whole systems
IT approach
No duplication, saving time and money. Easier to track patient pathways (cradle to grave). Easier to identify patient health problems. Easier to identify patients health improvement needs. Smoother integration into mainstream services
No duplication -
saving time and
money. Robust
collection of data
information.
Easier to track
patient pathways
(cradle to grave).
Smoother
integration.
No duplication. Saving
time and money.
Robust collection of
data information.
Easier to track
patients pathways
(cradle to grave).
Easier to identify
patient's health
improvement needs
Funding.
Communication.
Multi-agency working.
Agreement of core data set.
Dedicated IT resources.
Staff training.
Change in culture -
'information sharing'.
Funding.
Timescales to implementation.
Reluctance to change - 'stuck in
the mud'.
Silo working.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
_____________
______________
North West Community Provider Alliance Clinical Pathway Workshop 2009 63
2.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery
Barriers to Delivery
Health Improvement to underpin every community/ acute pathway
Reduces health
inequalities.
Long term
health benefits.
Helps to
reduce Long
Term
Conditions.
Keeps patients
on a health
improvement
programme
even when
they are on a
different
pathway.
Reduces acute
admissions.
Reduces
morbidity.
Improved
quality of life
Reduces
inequalities.
Tracks patients
and money
through
pathways.
Reduces acute
admissions,
therefore, long
term financial
savings. Data
analysis of local
population
morbidity etc.
Financial benefits
as people are
included in
pathways and are
kept healthy for
longer, therefore,
reducing acute
incidents.
New culture of delivering
Health Improvement through
whole pathway system.
Reduces cost of Long Term
Conditions and acute
admissions.
Training for all health care
professionals in health
improvement and health
promotion.
Workforce development.
'Buy in’ of clinicians.
`Buy in’ from
commissioners.
Training and education.
Quality over quantity.
Patients more likely to
change behaviour and
keep new lifestyle.
Health improvement
written into every
SLA/Contract/Service
Specification.
Management backing at
SHA level.
Evidence based practice
Commissioners overly
focussed on activity and
short term targets. i.e.
quantity versus quality.
Time pressure on clinicians.
Time spent on 'fire fighting'
not on health improvement.
Misinterpretation of
evidence based practice.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
________ ________
North West Community Provider Alliance Clinical Pathway Workshop 2009 64
3.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
One point of
access/contact
for health
improvement
services
Reduced
duplication of
services.
More user
friendly, Easier
to access
services.
Quicker more
direct access to
appropriate
services at the
right time in the
right place by
the right
professional.
Improved
communication
Reduced
stigma
Reduces
duplication.
Quicker more
direct access to
appropriate
services.
Improved 'joined
up' working.
Improved
communication
with other
healthcare
professionals.
Reduces duplication.
More user friendly,
therefore, easier to
access services.
Improved 'joined up'
working with other
health care
professionals.
Clear vision agreed by all partners. Partnership working in health and local authorities - third sector partnerships. Accommodation - agreement of use. Communication. Inter-agency working relationships
Lack of agreement with all
partners.
Lack of useful
accommodation.
Staff resistance.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
_______________
_________________
North West Community Provider Alliance Clinical Pathway Workshop 2009 65
4.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Addressing
health
inequalities
Long term
health gain for
children and
young people.
Reduced social
exclusion.
Improved
healthy
lifestyle.
Reduced
chronic
conditions.
Reduced Life
threatening
illnesses.
Decreases
childhood
morbidity.
Improved
mental health
and well being.
Long term health
gain for children
and young
people. Reduces
social exclusion.
Improves a
healthy lifestyle.
Reduces chronic
conditions.
Reduces Life
threatening
illnesses.
Decreases
childhood
morbidity.
Improved mental
health and well
being. Financial
gains. Better
SLAs and service
specifications.
Reduces long
term costs.
Change of culture and delivery.
IT systems to track local
population and ethnicity.
Long term health gain for children
and young people.
Reduces social exclusion.
Improves a healthy lifestyle.
Reduces chronic conditions.
Reduces life threatening illnesses.
Decreases childhood morbidity.
Improved mental health and well
being.
Commissioning through
targeted funding.
Good social marketing.
Data packaging.
Total stakeholder ‘buy
in’ with a multi-agency
flexible approach.
Community health
development.
Partnership approach
involving all
organisations.
Lack of funding.
Staff,
organisations not
operating together.
Commissioners have a
'blanket' approach - 'one
size fits all'.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
__________________ ____________________
North West Community Provider Alliance Clinical Pathway Workshop 2009 66
MENTAL HEALTH
North West Community Provider Alliance Clinical Pathway Workshop 2009 67
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers To Delivery
Barriers to Delivery
Community single point of access and triage to mental health system that also meets the needs of people with mild-moderate common mental disorders.
Encourages a personal pathway plan by phone/person - who,what,where, when, why and how. Appropriate referral first time with a faster streamlined service. Outcomes will be more positive with informed choice
Value for money. Earlier intervention means a much more efficient and effective service with reduced queues and handoffs. Integrated lean system that enables better outcomes
Patients are deflected from A & E and reduced inappropriate referrals to secondary care. Patients are referred to the right person, in the most appropriate place. This increases capability of care system to meet mental health needs. Reduction in prescribing is achieved with improved outcomes.
Strong leadership is needed from providers to maximise the benefits from all resources; (ie financial, estate, workforce). Commissioners with effective investment plans in community services and commitment to pump-prime developments to support resource shift. Critical mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Standard specification across partnership working with benchmarking for quality and data recording. Governance across patient pathways for patient info/data sharing. By using intelligent commissioning there can be collaboration between commissioners and other partners.
Collaboration limited across
pathways as a result of
different incentives.
Insufficient community
resources.
Boundaries: registered
/resident .
Lack of leadership.
Commissioner development
of market - fragmentation,
competition, lack of co-
operation, reduced
innovation.
Capacity and capability
within community providers
to tender.
Staff morale.
North West Community Provider Alliance Clinical Pathway Workshop 2009 68
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• No specific guide for mental health services. • There is a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.
• Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.
• This must also streamline access to mental health pathways not only to avoid fragmentation of care but also to ensure the benefit from new provider relationships across the independent, third sector and social enterprise, is sensitively managed.
• There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.
North West Community Provider Alliance Clinical Pathway Workshop 2009 69
2.
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Alignment of community services - with community mental health expert practitioners working in an integrated way with Primary Health Care Teams.
Increased access and improved recognition. Mental Health aligned with other mainstream interventions through comprehensive and co-ordinated packages of care. Step up and step down of care. Clients can return to work, with increased choice, and empowerment. Clients can have a choice of opting in and out as needed with informed discharge.
Value for money. Robust Clinical Governance and national target delivery. World Class Commissioning targets are met and QoF delivery is improved. Improved GP practice based knowledge of population.
Systems will be more efficient – integrated and person centred.
Strong leadership is needed from providers to maximise the benefits from all resources. Commissioners with effective investment plans in community services and commitment to pump-prime developments to support resource shift. Critical mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker.
Pathway/Collaborative across
pathways - different incentives.
Resources.
Boundaries: registered/resident.
Lack of leadership.
Commissioner development of
market - fragmentation, competition,
lack of co-operation, reduced
innovation.
IAPT model still being tested.
TCS process.
Staff morale.
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• No specific guide for mental health services
There is a need to ensure all health and social care staff are able to
recognise and detect common mental health problems and quickly help the
person find appropriate help through care pathways.
North West Community Provider Alliance Clinical Pathway Workshop 2009 70
3.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Co-produced (commissionersproviders & service users) integrated care pathways and criteria that are dynamic and regularly reviewed in partnership .
Promotes choice through confidence and clarity of available pathways. Promotes full engagement and co-production. Delivers better outcomes and processes, with lack of duplication.
Value for Money. Reduced stigma and reduced DNAs. Improved efficiency and outcomes.
Shift of focus to address high level of need at an earlier stage and reduce worklessness
Strong leadership is needed from providers. Commissioners have clear investment plans to support resource shift. Critical Mass of community mental health providers with flexible workforce. Benchmarking for quality and data recording. Governance in patient pathways for patient info/data sharing.
Pathway/Collaborative across pathways -
different incentives. Pathway/Collaborative
across pathways - different incentives.
Resources: finance, workforce, capacity.
Boundaries: registered/resident. Lack of
leadership. Commissioner development of
market - fragmentation, competition, lack of co-
operation, reduced innovation.
De-stabilising historical pattern of service.
Capacity and capability with community
providers to tender. IAPT model still being
tested.
TCS process.
Staff moral.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• No specific guide for mental health services. • Services will need to be designed to provide rapid access to a care
pathway that is relevant to the person's needs and provided by staff with
appropriate, up to date skills, to ensure people get the best help at the
right time from the right people.
North West Community Provider Alliance Clinical Pathway Workshop 2009 71
• This must also streamline access to mental health pathways not only to
avoid fragmentation of care but also to ensure the benefit from new
provider relationships across the independent, third sector and social
enterprise, is sensitively managed.
• The development and application of clinical pathways such as those in
the Map of Medicine offer clinicians and service users the opportunity to
access consistent quality of services.
• Appropriate clinical pathways will be developed and used to ensure
access to consistent quality of services.
North West Community Provider Alliance Clinical Pathway Workshop 2009 72
4.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform Enablers to Delivery Barriers to Delivery
Fit for purpose of Community Mental Health Service delivery - non stigmatising, flexible hours, community/ primary care based and mainstream
Patients and Professionals promote recognition of common problem. Focus on mental well-being reduces stigma.
Results in fewer incidents/ complaints with improved access and inclusion. Promotes cultural sensitivity.
Patients are deflected from A & E. Reduce inappropriate referrals to secondary care. Patients are referred to the right person, in the most appropriate place. This increases capability of care re: Mental Health. Reduction in prescribing is achieved with improved outcomes.
Strong leadership is needed from providers with resources, financial, estate, workforce. Pump-priming by Commissioners and investment plans to support resource shift. Critical Mass of community mental health providers. There is flexibility for providers to shape workforce e.g. graduate worker. Standard specification across partnership working with benchmarking for quality and data recording. Governance in patient pathways for patient info/data sharing. By using intelligent commissioning there can be a collaboration between commissioners and other partners e.g. prison
Pathway/Collaborative across
pathways - different incentives.
Resources: finance, workforce,
capacity.
Boundaries: registered/resident.
Lack of leadership.
Commissioner development of
market - fragmentation,
competition, lack of co-
operation, reduced innovation.
De-stabilising historical pattern
of service.
Capacity and capability with
community providers to tender.
IAPT model still being tested.
TCS process.
Staff morale.
North West Community Provider Alliance Clinical Pathway Workshop 2009 73
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• No specific guide for mental health services. • Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.
• This must also streamline access to mental health pathways not only to avoid fragmentation of care but also to ensure the benefit from new provider relationships across the independent, third sector and social enterprise, is sensitively managed.
• There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.
• The development and application of clinical pathways such as those in the Map of Medicine offer clinicians and service users the opportunity to access consistent quality of services.
• That there is a greater recognition of the need for mental health promotion for the general population particularly those focusing on young people and prevention.
• There is a need to co-ordinate substance misuse services, recognising the wide range of actual and potential partnerships, not just in health, to reduce the risk of exclusion and ensure early and opportunistic interventions.
• The links between social issues and mental health from the impact of issues such as deprivation, homelessness and worklessness to be more widely recognised and the need for closer working between health and social care.
North West Community Provider Alliance Clinical Pathway Workshop 2009 74
5.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Skilled workforce with capacity and capability to respond to clients in crisis.
Better outcomes Increased confidence with more responsive services, Greater enablement of self management, resilience and recovery for patients
Produces better outcomes. Value for money. Promotes Innovation to help sustain service development and improvement. Recruitment of innovative and creative staff
Encouraging innovation means pushing boundaries to obtain continuous improvement.
Strong leadership from providers. Resources: financial, estate, workforce. Pump-prime/investment plans to support resource shift. Critical Mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Benchmarking. Pathway governance + info/data sharing. Intelligent commissioning. Collaboration between commissioners
Pathway/Collaboration across
pathways - different incentives.
Resources: finance, workforce,
capacity.
Boundaries: registered/resident.
Lack of leadership.
Commissioner development of
market - fragmentation,
competition, lack of co-operation,
reduced innovation.
De-stabilising historical pattern of
service.
Capacity and capability with
community providers to tender.
IAPT model still being tested.
TCS process.
Staff morale.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• No specific guide for mental health services. • All staff will have the appropriate and up to date skills to support those who access services wherever they access it.
North West Community Provider Alliance Clinical Pathway Workshop 2009 75
CHILD HEALTH
North West Community Provider Alliance Clinical Pathway Workshop 2009 76
1.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Develop a
standardised
approach
across
organisations
This will enable
equity of service
for all patients
and give quality
assurance and
raise standards.
Develop
minimum
standards
across all
partners.
Improved
communication
and better
involvement of
GPs
Consistency across
organisations will
reduce confusion and
increase efficiency.
Consistency will
ensure minimum
standards for quality
assurance,
benchmarking/defining
tariffs. This will start to
improve efficiency and
effectiveness of staff
time
A business plan with a
standardised approach that
can move towards
delivering efficiency
savings.
A standardised approach will be
the driver to enable improved
leadership/capacity.
Pooled resources and creation
of minimum standards will
enable cost savings which in
turn could increase 'buy in’ from
other stakeholders.
IT systems that support a
standardised, consistent
approach to quality and
outcome metrics.
Lack of funding to
standardise systems
and services will lead to
inequity,
Reduce clinical
autonomy and
ownership.
Very local interpretation
of standards limiting
individualised care,
innovation and spread
and adoption of best
practice.
North West Community Provider Alliance Clinical Pathway Workshop 2009 77
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Children, young people and families are involved in planning and
evaluating services.
• Work with commissioners to agree outcome data.
• Work with Commissioners to develop services so that children and young
people can be cared for at home.
• Identify those who may be disadvantaged or marginalised in society
Target need based on your Children’s and Young People’s Plan.
• Improving commissioning at local authority level. Joint
commissioning of all child health services.
• Commissioners and services work in ways that ensure
children, young people and their families are at the
centre of service design and provision, and that their
voices are heard throughout.
• Develop local hub services in collaboration with
secondary care - moving towards integrated service
models, including maternity pathways and featuring
mutual training and education.
• Build on good practice models of integrated working
across services, underpinned by strategic workforce
planning and training.
• Research and building of evidence base for healthcare
practice and interventions are supported and
developed at all levels.
North West Community Provider Alliance Clinical Pathway Workshop 2009 78
2.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Facilitate
partnership and
integrated
working.
Smooth effective
care pathways.
Timely and
seamless care.
Care closer to
home.
Greater
involvement of
GPs.
Commissioners can
commission a complete
pathway (lead provider),
Shared resources and risk
assessment.
Opportunities for joint
training, better
understanding of roles,
increased opportunities for
clinical supervision
Shared and
measured
outcomes.
Shared
records/information
systems
Development of joint
assessment, joint posts, joint
training, pooled resources
(devolved budgets),shared
systems, joint planning,
Children's Trust opportunities,
shared outcomes .
New roles working differently
and committed to towards
partnership working.
Culture of
organisations.
Lack of information
sharing and record
keeping.
Commissioning
arrangements are
not standardised.
Commissioners may
not have a full
understanding of
roles required.
North West Community Provider Alliance Clinical Pathway Workshop 2009 79
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Strengthen partnership working across Children’s
Trusts and children’s social care, community services
and organisations such as ambulance trusts, acute
trusts, children’s /social services, GP practices (and
practice based commissioners), voluntary and
independent sectors so that care and treatment can be
aligned along a care pathway and co-ordinated around
the needs of the service users.
• Improve commissioning at local authority level. Joint commissioning of all
child health services.
• Commissioners and services work in ways that ensure children, young
people and their families are at the centre of service design and provision,
and that their voices are heard throughout .
• Develop local hub services in collaboration with secondary care - moving
towards integrated service models, including maternity pathways and
featuring mutual training and education.
• Build on good practice models of integrated working across services,
underpinned by strategic workforce planning and training.
North West Community Provider Alliance Clinical Pathway Workshop 2009 80
3.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Development of
clinical
pathways for
acute/complex
needs.
Improved access
to most
appropriate
assessment and
care packages.
Improved choice
with greater
awareness of
available services.
Timely access and
interventions.
Confidence in
quality, outcomes
and specialist
expertise of staff
operating in an
integrated way.
Quality assurance and
evidence will enable
commissioners to develop a
strong and complete
pathway,
Professional roles will be
clarified with the potential
for wider scope and
increased potential for
integration.
Better governance and audit
arrangement.
Monitoring of clear
standards will be more
successful and will also
address inequalities..
Shift from Acute to
Community i.e. In-
Reach model with
patients at the centre.
By using
standardised,
measurable
approaches with a
local focus, then,
shared care/expertise
will be attainable.
Increased quality and
efficiency.
Pathways will need clinical
leadership and ‘buy in’ from
professionals,
commissioners, providers
and other expert group
organisations.
Pathways designed with
reference to NICE guidance,
Lean Thinking, and examples
of good/best practice
Current lack of
business
acumen/support for
community services
to collaborate or co-
ordinate the pathway
delivery.
Lack of quality
metrics
Organisational
boundaries - staff
resistance.
North West Community Provider Alliance Clinical Pathway Workshop 2009 81
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Know about local health needs and plan services accordingly.
• The voices of children, young people and families are central to
planning the pathways and the evaluation of services.
• Identify children who need safeguarding.
• Work collaboratively with others who work with local children and
families agreeing and developing a common vision, goals and models
of good practice.
• Develop additional healthcare services in their own homes or in
settings closer to their homes.
• Children's Clinical Pathway Groups.
• To involve Health Improvement.
• Reduction in obesity, emotional health and wellbeing,
teenage pregnancy, sexually transmitted diseases, drug
and alcohol use, targeting areas of deprivation.
• Early Identification.
• Poor or ill health managed through Primary Care, and
parents.
• Develop a range of assessment tools to support
identification, underpinned by clinical expertise through
networks, supporting primary and community care.
• Commissioners and services work in ways that ensure
children, young people and their families are at the centre
of service design and provision, and that their voices are
heard throughout.
North West Community Provider Alliance Clinical Pathway Workshop 2009 82
4
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Strengthen
universal and
health
improvement
role
The
underpinning
of health
improvement
within all
clinical
pathways will
provide easier
access, earlier
identification
and
intervention,
promote
patient
confidence and
self care.
Patients will be
empowered
through a
better
understanding
of services.
Promotes and
enables earlier
intervention,
better value for
money, reduces
inequalities and
improves
outcomes.
Patients are
helped towards
making informed
decisions.
Better
understanding of
local needs in the
short, medium
and longer term.
Resources can
also be
targeted
appropriately,
Value for money
across the
whole system.
Resources used
more efficiently.
Prevention and
earlier
intervention.
Local Health Improvement evidence,
policy documents, and local drivers
with dedicated professional staff can
all help to prove that Health
Improvement is a valuable tool for
underpinning all pathways.
Support of Health Protection Agency,
other organisations, agencies and
local councils. Existing equal
partnerships must drive this initiative
through to enable a clear service with
standardised specifications (look at
national templates).
Clear objectives/targets help to
reinforce the Health Improvement
roles.
Relevant information and the
standardised use of Informatics to
enable consistency across all
pathways and opportunity for
benchmarking and sharing innovation.
Staff and parents engaged in service
redesign.
Lack of resources: staff,
finance and estate.
Governance issues re:
partnership, different
organisations, cultures, budget
controls.
Increased contestability of
services.
Resources and expertise
needed to engage with the
hard to reach families.
Public expectations.
North West Community Provider Alliance Clinical Pathway Workshop 2009 83
Priorities in Transformational Guides Priorities in Healthier Horizons for the North West
• Use of public data about ill and disabled children to inform and
agree local priorities.
• Empowers parents and carers to be able to deliver health care to
their ill or disabled child through the provision of adequate training
and ongoing support.
• Equip other partners such as teachers with the skills and knowledge
to recognise illness and exacerbations or deterioration in a child or
young people.
• Integrate and co-ordinate all services that contribute to caring for a
child through an illness or disability, making sure universal,
preventative services continue to be offered.
• Develop ‘buddy’ systems to support families.
• Develop services and approaches to support siblings of children
with illnesses or disabilities.
• Ensure staff have ongoing joint training.
• People are developed to be high quality community ‘practitioners,
partners, leaders’ who can clinically own and lead local change.
• Health Improvement is part of integrated pathways.
• Build on good practice models of integrated working across
services, underpinned by strategic workforce planning and
training.
• Develop local hub services in collaboration with secondary
care - moving towards integrated service models, including
maternity pathways and featuring mutual training and
education.
• Research and building of evidence base for healthcare
practice and interventions are supported and developed at
all levels.
North West Community Provider Alliance Clinical Pathway Workshop 2009 84
5
Top 3-5 Improvements
Benefits for Patients Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Joined up
adequately
financed
commissioning
group
Less duplication,
improved service,
easier access,
economies of scale,
better communication,
clear roles,
responsibilities and
single point of access,
NSFs, Healthy
Horizons, NHS Plan,
Children's Plan,
Choosing health will
support and enable the
above
Better use of resources.
Standard and clear target
sand measured outcomes will
help with shared monitoring
and accountability.
All partners signed
up to shared
objectives and
vision,
Standardised
monitoring of
outcomes.
Improved quality,
efficiency and
productivity.
Clear standardised
service specs enable
clear objectives and
targets.
Increased resources.
Relevant information.
Audit.
A strong steer
towards networking
and partnership
working.
Clear and strong
governance
framework with Child
& Family at the
centre.
Dedicated
professional staff
producing clear
evidence, policy
documents, local
drivers. .
Lack of
resources/capacity.
Governance issues
Provider/commission
er split, where the
issue of
contestability will
increase.
There are also local
demographics - age,
complex health
needs, deprivation
and poverty to take
into account.
Appropriate
accommodation plus
costs.
North West Community Provider Alliance Clinical Pathway Workshop 2009 85
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Work with Commissioners to agree the outcome data that needs to be
collected for a specific service area to demonstrate effective
intervention.
• Link this to quality framework and, if appropriate, contracts including
the payment framework for commissioning, quality and innovation.
• Target needs based on your Children's and Young People's Plan
Strengthen partnerships working across Children's Trusts, health and
children's social care.
• Support teams to develop creative approaches to service provision,
which reflect the five 'Every Child Matters' outcomes and will improve
choice and personalisation for children, young people and their
families.
• Support and empower practitioners to develop innovative
multidisciplinary teams using approaches such as transformational
attributes.
• Commissioners and provider management teams must be responsible
for developing a competent workforce that will deliver current and
future services safely, effectively and who have a positive impact on
service user experience.
• This will include thinking about workforce planning aligned to patient
need and the commissioning of sufficient education and training
places for the future.
• Work with education commissioners and universities to ensure
education programmes at all levels.
• Our vision for the future, in terms of the commissioning
and provision of services, is one where these are done at
the most appropriate level through formal joint
commissioning arrangements and integrated delivery.
• Develop local hub services in collaboration with
secondary care - moving towards integrated service
models, including maternity pathways and featuring
mutual training and education.
• Build on good practice models of integrated working
across services, underpinned by strategic workforce
planning and training
• Improving commissioning at local authority level.
• Joint commissioning of all child health services.
North West Community Provider Alliance Clinical Pathway Workshop 2009 86
6.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Improving
outcomes for
children and
families (e.g.
admissions,
obesity,
accidents,
smoking will
reduce and
health will
improve).
Improved
parenting,
Children and
families are
engaged,
enabled,
empowered.
Increased
confidence in
services.
Improved focus
on:
self/homecare,
maternity health,
teenage
pregnancy,
safeguarding,
obesity, alcohol,
drug use.
Policies such as
Children's NSF,
Every child
matters used as
guidelines.
Target resources
appropriately to prevent
hospital admissions.
Evidence will be through
measured outcomes,
improvement, reduced
health inequalities
Better use of
workforce skills
with succession
planning.
Improved quality,
safeguarding,
service
improvements,
horizon scanning,
Reduction in health
inequalities.
Clear standardised service
specifications.
Clear and strong governance
framework. with Child &
Family at the centre.
System engagement and
support.
Lack of resources/capacity/recruitment + retention does not help new initiatives. Partnership governance issues re: partnership, different organisations, cultures, budget controls. Local demographics - age, complex health needs, deprivation and poverty to take into account. Public expectations.
North West Community Provider Alliance Clinical Pathway Workshop 2009 87
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
• Information to empower children, young people and their families.
Clear comprehensive information and support regarding a child or
young person’s condition, including sources for further support,
enable children, young people and families to retain ownership of their
individual lives.
• Equip parents with skills and knowledge to recognise acute
exacerbations/ deterioration and to treat their child or seek expert
help as appropriate.
• Health Improvement is part of the integrated pathways .
• There should be a 'systematic' programme throughout the North West to reduce the need for inpatient care days, achieved through: Increased conversion to day case care, decreased length of stay for acute admissions through whole pathways redesign.
• Better co-ordinated team based and proactive care for children with long term conditions, involving the GP, children's community matrons and the team around the child.
• Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout .
• Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.
North West Community Provider Alliance Clinical Pathway Workshop 2009 88
MATERNITY AND NEWBORN CARE
North West Community Provider Alliance Clinical Pathway Workshop 2009 89
1. Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers To Delivery
Barriers to Delivery
Commission
integrated
maternity and
child health
pathways.
Universal
Journey
Planner
signposting
access.
Continuity of care for the family. Improved access and choice. Improved outcomes for women and children.
Improved outcomes, access and choice. Greater efficiency in pathway delivery. More integrated care.
High quality and productive pathways. Greater co-operation between providers. Better use of workforce skills.
Clear outcomes agreed and monitored with clarity of exactly what is provided. Shared data collection Good IT systems will increase staff satisfaction. Children's strategy. Public Health agenda.
Maternity services are commissioned with
acute providers.
Culture and organisational boundaries.
Separate IT Systems.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
________________
• Enhance the midwifery role to include public health approach to care and
greater autonomy in midwife led services. This will include outreach work to
teenage mothers, asylum seekers, substance misusers and other vulnerable
groups.
• Offer all women an individualised risk, needs, preferences and benefits
assessment at decision points during their care, where the woman and her
midwife will discuss the choices available to her and her family (The Child
Health Promotion Programme, DH 2008).
• Increased partnership working between midwives, midwifery assistants, health
visitors, social workers and other professionals involved in the woman's care.
North West Community Provider Alliance Clinical Pathway Workshop 2009 90
2.
Top 3-5 Improvements
Benefits for Patients
Benefits for Commissioners
Benefits for System Reform
Enablers to Delivery Barriers to Delivery
Commission
specialist
pathways.
Improved access to most appropriate assessment and personalised care package. Confidence in the quality and expertise of service providers. Improved communication.
Improved outcomes. High quality and responsive pathways. Improved safeguarding. Reduction in teenage pregnancies. Increase in smoking cessation.
Improved delivery of quality and productive care – right person, right place, right time.
Children's Act.
Children's plan.
Department of Health Targets.
Local targets.
Integrated training/modules.
Separate IT Systems.
Culture and organisational boundaries.
Separate performance monitoring, reporting and
accountability.
Separate governance arrangements.
Same quality measures.
Priorities in Transformational Guides
Priorities in Healthier Horizons for the North West
_________________
• Collaboration across health communities to ensure women who require
specialist care can access what they need without delay and transfer
policies are in place.
• Strong commissioning partnerships between the community, hospital,
social services, education and the third sector will be developed to
ensure that women who require specialist services can access those
they need without delay.
North West Community Provider Alliance Clinical Pathway Workshop 2009 91
With thanks to the workshop participants who shared their expertise and their passion for community services to effectively contribute to
addressing health inequalities and improving the health and well being of the people we serve across the North West.
The clinicians and practitioners were from the Community Provider Services of:
Blackpool PCT Manchester PCT
Bolton PCT Oldham PCT
Bury PCT Salford PCT
Central Lancashire PCT Sefton PCT
Cheshire East and Central Cheshire PCT Stockport PCT
East Lancashire PCT Tameside and Glossop PCT
Halton and St Helens PCT Trafford PCT
Heywood, Middleton and Rochdale PCT West Cheshire PCT
Knowsley PCT Wirral PCT