Service Redesign

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Service Re-design
Back to the Future Jim Heys Deputy National
Director CHD Collaborative Susan Fairlie
National Manager CHD Collaborative
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The National Perspective circa 1994
Government Public Expenditure Survey
DoH determines policy
Regional Health Authorities
100 Local HAs
3500 GPFHs
400 Acute Trusts
5000 non GPFH
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Precursor

• Internal Market seen as divisive
• Competing Trusts
• Highly fractured health care system
• 100 Health Authorities
• 3500 Fund Holders
• 400 Trusts
• .little strategic co-ordination
• Little Health Social care integration
• Performance based on alone (efficiency index)

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New NHS Modern Dependable- a blueprint

• Quality at the Heart of the service
• doing the right things , at the right time,for
  the right people and doing them right first time
• Keep what works
• Discard what doesnt
• The 3rd Way..system based on partnership and
  delivery

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Blueprint

• Introduced the concepts of
• National Service Frameworks
• National Institute for Clinical Excellence
• Clinical Governance
• Commission for Health Improvement

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Guiding principles

• Health Improvement (across populations)
• Fair Access (equity end post code lottery)
• Effective Delivery (time)
• Efficiency (process variation)
• Patient carer experience
• Health Outcomes (across the country..disease
  focus)

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Detailing the Blueprint

• A First Class ServiceQuality in the new NHS
  (1998)
• Clinical Governance in the New NHS (1999)
• Saving Lives Our Healthier Nation (1999)
• National priorities Guidance 2001\02 02\03 (1999)
• National service Framework for CHD (2000)
• NHS Plan , a plan for investment a plan for
  reform (2000)
• Improvement , Expansion , Reform the next 3
  years PPF 2003-2006
• Raising Standards Improving Performance in the
  NHS (2003)

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Controversy without impact
Transformation
Improved outcomes
Status quo
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Role of the Modernisation Agency

• Purpose
• ..to work with individuals , teams NHS
  Organisations to find promote improved ways of
  delivering health services better health
• Organised to support delivery of Plan targets and
  underpinning strategies
• modernisation is the transformation of the
  delivery of care through the implementation of
  the NHS Plan

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August 2000 July 2001 July 2002 CHF
patients Prescribed ?-blocker Benchmark Top
12.5 at August 2000
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141.5
-23.4
108.5
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Quarterly ingredient costs for statins in England
14 million per week
2 million per day
NSF published
66 MILLION SCRIPTS PER YEAR BY 2010
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Role of Collaborative

• to improve the experience outcomes for people
  who have , or are at risk of developing Heart
  Disease by redesigning the whole pathway of care
• Supports delivery of the NSF

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Workstreams
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GP referrals tocardiology outpatients
NSF
1999/2000
2000/2001
2001/2002
2002/2003
2003/2004
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Collaborative methodology

• Apart from the tools and techniques..
• Workforce and role redesign
• GPwSIs, PwSIs, HCAs
• Sharing improvements
• Peer support-Smart groups
• Learning from patients

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21st Century Primary Care

• Mule info and access points
• Expert patients and self care (CDs for patients)
• Increasing CDM
• Increasing Self Care and Self management
• Expanding Ambulatory Care
• Public Health oriented Clinicians
• Active in commissioning of Secondary Care
• Choice for patients and clinicians
• Increasing accountability
• Greater use and interrogation of IT systems
• Group consultations

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NPDT

• Established February 2000
• A team of less than 45 inc. PMS Dev Team
• Based in Manchester, England
• Main programmes of work
• National Primary Care Collaborative
• PMS development
• Smart Care Programme
• Healthy Communities Collaborative
• National Falls Collaborative
• Clinical Leadership Development

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3 key aims

• -90 of patients can access their primary health
  care professional routinely the next working day
• -A reduction in the mortality of patients with
  proven ischaemic heart disease by 30 in 3 years
  and 50 in 5 years in participating sites
• -Establishment of capacity and demand management
  systems at PCT level for commissioning secondary
  care

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Phase I

• 80 PCTs across England in 4 waves of 20
• 456 core practices
• Over 1000 practices as at April 2003
• Over 7.5 million patients

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Rapport Online
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A First Class Servicequality in the new NHS
(1998)

• Statutory Duty of Quality
• Introduced Clinical Governance at the Heart of
  the NHS
• A framework through which NHS organisations
  are accountable for continuously improving the
  quality of their services and safeguarding high
  standards of care by creating an environment in
  which excellence in clinical care will flourish.

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Why is this important ?

• C.G. focuses on all activities that deliver care
  to patients.
• Several models science in own right however it
  encompasses
• Clinical effectiveness evidence based medicine
  best practice
• Risk management clinical , organisational and
  environmental
• Audit Evaluation analysis of significant
  clinical events (Organisation with a Memory)
• Patient involvement and viewpoint inc analysis
  of complaints
• Learning at all levels

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• Impact of the new GMS Contract
• gives GPs a better working life and improve
  services for patients
• gives GPs control over their workload
• attracts extra funding into general practice
• improve recruitment and retention in the
  profession
• a practice-based contract between the whole
  practice and the Primary Care Organisation (PCO)
• Individual GP lists will cease.
• practices will be paid for delivering quality
  patient care, through the Quality and Outcomes
  Framework (QOF)
• The current GP 24 hour responsibility for patient
  care ceases
• PCOs will have the responsibility of delivering
  Out of Hours care.

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nGMS Contract The CHD element of the QOF could
generate a maximum of 101 points For the average
sized practice (5,000 patients) this represents
an income of 7,575 in 2004/5 and 12,120 in
2005/6. This is a significant improvement on
how GPs are currently funded to deliver CHD
care. If they achieve 100 in the other targets
areas of Heart failure, Hypertension, CVA, COPD,
Asthma, Diabetes, Mental Health, Cancer, Epilepsy
and Hypothyroidism . 70,000 towards the
practices income.
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A Framework for Delivering Improved Quality
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Interrelationship of Governance Structures
Clinical governance
Redesign considerations
Corporate governance
Financial governance
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www.nice.org.uk
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Population Management More than Care Case
Management
Measurement of Outcomes Feedback
Targeting Population(s)
Redesigning Processes
Level 3 Highly complex members
Case Management
Level 2 High risk members
Assisted Care or Care Management
Level 1 70-80 of a CDM pop
Usual Care with Support
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Impact of heart failure nurses on deaths and
readmissions Blue et al BMJ 2001323715-718
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Aggregate DataEchocardiography/Bed days
savedActual and Forecast
218 Acute Trusts
5.25 days
44 Acute Trusts
1 day
Target 2000 beds saved for alternate use by
March 2 Echo, Transfers for angiography, PCI,
cardiac surgery, Heart Failure management, Early
Discharge, Etc Financial Impact 2000 at 150 per
day times 365 109,500,000 per annum -
(exceeds total 6 year programme budget)
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The National Perspective 2004
Government Public Expenditure Survey
DoH
Policy determined with Tsars
Modernisation agency
SHAs
PCTs
CHDC
Service Level Agreements (Via Commissioners)
Provider Trusts delivering NSF ,PPF Local targets
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Making it happen the Planning Framework

• Introduced 3 year planning
• Introduced the Local Delivery Planning (LDP)
  process
• Determine Health social care responsibilities
  a shared agenda
• Establishing sound local Performance monitoring
  arrangements

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The Planning Priorities Framework2003 - 2006

• Improve access through
• Better emergency care
• Reduced waiting ,increased appointment booking
  and more choice
• Improve services and outcomes in
• Cancer
• Coronary Heart Disease
• Mental Health
• Older People
• Children
• Diabetes
• Etc

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Performance assessment

• PPF set Targets , standards Benchmarks
• Brought together in LDP Detailed Document
  incorporating Commissioning plans and finances
  (and SLAs) risk assessed progress towards
  targets and trajectories.
• Monitored Via StHAs LDP performance
  management arrangements (PAFs)
• Assessed By CHI Star Ratings
• Perform to plan earned autonomy

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Where to next ?
Locally determined
Nationally determined
3 years
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Lessons Learned

• Aligning incentives to reinforce agreed
  principles enables delivery
• Develop capacity for continuous improvement
  across entire patient pathway
• Achievement of national standards via local
  creativity
• Top down vs Bottom up ? both and

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Contact details

• Jim.heys_at_npat.nhs.uk
• Susan.fairlie_at_npat.nhs.uk
• www.modern.nhs.uk/chd