18 Weeks Commissioning Pathways

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18 Weeks Commissioning Pathways

• Jenny Bareham
• Head of Service Transformation, DH
• Paul Griffiths Delivery Manager
• 18 Weeks Team Technology Neurology

November 2007 Version 1.0
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Currently, some care pathways include unnecessary
sequential steps, not all of which provide
clinical value for patients

• Mix of routine and complex cases, as well as
  emergency and electives using the same processes
• Often inpatients where day cases would be more
  appropriate

• Mainly hospital based with follow-ups continuing
  in the hospital for extended periods of time

• Often long waits between tests due to previously
  hidden diagnostic waiting times for tests and
  results
• Often serial and repeat testing

• Potential for multiple appointments following
  diagnostics prior to final assessment and
  treatment decision

• Little early pre-assessment meaning patients can
  be found unfit for surgery, or patients are
  unclear of outcomes of surgical intervention

• Largely based in general practice
• Limited use of primary care professionals
• Limited access to diagnostic
• Limited visibility of prospective pathway

• Little application of one stop services
• Mainly provided by consultants

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3. Driving implementation and transformation
Drive efficiency and quality incurrent processes
and models of care
Delivery of 18 weeks
Challenge current models of practiceto develop
transformational change
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Service Transformation Vs Service Improvement

• Service Improvement
• Tools and techniques to deliver efficiency and
  productivity along the pathway
• Help clear the backlog
• Help deliver service transformation
• Service Transformation
• Something that looks and feels very different
  from when it started
• The objective is to not only influence processes,
  but to change mindsets, cultures, activities, and
  organisational power bases
• Why?
• Because more of the same faster wont work!
• Shift from stages of treatment into whole pathway
• Sustainability of service improvement on stages
  of treatment

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New pathway models are emerging which address the
issues of existing pathways

• Provision of services to support the management
  of self-limiting conditions, and use of
  appropriate treatments for onward care e.g. NHS
  Direct, Pharmacist.

• Provision of generalist primary care in a
  community setting, including access to the
  appropriate diagnostics and treatment. Provided
  by a range of appropriately trained primary care
  professionals

• Provision of care provided by a range of
  specialists (consultants, GPwSIs, nurse
  consultants) in the community (e.g. Integrated
  Clinical Assessment and Treatment Services) or
  hospital setting (e.g. outpatients)

• Provision of care provided by a supra-specialist
  for patients requiring highly specialised low
  volume care e.g. care provided within a tertiary
  centre.

• Provision of services in community or hospital
  settings to support the ongoing care of patients
  following treatment. This includes follow-up
  appointments following surgery.

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Development of 18 Week Commissioning Pathways

• Development of condition and symptom based (where
  possible) good practice 18 week commissioning
  pathways for the highest volume 12 specialties
• To
• Challenge existing practice
• Utilise service improvement tools and techniques
• Maximise opportunities for transformational
  change
• Support commissioners to deliver 18 weeks
• Commenced publication January 07

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Principles
Clinically driven pathways that commence at the
patients presentation of symptoms and end at
completion of the patients journey
Pathways not defined by whether they are
delivered in primary or secondary care, or by
which specialty or professional

• Patient focussed e.g. reflect the patients view
  of when the pathway starts and finishes, as well
  as their health needs and preferences

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Pathway Development 2 phases
Outlining the service model to support
commissioners in commencing local discussions on
service models - transforming the pathway
Phase 1
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• 18wkPathway_SkinLesion_060807.pdf

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Pathway Development 2 phases
Outlining the service model to support
commissioners in commencing local discussions on
service models - transforming the pathway
Phase 1

• Populating the remainder of the template,
  incorporating information to support
  implementation applying service improvement
• Workforce skills and competencies
• Technology enablers
• Service improvement models
• Quality of life assessments
• Identifying commissioning levers

Phase 2
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Phase 2 - Examples (not all information is
necessarily applicable to this pathway)
Streamlining services to improve productivity
Introducing extended roles - skills and
competency based
Assessing QoL from the outset
Running a one-stop clinic
Direct access diagnostics unbundling tariff
Day Surgery
Using PACs to ease reporting
Using alternative providers for review and
follow-up
Direct listing for surgery
Early pre-assessment
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What I will cover

• Engagement
• Findings from engagement
• Underlying approach to technology
• Technology being taken forward by
• Delivery mechanisms

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1. Engagement
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2. Findings from engagement
Technology gaps for commissioners

• Multiple organisations involved- who does what?
• want help mapping technology benefits to
  national priority areas
• Unbiased evidence that technology works with
  particular populations and specific settings
• Indications of type of solution technology
  represents immediate medium or long-term
• Cost (initial outlay/ start-up costs)
• Cost effectiveness
• User satisfaction evidence that patients and
  carers can use and like technologies
• identify how technology can enable
  transformational change

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3. Underling approach to technology
Focus on

• Earlier and better diagnostics in primary care,
  reducing
• demand for referral into diagnostics or
  secondary care
• Better diagnostics, reducing demand for
  needless investigative procedures
• Less invasive treatments creating increased
  efficiency of bed usage

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4. Technology taken forward by

• Identify the top 5 high impact technology
  advances for each specialty
• Develop high level technology stakeholder map
• Establish links with key stakeholders
• Establish Technology Expert Steering Group to
  test robustness of case studies etc

• DH 18 weeks team

• Help identify appropriate technology for high
  impact matrix
• Identify case studies of technology as a
  service transformation enabler across all
  pathways

18 weeks project / clinical leads

• Newsletter to all 18 Week website subscribers
  this week
• Comms through CHAIN innovation forum this week
• Hotseat interview with some of key partners

Stakeholders
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5. Delivery mechanisms
CommissioningPathways

• links to CfH products including Choose and Book
  through web content tool being developed and
  onto Pathway
• Case studies to be incorporated into the wider
  case study library
• High level stakeholder map
• Matrix of Top 5 High Impact Technology Advances
  to be incorporated into the web content tool
  and possibly the 18 Weeks toolkit being
  developed

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5. Delivery mechanisms High impact matrix
5. Delivery mechanisms High impact matrix

• Proposalstested against

• Adoption rate
• Clinical Functions (what it does)
• Workforce implication (training and education)
• Doing things differently (closer to home, new
  roles etc)
• Evidence (supporting journals etc)
• Special considerations (calibration, maintenance
  etc)

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5. Delivery mechanisms High impact matrix
some proposals made to date

• Proposalsto date

• Cardiac ECG Telemedicine - Broomwell Healthwatch
  (Greater Manchester and Cheshire Cardiac
  Network)
• Allows 12-lead ECG to be carried out in GP
  practice by doctor or nurse results fed into
  Broomwell Cardiac Centre for interpretation
  and advice
• Text / internet system for managing DNAs in
  Bromley helps free up capacity of non-medical
  staff
• Telemedicine review of optometric images aids
  with training and development of new roles

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Developing and Implementing New Pathways of Care

• New pathways of care will be needed to sustain
  18 Weeks
• Commissioning Pathways help to focus discussions
  around local service requirements, including
  setting, workforce, technology required
• Tailoring services to meet the needs of the local
  population and based on local capacity and
  capability
• Using the right staff, at the right place, with
  the right equipment is fundamental to ensuring
  that the pathways are high quality, delivered
  effectively and are sustainable

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Useful Links/Contacts

• www.18weeks.nhs.uk
• Jenny Bareham jenny.bareham_at_dh.gsi.gov.uk
• Paul Griffiths paul.griffiths_at_dh.gsi.gov.uk