Project charters

1
Project charters

• Birmingham
• Derbyshire
• Manchester
• Stour
• Torbay

2
Can the clinical and economic benefits of
education for Heart Failure patients be expanded
in high risk populations through innovative
enrolment strategies?

• Problem statement
• 5 of hospital admissions are related to heart
  failure (HF), half of which could be prevented
  through support with self care management (NSF
  for CHD, 2000). Specifically, evidence indicates
  that comprehensive education about heart failure
  reduces hospitalisation for this condition by
  nearly 40 (Coll, 2002).
• Since the incidence of heart failure is up to 4
  times higher in the South Asian (SA) patients
  (BMJ, 2003), this group could benefit most of
  education programs. South Asian population is
  very large in Birmingham but an important
  limitation to the implementation of these
  effective education programs is the challenge of
  targeting difficult to reach population.
• Patients involved
• SA patients with mild, moderate and
  moderate-severe HF.
• Potential benefits
• Increase in rate of enrolment of SA patients with
  HF in education programs
• Increase the rate of completion of education
  programs
• Reduce the number of drop-outs from education
  programs
• Increase the confidence in management of the
  disease and overall patient satisfaction
• Long-term reduction of hospital admissions
  through improvement of clinical outcomes (disease
  management and progression)

• Levers for shift to be tested
• Segmentation program specifically targeting a
  high risk culturally sensitive patient population
• Integration joint enrolment effort by nurses,
  GPs and community leaders
• Proposed measures
• Size of target population
• Increased number of patients interested in the
  course and increased waiting lists
• Increase in number of patients attending and
  completing the programme
• Increased confidence and satisfaction by patients
  and carers
• Cost-benefit modelling extrapolating in a
  mid-term or long-term scenario to evaluate
  potential benefits in terms of avoidance of
  admissions.
• Project team
• Project Lead Karen Naylor
• Programme Manager Janine Ginn
• Timetable
• Early July sign off of charters and measures
• End July - finalise design and plan for field
  testing and sign off of all the data and metrics
  to be measured
• August programme and intervention design

3
Can integrated early care in a pain clinic
improve management and satisfaction of Low Back
Pain patients?

• Problem statement
• The provision of pain management is unevenly
  distributed across this health economy. The lack
  of a multidisciplinary team in Primary care
  results in patients receiving fragmented and
  inconsistent care. Research evidence supports the
  need for assessment treatment by doctors,
  physiotherapists, clinical psychologists, and
  clinical nurse specialists.
• Patients involved
• Patients with low back pain as a primary
  diagnosis.
• Potential benefits
• A one stop shop enabling patients to see
  several health professionals in a single visit
  will reduce the need for multiple out patient
  appointments.
• The development of an agreed treatment plan early
  in the patient journey will result in the patient
  seeing fewer and more appropriate secondary care
  specialists.
• Patients not requiring high level intervention
  will be managed in Primary care.
• Consistent early advice/ intervention should
  result in earlier return to work impacting on
  DHSS ( unemployment incapacity benefits) and
  the high total cost to GDP of back pain ( 11
  billion in 2003 Van de Houltard)
• Patients satisfaction with the service provision
  will increase

• Levers for shift to be tested
• Integration joint enrolment effort by all health
  professionals involved in low back pain
  management
• Simplification from a journey that involves
  multiple referrals and intereferrals to a
  one-stop shop
• Substitution of acute services for community
  services
• Proposed measures
• Reduction in number of visits, referrals and
  intereferrals
• Earlier diagnosis and treatment for patients
• Decreased waiting times
• Increased patient satisfaction with management
• Savings for the NHS (extrapolation)
• Cost-benefit analysis (extrapolation)
• Project team
• Project Lead Eve Jenner
• Project Champion Barbara Hoggart
• Programme Manager Janine Ginn
• Timetable

4
Can urinary continence in women be appropriately
managed in the community so that early and
effective more efficient treatment is provided?

• Problem statement
• There is a need for a co-ordinated, comprehensive
  fully integrated continence service across the
  whole health economy
• 2.5 4 million with urinary incontinence (RCP
  1995) (Under reported)
• 42 of women over 18yrs of age in UK have urinary
  incontinence.
• Women with stress incontinence wait an average of
  4 years before going to their GP to admit to a
  problem.
• Within Birmingham East and North there is
  currently no integrated journey for continence
  management, resulting in a fragmented service for
  our patients. There are multiple referrals to
  multiple health professionals across the area,
  resulting in complex journeys and confusion for
  the patient.
• Patients involved
• Women over 40 diagnosed with urinary
  incontinence.
• Potential benefits
• Simplify the patient journey that leads to
  earlier treatment
• Reduce the resource use associated with disease
  management by reducing the number of referrals

• Levers for shift to be tested
• Segmentation program specifically targeting
  women over 40 years old diagnosed with urinary
  continence
• Simplification more simple patient journey
• Substitution management of most patients in the
  community
• Proposed measures
• Reduction in the number of out patient referrals
  to urology / gynaecology and inter-referrals
  (reduction in the hand offs between health
  professionals during the patients journey)
• Improved times from symptoms to diagnosis and
  diagnosis to treatment.
• Increased use of the triage service
• Cost-benefit modelling
• Project team
• Project Lead Annette Woodward
• Programme Manager Janine Ginn
• Timetable
• End July sign off of charters and measures
• Mid August - finalise design and plan for field
  testing and sign off of all the data and metrics
  to be measured and collection of baseline data
• September enrolment

5
Project charters

• Birmingham
• Derbyshire
• Manchester
• Stour
• Torbay

6
Can an admissions avoidance scheme for COPD
patients improve clinical and economic outcomes
and increase the confidence of patients and
carers in the management of the disease?

• Problem statement
• COPD (Chronic Obstructive Pulmonary Disease) is a
  chronic, progressive disorder, characterised by
  airways obstruction.
• Nearly 900,000 people in the UK have been
  diagnosed with COPD and half as many again are
  thought to be living with COPD without the
  disease being diagnosed.
• However, it is perceived that much of the
  activity currently undertaken in hospital
  settings with COPD patients can be treated in the
  community and patients homes thus reducing the
  number of hospital admissions.
• Patients involved
• Patients with COPD that are classed as high
  risk placed on to the admission avoidance
  scheme.
• Potential benefits
• Improved clinically and economically relevant
  outcomes
• Improve clinical management and self care
• Improved patient and carer confidence in their
  ability to manage the disease and patient
  satisfaction with management
• Levers for shift to be tested
• Segmentation program specifically targeting mild
  and moderate COPD patients
• Substitution acute care substituted by
  specialised respiratory nurses in community
  setting and self management

• Proposed measures
• Increased confidence and satisfaction by patients
  and carers
• Increased number of patients receiving self
  management plans
• Reduction in AE admissions (avoidance) long-term
  (for ongoing work)
• Cost-benefit modelling extrapolation
• Project team
• Project champion Martin Cassidy
• Timetable
• 1st June first patients in study
• End July - finalise design and plan for field
  testing and sign off of all the data and metrics
  to be measured
• Mid August gateway 2 and baseline data
  available
• Nov-Dec - evaluate results

7
Can the unnecessary admissions to AE be reduced
with the implication of the voluntary sector in
emergency management for patients feeling unwell
or with non-threatening injuries?

• Levers for shift to be tested
• Segmentation program specifically targeting a
  population feeling unwell and calling 999
• Integration joint enrolment effort by voluntary
  sector and public national health service sector
• Substitution of acute care services in AE by a
  combination of CP/ECP, community care and
  voluntary sector services
• Proposed measures
• Reduction in AE admissions
• Increased in amount and proportion of patients
  under Cat 26B and CAT Cs visited by CP/ECP
• Number and proportion of patients under 26B/Cat
  Cs who should be visited by a CP/ECP but are not
  and reasons for that
• Number of patients who are referred the following
  day to a community doctor
• Number of patients who use the sitting services
  by the Red Cross
• Cost-benefit modelling short-term and long-term
  extrapolation
• Project team
• Project leads Andy Moss (EMAS)
• Project Manager Kay Dhesi
• Timetable

• Problem statement
• A significant amount of patients who call 999
  that are feeling unwell or who have non-life
  threatening injuries end up being admitted into
  AE unnecessarily. This does not match patients,
  carers and families preferences and results in a
  inefficient use of acute setting health care
  resources, compromising capacity availability for
  patients in need of this type of support. The
  intervention of Community Paramedics (CP) or
  Emergency Care Practitioners (ECP) rather than
  core crews reduces dramatically the probability
  of patients ending up in AE and admitted into
  hospital. Also, the availability of services by
  the voluntary sector, like sitting services by
  the Red Cross, could allow many patients to be
  watched overnight and then referred to a doctor
  the following day, again avoiding an unnecessary
  admission to AE.
• Patients involved
• Patients from the area of South Derbyshire PCT
  who dial 999 feeling unwell (CAT B 26 of the
  EMAS code) and those patients with non-life
  threatening injuries (CAT Cs of the EMAS code).
• Potential benefits
• Reduction in the rate of admissions to AE for
  those patients classed as CATB 26 and CAT Cs,
  thus bringing about financial savings to Southern
  Derbyshire/Derbyshire Dales PCT.
• Increase in the use of ECP/CP type of staff when
  codes B26 and CAT Cs are identified, as opposed
  to the current default closest available crew.
• Increase the use of sitting services by the
  voluntary sector (particularly by the red Cross).
• Financial savings for EMAS through improved
  dispatch procedures

8
Can appropriate management of patients at the End
of Life lead to more people dying in their place
of preference, mainly home?

• Problem statement
• Nationally, the preferred location of death for
  all patient cohorts is in the home (56), with
  the alternative locations of hospital (11),
  Hospice (24) and Care Homes (4) as less
  favoured. however, the actual place of death is
  predominantly the hospital (56) followed by Care
  Homes (20) and the Home (20) (reference
  sources).
• It is perceived that through a better
  co-ordination of community facilities/services
  and improved education and training for staff,
  families and carers then a shift in the location
  of death to meet the preference of the patient
  can be realised.
• Patients involved
• Cancer and non-cancer patients at the EoL.
• Potential benefits
• A redesigned service shall enable the individual
  to die in their preferred setting and thus reduce
  unnecessary admissions for patients at their EOL.
  
• The identification of the number of patients who
  are identified will be improved (and it is
  likely that the number also increased)
• More patients will die or be prepared to die in
  their place of choice
• Professionals satisfaction with EoL management
  will be increased.
• Ultimately, in the long-term this should bring
  about a reduction in the number of emergency
  admissions to Chesterfield Royal.

• Levers for shift to be tested
• Segmentation program specifically targeting at
  patients in the EoL phase
• Integration joint effort by GP practices to put
  in place an EoL management program
• Substitution less admissions to hospital and
  more deaths taking place at the preferred place
  for death by patients and families (mainly home)
• Proposed measures
• Number of patients identified at EoL
• Number of patients for whom mechanisms to
  appropriately manage EoL are put in place
  (conversation with patient and / or carers)
• Increase in number of patients dying at home
• Description of current management of patients
  inappropriately admitted into hospital at EoL
• Cost-benefit modelling long-term extrapolation
• Project team
• Project champion Sue Cohen
• Project manager Jennifer Stothard
• Timetable
• Early July sign off of charters and measures
• July - Audit at the Chesterfield Royal,
  recruitment of GP practices to participate,
  design of questionnaires for data collection
• September launch of new management for EoL
  patients

9
Project charters

• Birmingham
• Derbyshire
• Manchester
• Stour
• Torbay

10
Can diabetes outpatient appointments in secondary
care be reduced by extending primary care
services?

• Problem statement
• The current diabetes patient journey is complex
  and unclear
• which results in increased duplication of
  services and
• outpatient appointments in secondary care. In the
  period
• between 2004-2006 nearly 13563 follow-up
  appointments
• were made in MDC. In nearly 75 of these cases a
  specialist
• treatment is not required. There is a need to
  define simplified
• Patient journey for diabetes and identify
  activities within
• Secondary care that can reasonably be delivered
  within
• primary care reducing pressure within the acute
  sector to
• deliver services faster
• Patients involved
• Diabetes type-2 patients with the exclusion of
• Unscheduled activity
• Complex diabetes management
• High risk age groups
• Pregnancies

• Levers for shift to be tested
• Simplification and standardisation from a
  patient journey that involves unclarity and
  duplication of work resulting in excessive
  referrals to secondary care
• Substitution of secondary services by primary
  care services i.e. extended services by GP
  practices
• Proposed measures
• Reduction in diabetic type-2 outpatient
  appointments
• Change in the level of services (as defined in
  the ladder model) offered by GP practices
• Cost benefit analysis
• Patient and carer/relative satisfaction
• Project team
• Programme lead Sara Radcliffe
• Project lead Edward Dyson
• Practice lead Robert Varnam Ann Maw
• Timetable
• July 2006 - sign off of project charter
• Aug2006 - finalise design and plan for field
  testing
• Aug-Dec 2006 - carry out field test

11
Can less complex gynaecology outpatient
appointments in secondary care be reduced
byextending primary care services?

• Problem statement
• Central Manchester currently spends 900,000 on
  gynaecology outpatients. In 2004-2005 nearly
  11,000 gynaecology appointments were made in
  secondary Care approximately 1/3 new and 2/3
  review
• Local evidence suggests that there is scope to
  raise and standardise the work undertaken in
  primary care prior to referral on to secondary
  care for a number of more common conditions.
• The purpose of the project is to define the
  activities currently undertaken within secondary
  care that could reasonably be delivered within
  primary care, identify the obstacles preventing
  primary care from undertaking this work and test
  the impact of removing the obstacles.
• The first phase will cover infertility further
  phases will cover dysfunctional bleeding and
  Polycystic Ovarian Syndrome (PCOS).
• Patients involved
• The project will cover the investigation of adult
  patients with infertility problems in the first
  phase
• The second phase will include female adult
  patients with dysfunctional bleeding.
• Potential benefits
• The reduction in gynaecology OP appointments in
  secondary care and the provision of more care
  within GP practices should
• Allow secondary care to reduce waiting times
• Allow secondary care to focus on the more complex
  conditions that can only be treated in secondary
  care
• Allow the transfer of resources from secondary to
  primary care
• Improve the patient/carer experience through the
  provision of care closer to home

• Levers for shift to be tested
• Standardisation from an unclear patient journey
  that can involve duplication and excessive
  outpatient attendances to a single agreed work-up
  prior to referral.
• Substitution of services in secondary care by
  primary care services.
• Proposed measures
• Reduction in gynaecology outpatient appointments
  per referral/reduction in referrals
• Change in the level of services offered by GP
  practices
• Cost benefit analysis
• Patient/carer satisfaction
• Project team
• Programme lead Sara Radcliffe
• Project lead Caroline Davidson
• Practice lead Dr Colin Hoddes Dr Manisha
  Kumar
• PBC Scheduled Care lead Dr M Griffiths
• Clinical lead secondary care Dr Edi-Osagi
• Management lead secondary care L Chantler
• Nurse lead secondary care P Kilcoyne

12
Can a new commissioning model for urgent care be
developed and help to facilitate in shift in care?

• Problem statement
• Manchester has developed a range of urgent care
  services including AE, PCEC, rapid response, OOH
  support, Cat C desk and social care. However,
  issues remain in terms of achieving the 4 hour
  target and appropriate ownership of specific
  urgent care services. Whilst individual services
  may be working effectively there is no
  overarching framework for coordinating
  activities. This study seeks to develop a new
  commissioning model for urgent care owned by the
  PCB hub which will fit into the Manchester PCT
  framework.
• Patients involved
• The project will consider all major groups of
  patients using urgent care service within central
  Manchester
• Potential benefits
• Identification of a model for commissioning new
  and innovative solutions to the provision of an
  improved urgent care system
• Development of an agreed framework that will
  allow specific services to be developed jointly
  by the urgent care providers
• Establishes a mechanism within the new PCT and
  PCT hub for commissioning urgent care and
  achieving shift

• Levers for shift to be tested
• Integration joint ownership of services between
  providers
• Substitution potential shift of urgent care
  services to a more appropriate setting
• Proposed measures
• Identifies potential KPI measures
• Projected reduction in admissions
• Projected cost/benefit analysis
• Patient and carer/relative satisfaction
• Project team
• Sara Radcliffe Project Champion
• Chris Euston Project Manager
• Jodi Kelly Project Support
• Timetable
• Aug 2006 complete charter and plan
• Sept 2006 engage stakeholders, research and
  preparation
• Early Oct 2006 Workshop on alternative
  commissioning models

13
Project charters

• Birmingham
• Derbyshire
• Manchester
• Stour
• Torbay

14
Can nurse appointments be shifted using
self-monitoring in hypertension?

• Problem statement
• Patients with hypertension (HT) are invited to
  attend a nurse appointment twice a year.
  However, some patients do not want or need to
  attend appointments this frequently and there is
  a high DNA rate. The stress caused by attending
  for monitoring can result in inaccurate readings.
  
• Patients involved
• Cohort patients diagnosed with HT but no other
  co-morbidity and specifically those newly
  diagnosed or due to be recalled for their review
  during the period of the project (1200 patients
  with HT registered at surgery 50 have no other
  disease)
• Potential benefits
• Reduction in unnecessary nurse appointments
• Reduction in wasted patient time
• Greater empowerment of patients and improved
  patient experience
• Resultant financial benefit

• Levers for shift to be tested
• Substitution
• - Patient held records
• - Self-monitoring
• - Empowering patients through providing improved
  
• patient information
• Proposed measures
• Patients recruited to self-monitoring project
• BP readings received from self-monitoring
  patients
• Reduced number of clinic appointments for
  hypertension
• Improved service users satisfaction with
  services
• Cost analysis
• Project Board and Project team
• Project champion Graham Archard
• Practice lead Alison Nutt
• Patient lead John Reeves
• PCT - TBC

15
Can avoidable hospital attendances be prevented
and/or length of stay reduced through a
practice-based liaison nurse service for
vulnerable patients?

• Problem statement
• A set of patients has been identified who are at
  a high risk of admission to secondary care and
  who are receiving information to signpost
  appropriate care by a liaison nurse based at
  Stour Surgery. There is a need to determine how
  effective this communication and planning has
  been in avoiding readmission and whether there is
  scope for further avoidance through assisted
  discharge from planned and AE hospital
  attendance.
• Patients involved
• Those on vulnerable patients list (115 patients
  over last 12 months 20 patients currently on
  list)
• Potential benefits
• Reduction in admissions to AE
• Reduction in admissions to secondary care beds
• Improved patient, carer/relative experience
• Resultant financial benefit

• Levers for shift to be tested
• Integration
• - shared communication of management plan
• - improving inter-agency working
• Substitution - signposting to the most
  appropriate person to manage care
• Proposed measures
• Reduction in emergency admissions for this
  patient cohort
• Reduction in length of stay in hospital
• Patient and carer/relative satisfaction
• Cost analysis
• Project team
• Project champion Simon Coupe
• Practice lead Heather Amey
• Timetable
• 12 July sign off of project charter
• End July - finalise design and plan for field
  testing

16
Project charters

• Birmingham
• Derbyshire
• Manchester
• Stour
• Torbay

17
Can the quality of care for diabetes patients be
improved by increasing management of insulin
therapy in primary care?

• Problem statement
• Patients requiring insulin initiation who are
  referred to secondary care could, through
  appropriate training and support for GP
  practices, be managed in primary care.
• Patients involved
• Patients requiring insulin initiation in selected
  GP practices (5 practices to be selected from the
  22 practices in Torbay Care Trust)
• Potential benefits
• Increased initiation of insulin in primary care
• Improved general diabetes skills in primary care
• Reduced hours spent by specialist nurses on
  insulin initiation
• Reduced referral to secondary care for initiation
  of insulin
• Convenience and better continuity of care for
  patients
• Resultant financial benefits

• Levers for shift to be tested
• Substitution substituting primary care for OP
• Proposed measures
• GP practices initiating insulin
• Level of competence of primary care staff
• Hours spent by specialist nurses on insulin
  initiation
• Patient experience
• Cost analysis
• Project leader
• Christine Jackson
• Project champion
• Adrian Jacobs
• Timetable
• 10 Jul - design workshop
• Aug - finalise design and plan for field testing

18
Can clinically appropriate access to diagnostics
can be planned with the outcome of reducing
unplanned admissions to an acute hospital setting?

• Problem statement
• A substantial number of inappropriate hospital
  admissions
• are associated with diagnostic services relating
  to
• Heart failure
• Deep vein thrombosis/pulmonary embolus (DVT/PE)
• Blood transfusion
• MRI
• One-stop flexi-sigmoidoscopy/barium enema
• Patients involved
• Patient cohorts to be defined for each of the
  five sub-projects.
• Potential benefits
• Improved patient experience
• Support to the delivery of the Integrated Care
  Network and the necessary bed reductions in the
  acute trust
• Support to achieving financial balance
• Front-loading the care pathway with diagnostics
  to assist in achieving the 18-week referral to
  treatment completion target

• Levers for shift to be tested
• Substitution direct GP access to diagnostics
• Proposed measures
• Measures to be defined for each of the five
  sub-projects.
• Project team
• Lynne Leyshon, Divisional General Manager
• Sharon Matson, Head of Service Improvement
• Timetable
• 5 Jul - sign off project charter with PEC
• 10 Jul - design workshop
• Aug - finalise design and plan for field testing
• Aug-Dec - carry out field test
• Nov-Dec - evaluate results

Note scope being revised to develop a framework
for selecting diagnostic tests appropriate for
shift. Project Charter available 4th October
19
How can the organisation and quality of care for
patients in the last year of life be optimised?

• Problem statement
• How can the organisation and quality of care for
  patients in the last year of life be optimised?
• Patients involved
• Patients in the last year of their life, within 2
  zones (Paignton North and Torquay South)
• Potential benefits
• Increase the proportion of people dying in their
  place of choice
• Improved patient choice and experience
• Resultant financial benefits
• Levers for shift to be tested
• Integration
• Substitution changing referral patterns

• Proposed measures
• Expected deaths from death certificates
• Training
• Number on GSF
• Number dying in place of choice
• Avoided admissions
• Cost analysis
• Project leader
• Di Conduit
• Timetable
• Aug - finalise design and plan for field
  testing
• Aug-Dec - carry out field test
• Nov-Dec - evaluate results