Neurological Optimal Service Design Workshop 10 November 2015 Defining “what to change” using the NHS Right Care methodology

Today’s agenda (1) Introduction and Purpose of Today 10.15am - The purpose of today’s workshop - Why NEW Devon CCG has adopted NHS Right Care - How NEW Devon CCG uses NHS Right Care in QIPP planning Gap Analysis 10.35am - Summary of deep dive findings - Review of deeper performance analysis - Best practice / optimal practice review - Q&A on deep dive findings BREAK 11.45am Adopt, Improve, Defend (AID) 12.00noon Work in groups to define: - Which best/optimal practice should be adopted - Which current practice should be improved - Which current practice can be defended - Feedback AID recommendations LUNCH (1.15pm)

Today’s agenda (2) Service Redesign 1.45pm Taking AID outputs, design the specification for the service Action / strategy planning 3.00pm Produce action plan for new service specification and define strategic statements for longer term improvement Workshop Feedback 3.35pm Feedback to make workshop a better learning experience Questions 3.45pm - Final opportunity for questions

Optimal Service Design Workshop Introduction & purpose of today

Workshop Purpose To understand how NHS Right Care is used by NEW Devon CCG To understand the theory behind NHS Right Care To understand the findings of the service deep dive and further analyse the topics selected for improvement To design optimal service solutions to: Resolve issues identified during the analysis Set performance parameters for the new service design Identify any strategic requirements Reduce unnecessary variance in outcomes, quality & cost To learn a standardised approach to evidence based change in NHS NEW Devon CCG

Systematic QIPP Development Adoption of NHS Right Care NHS NEW Devon CCG must maintain a continuous list of improvement opportunities to ensure that QIPP requirements can be met each year To do this we must adopt a standardised approach to QIPP development that will bring clarity and assurance to the QIPP proposals NHS Right Care is designed for CCGs to tailor to their purposes using the overall methodology as a blueprint NHS NEW Devon CCG will develop its use of the Right Care system in outline and refine it as the QIPP programmes develop, effectively testing it with delivery and improving as we go 5YFV “closing the gap” target for NEW Devon is to be upper quintile across the board, therefore all opportunities will be valued at a top 20% indicator The deep dive has selected areas showing variation in the service that we need to change to meet peer performance and move towards national upper quintile We are here to identify and agree changes to the service to improve outcomes, cost and quality

Systematic QIPP Development NHS Right Care Overall Methodology We are here “What to change”

Systematic QIPP Development Phase 1 - Where to look Where to look will happen once each year to produce a high level ranked list of opportunity to pursue We do this using a series of nationally available indicative data comparing our performance against a selected peer group of health economies The output of this phase is a scoped and ranked list of opportunity Commissioning for Value Atlas of Variance Programme Budgeting Local Interpretation Benchmark, value, rank and prioritise themes using agreed national and local data. Identify opportunity of top ranked themes. Produce a scope per theme. Present scope to steering group for go/no go decision. Themes ranked With a scope per theme

Systematic QIPP Development Phase 1 - Where to look (2013/14 data) We have ranked all services by value (a combination of demand, outcomes, cost and performance) 2013/14 performance shows a total value against peer of £116M and against the national upper quintile position of £268M 16 of the 22 categories have been selected for deep dive review in 4 waves in 15/16 These are not the QIPP targets but an indication of where our services are sub optimal compared with other health economies

Systematic QIPP Development Phase 2 part 1 - What to change What to change starts with a deep dive exercise focusing on the selected theme The deep dive pack is analysed and QIPP plans are defined with sufficient evidence to produce a project mandate. The output of this phase is a project mandate NHS Right Care deep dive is completed (6 weeks) Detailed deep dive is analysed and prioritised and planned targets defined (3 days ) Implementation plans are drafted, business cases defined and project mandate produced (2 days) Mandate assessed at steering group for go/no go decision Note: An example mandate is in your handouts

Systematic QIPP Development Phase 2 part 2 – What to change – today’s workshop Once the mandate is approved we can undertake deeper analysis of the selected QIPP projects This deeper analysis culminates in an optimal service design workshop including providers, patients and CCG members The output of this phase is a project initiation document including the new service design, strategy and implementation plans Assess gaps to best in class Clinically led pathway redesign Strategy for theme Complete Strategy to action plans, full business case, & full PID Test against gold target and initial objective Full PID assessed at steering group for go/no go decision

Systematic QIPP Development Phase 3 - How to Change Once the PID is approved we can start to implement the planned changes Implementation will follow the NHS NEW Devon CCG turnaround methodology and will seek to deliver benefits as fast as possible Projects will be delivered and sustained under the Turnaround governance structure

Optimal Service Design Workshop Systematic QIPP Development Questions?

Optimal Service Design Workshop Gap analysis

Optimal Service Design Workshop Summary of deep dive findings Key messages: Overall spend is in 2nd highest quintile nationally Total variance from upper quintile of between £6.9m - £15.2m Acute Care Outpatients £2.4m - £4.3m Acute Care Non-elective Admissions £2.7m - £5.6m Primary Care Prescribing £1.8m - £5.3m Epilepsy outcomes appear to be poor for ‘seizure-free for preceding 12 months’ indicator Epilepsy prevalence is high Long waits for diagnosis? (LINK survey 2013).

Optimal Service Design Workshop Summary of deep dive findings Neurology deep dive identified 3 priority opportunities: To improve O/P pathways, outcomes and to reduce number of outpatient attendances - Neurology – epilepsy and headaches - Chronic pain and relevant diagnostics Prevention and reduction of non-elective admissions manage and prevent repeat attenders Primary Care prescribing - reduce volume and cost of prescribing.

Optimal Service Design Workshop Outpatients

Optimal Service Design Workshop Summary of deep dive findings Outpatients (opportunity between £2.4m - £4.3m) 2nd highest neurological outpatient spend Largely driven by CHRONIC PAIN (44% of total neurological outpatient spend) Neurological outpatient spend Chronic pain outpatient spend

Optimal Service Design Workshop Summary of deep dive findings Pain Management - outpatients Total number of O/P attendances across NEW Devon = 16,567 80% of attendances are seen at PHNT (8,763) and RD&E (4,499) Variation across NEW Devon in how pain management services are accessed Referral source PHNT RD&E NDHT GP 2,656 (30%) 973 (21%) 559 (19%) Consultant other than A&E 5,685 (64%) 2,164 (48%) 73 (2.5%) Consultant responsible for O/P episode 51 (0.5%) 791 (17.5%) 2,230 (76%)

Optimal Service Design Workshop Summary of deep dive findings Pain Management - outpatients Variation in first to follow-up ratio Type Pain volume F/F-up ratio ROYAL DEVON AND EXETER NHS FOUNDATION TRUST First attendance 1,751 Follow-up attendance 2,748 1.6 PLYMOUTH HOSPITALS NHS TRUST 1,772 6,971 3.9 There were 4,223 more follow-up attendances at Plymouth Hospitals NHS Trust at a cost of £376,000

Optimal Service Design Workshop Summary of deep dive findings Epilepsy Map 15: Percentage of people with epilepsy aged 18 years and over on GP epilepsy registers who were seizure-free for the preceding 12 months by CCG 2013/14 Domain 2: Enhancing quality of life for people with long-term conditions NEW Devon 65.8% compared with a national median of 73.7% Directly standardised mortality rate for epilepsy is 1.7 per 100,000 compared to 1.6 national median Large variation across practices – 29 have epilepsy outcomes significantly lower than expected 2nd highest quintile for anti-epileptic drugs (but we know these are also used for pain management)

Questions / Opportunities What opportunities exist to reduce Pain Management O/P attendances? What is driving the variation of referral patterns into Pain Management? What opportunities exist to reduce Pain Management O/P follow-ups?  What opportunities exist to reduce variation in first to follow-up ratios for Pain Management O/P? What opportunities exist to improve epilepsy outcomes across 29 practices where outcomes are significantly lower than expected? What can we learn from each other across the localities?

Optimal Service Design Workshop Non-elective admissions

Optimal Service Design Workshop Summary of deep dive findings Non-elective admissions (opportunity between £2.7m - £5.6m) Age standardised non-elective admissions are high Driven by a select group of 6 HRGs Large volume of non-elective admissions for headaches and migraines Age Standardised Non Elective Admission Rates for all CCGS

Optimal Service Design Workshop Summary of deep dive findings Non-elective admissions 313 - convulsions 207 - dizziness & giddiness 183 - epilepsy Data HRG Sum of Volume Sum of length_of_stay average LOS AA22A - Non-Transient Stroke or Cerebrovascular Accident, Nervous System Infections or Encephalopathy, with CC 126 887 7.04 AA22B - Non-Transient Stroke or Cerebrovascular Accident, Nervous System Infections or Encephalopathy, without CC 17 51 3.00 AA25A - Cerebral Degenerations or Miscellaneous Disorders of Nervous System, with CC 416 2557 6.15 AA25B - Cerebral Degenerations or Miscellaneous Disorders of Nervous System, without CC 22 15 0.68 AA26A - Muscular, Balance, Cranial or Peripheral Nerve Disorders, Epilepsy or Head Injury, with CC 921 4109 4.46 AA26B - Muscular, Balance, Cranial or Peripheral Nerve Disorders, Epilepsy or Head Injury, without CC 91 100 1.10 AA29A - Transient Ischaemic Attack with CC 367 737 2.01 AA29B - Transient Ischaemic Attack without CC 21 0.71 AA31A - Headache, Migraine or Cerebrospinal Fluid Leak, with CC 593 849 1.43 AA31B - Headache, Migraine or Cerebrospinal Fluid Leak, without CC 163 154 0.94 PA01A - Nervous System Disorders with CC 43 320 7.44 PA01B - Nervous System Disorders without CC 109 86 0.79 Grand Total 2889 9880 3.42 Alternatives to admission?

Optimal Service Design Workshop Summary of deep dive findings Non-elective admissions and discharge Majority of non-elective admissions from care homes are for: % of total non-elective admissions for HRG - Muscular, Balance, Cranial or Peripheral Nerve Disorders, Epilepsy or Head Injury, with CC 7% - Cerebral Degenerations or Miscellaneous Disorders of Nervous System, with CC 42% - Transient Ischaemic Attack with CC 5% Majority of patients are discharged to ‘usual place of residence’

Questions / Opportunities What opportunities exist to reduce non-elective admissions relating to: Dizziness and giddiness Epilepsy Headaches and migraines What alternatives are there to non-elective admissions?

Optimal Service Design Workshop Primary care prescribing

Optimal Service Design Workshop Summary of deep dive findings Primary care prescribing (opportunity between £1.8m - £5.3m) NEW Devon expenditure on neurological prescribing is higher than the national median and that of its 10 CCG peers High levels of item prescribing but not necessarily matched by higher spend Neurological primary prescribing, NEW Devon compared with 10 most similar CCGs.

Optimal Service Design Workshop Summary of deep dive findings Primary care prescribing (opportunity between £1.8m - £5.3m) High levels of item prescribing but not necessarily matched by higher spend Hypnotic and Anxiolytic drugs highest volume and cost of prescribing Primary prescribed items for neurological conditions, 2013/14 Cost of Primary prescribed items for neurological conditions, 2013/14

CNS prescribing variation across localities Optimal Service Design Workshop Summary of deep dive findings CNS prescribing variation across localities Western CNS prescribing high – mainly antidepressants , analgesics and anti-epileptics Pregabalin and gabapentin account for most of variation in anti-epileptics

Questions / Opportunities What opportunities exist to reduce prescribing of anti-eplileptics, anti-depressants, analgesics? Are prescribing guidelines for Pregabalin and Gabapentin clear and being followed? What alternatives to Pregabalin and Gabapentin are available? What opportunities exist for GP / Patient education about prescribing relating to pain management? What opportunities exist to support patient self-management of pain / epilepsy?

Optimal Service Design Workshop Best / Optimal Practice Review

Optimal Service Design Workshop Best / Optimal practice review West Hampshire CCG – improving services for people with long term conditions 1 in 5 have a neurological condition Issues: long delays in accessing expertise (in hospital and the community), poor access to information and advice, inequitable and fragmented services, gaps in service, lack of knowledge of pathways and services from GP/patient perspectives, lack of self-referral and peer support West Hampshire Neurology Strategy Dovetails with CCG’s strategy for LTC / aligns with Mental Health, Neurology and Dementia Strategic Clinical Network Supported self-care central to strategy Quick wins Headaches – single headache pathway; online headache diagnosis and decision-making tool; aims to reduce volume of migraines referred to neurology Epilepsy – new epilepsy nurse role; linking hospital, community and GP outreach services, reduction in ED attendances, specific service for first seizures, reducing avoidable seizures

Optimal Service Design Workshop Best / Optimal practice review Dudley CCG – developing an integrated neurology care pathway 1 in 16 have a neurological condition Issues: early signs and diagnoses, treatment and services, support and follow-up, on-going care Long-term neurological conditions strategy group – CCG, hospitals, Dudley Council, service users and carers, voluntary sector Solutions Formation of MDT neurological community care team (improve coordination of services and provide care closer to home) Community neurology – 98% patient satisfaction, savings of £38,000 from effective prescribing (over 12 months) Single point of contact for patients to MDT, self referral, reducing GP and consultant contact QIPP initiative to reduce neuro O/P referrals by 5% over 12 months – savings of £25,986

Optimal Service Design Workshop Best / Optimal practice review PainSense – managing chronic pain www.pain-sense.co.uk two digital apps designed to give more support for self-management for people living with persistent pain App version of the "Pain Toolkit" developed by Dr Frances Cole and Pete Moore, and an app version of the "Pain Management Plan" developed by Dr Cole and Professor Bob Lewin App-based needs assessment and patient-reported outcome tools, and eLearning resources for clinicians. Apps are integrated into clinical systems such as SystmOne and EMIS.   The App when combined with pathway redesign is demonstrating: (figures below are from the pilot of PainSense) Cash releasing savings from reduced prescribing (up to 20%) Reduced hospital costs (27% reduction in onward referrals to secondary care) Reducing primary care activity (50% reduction in consults) 80% more patients saying personal goals in managing pain were met

Optimal Service Design Workshop Questions?

Optimal Service Design Workshop Adopt, Improve or Defend

Optimal Service Design Workshop Adopt, Improve, Defend What: Identify the key elements of the service that are sub-optimal Determine if there is better practice for the element Elect to adopt better practice, improve current practice or defend current practice How: Map the backbone of the service in patient flow order Under each mapped step record the performance of the step Identify better practice for the suboptimal steps and put it under each step Elect to Adopt, Improve or Defend for that element Patient managed in primary care Patient managed in primary care then referred on Patient seen at outpatients but discharged at first appointment Patient receives follow up appointment Patient admitted Pathway Backbone 38% more than average in primary care 72% patients referred on from primary service 29% more than average discharged at first appointment 23% more than average follow up appointments 4.8% more patients admitted than average Pathway Performance NICE guidance on primary care management Gloucester model for primary care management Oxford model for O/P triage NICE guidance on patient initiated follow up Royal College recommendation on decision to admit Better practice Defend Adopt Improve Adopt Adopt AID

Optimal Service Design Workshop Service Redesign What: Having elected an AID category for each step of the service define what the step will look like and how it will perform Specify reasons with evidence for any defend decisions How: Map the backbone of the new service Under each mapped step record the expected performance Record key changes to current step to achieve the new one - “must” statements If necessary add a strategic statement for the step Patient still managed in primary care Patients requiring acute service identified early Patient triage completed by DRSS for GPwSI service Patient initiated follow up iaw NICE guidance Conservative treatment offered iaw guidance New Backbone 38% more than average managed in primary care 50% reduction of patients managed in two settings 40% reduction in discharge at first appointment 25% reduction in follow up appointments 4% reduction in admissions Expected Performance Currently best use of interface service in UK - Change spec for primary service - GP funding for back referrals Setup GPwSI service Adopt Oxford triage protocol - Standard letter to patient - Reappointment “hot line” Conservative treatment made available Key Changes / Defend evidence To increase primary care management To use patient decision aids To reduce surgical intervention Strategic statements

Optimal Service Design Workshop Action Planning What: Determine actions to make the key changes happen Align the actions with the project timescale: Implementation = making the change Delivery = measuring the benefit How: Complete a post it for each action as shown Put the post it on the timeline where the task starts Add new planning categories as they emerge For quick wins: date is ASAP; position on the timeline is not relevant Action: stop all physio referrals to outpatients Outcome: 2,300 unnecessary outpatient referrals stopped, 500 back referrals to GPs started Date (from –to): ASAP Owner: F Bloggs, commissioning lead Implementation Delivery Planning Category Sep Oct Nov Dec Jan Feb Mar Strategy Commissioning policy Pathway changes Quick wins

Optimal Service Design Workshop Workshop feedback

Optimal Service Design Workshop Feedback While completing your feedback forms please consider what went well, what didn’t go well, what helped it go well and what hindered it. Put comments on post its on the flip chart at the front What went well What went not so well Group working was good I didn’t understand the data I don’t think we’ve picked the right subjects More biscuits! Not enough pre reading Not being involved in analysis hindered CPD meant I could come today What helped What hindered

Optimal Service Design Workshop Next Steps In the next two weeks, the CCG project team will: Complete a project plan and business case for the proposed changes (PID) Complete any further analysis required to support the business case Identify and inform stakeholders of the planned changes Submit to the CCG turnaround steering group for formal acceptance as a QIPP scheme

Optimal Service Design Workshop Thank You