ODT Workforce Design Project Midlands Regional Collaborative 2 nd December 2014 Ella Poppitt, Head of Service Design Organ Donation and Transplantation NHSBT

Outline – Orientation to the ODT Workforce Project – Phase 1- basis and objective – Overview of Findings – Future Modelling of the SN-OD role – Overview of future plans and timescales – Q&A

Taking Organ Transplantation to 2020 Strategy –Measure 1 Consent/authorisation for organ donation Aim for consent/authorisation rate above 80% (2012/13: 57%) –Measure 2 Deceased organ donation Aim for 26 deceased donors per million population (pmp) (2012/13: 19.1 pmp) –Measure 3 Organ utilisation Aim to transplant 5% more of the organs offered from consented, actual donors –Measure 4 Patients transplanted Aim for a deceased donor transplant rate of 74 pmp (2012/13: 49 pmp)

ODT Workforce Project Objectives (Phase 1) Design a workforce model to meet the strategic aims and targets of the TOT 2020 strategy using evidence obtained from data and statistical review, literature review and internal & external stakeholder engagement. Ensure staff feel involved in the process and have had their views heard. Phase 1 :December September 2014 Phase 2: October December 2015

Phase One - Complete Flexible options to meet fluctuating demand Most roles involve 24hr working Family facing role = greater impact on consent Specialist and focused roles Variety of professional backgrounds The current Specialist Nurse role and the donation pathway Current and future donor activity National and regional service provision Future predicted donor activity for 2020 Length of process and time of day activity happens National, regional and individual consent rates Audit workload NHSBT staff Workshops International Review Data Analysis Options not to work 24hrs Remove theatre element from the role More time required for hospital development Time to build relationships with families No consensus on how the role should look Praise for SN-OD role from hospital partners 40% felt change required Main purpose of role – donor co-ordination; family liaison, raising awareness Stakeholder views

Statistics & Data Review for the Workforce Project

Areas of Data Investigated –Current regional activity –Configuration of the service –Forward modelling to 2020 –The impact of non-proceeding activity & opportunities –The donor process, associated timings & relationship to role –The importance of consent –SNOD consent rates –Multivariate analysis on consent paper –The impact of level 1, 2 and 3 activities and relationship to SNOD role –The impact of audit and data collection

Regional Profile of Donation Potential

Trust Activity 2013/14 by Level

The dots on the magnified London area are not to scale Level 1s Potential and Actual

The dots on the magnified London area are not to scale Level 1 + 2s Potential and Actual

The dots on the magnified London area are not to scale Level 1, 2 + 3s Potential and Actual

DBD: Length of Process Considerable regional variation hours

DCD: Length of Process Considerable regional variation hours

Heat Maps: Referral and SN-OD Attendance Activity Heat Maps for all significant time points in the donation process

Consent Rate Multivariate Analysis Associated most strongly with family consent (p<0.0001) Patient ethnicity; knowledge of a patient’s wish to donate; involvement of a specialist nurse for organ donation in the family approach The impact of the SN-OD on family consent Stronger for DCD than DBD, and was significant even when the impact of prior knowledge of the patient’s wishes was accounted for. Other significant factors Cause of death; the number of family members present during the donation conversation; the relationship of the primary consenter to the patient. Family refusal is a major barrier to donation in the UK Represents biggest opportunity to increase donor numbers, particularly for DCD. Improving the involvement of SN-ODs in the family approach is a key component of current strategies to increase UK consent rates

SN-OD consent/authorisation rate DCD DBD Demonstrated numerically SN-ODs in the current role do not actually approach that often (2 years data) Variable of rates of performance by SN-ODs Numbers not large (Maximum is 54 approached over 2 years- average 1 request every 2 weeks) Supports the need to have numerically less specialised staff requesting more often to become experts Impact on consent if you separate the requestor from the facilitator? PDA not designed to measure this Can only count cases where there is no doubt over the SNOD name. Point it time considered is who made the approach UK average is 15 approaches per annum per SN-OD (2013/14)

2013/14 SNOD attended NORS attended Actual donors Non proceeding donors (NORS attended) Organs Transplanted DCD DBD /08 For every 1 family approached for DCD 1 patient benefited from transplantation 2012/13 For every 2 families approached for DCD 1 patient benefited from transplantation The DCD Pathway

Donor Activity per Regional Team Does not reflect the levels of SNOD attendance for DCD

Respiratory failure 245 referrals, 140 attendances,28 NORS attendances, 25 donors= 37 kidneys, 1 liver transplanted Multi Organ Failure 1113 referrals, 471 attendances, 3 NORS attendances 3 donors= 5 kidney transplants Cancer, other than brain tumour 280 referrals, 106 Attendances, 0 NORS attendances= 0 donors Septicaemia 247 referrals, 101 attendances, 3 NORS attendances, 3 donors, 1 kidney transplant MOF/ Cancer/ Sepsis/Renal failure as a ‘cause of death’= 688 SNOD attendances (6 NORS attendances)= 6 Donors over 1 year DCD activity by ‘Cause of Death’ 1 April 2013 to 31 March 2014 Renal Failure 30 referrals, 10 Attendances, 0 NORS attendances= 0 donors

In the Context of SNOD Activity... Cases of MOF, RF, Cancer & Sepsis combined 688 SNOD attendances in 2013/14 (6 NORS attendances) 6 Donors, 6 Transplants In 2013/14 NHSBT deployed a SNOD on 114 occasions for every 1 organ transplanted 2633 SNOD attendances over 4 years 2010/ /14 (31 NORS attendances) 25 Donors, 30 Transplants Over these 4 years NHSBT deployed a SNOD on 87 occasions for every 1 organ transplanted DCDs aged > SNOD attendances over 4 years 2010/ /14 (27 NORS attendances) 11 donors, 6 transplants Over these 4 years NHSBT deployed a SNOD on 125 occasions for every 1 organ transplanted from a patient aged >81 years Plan: to conduct a piece of work to analyse this further: Significant impact on the volume of work within the SN-OD role

Workforce Modelling of the SNOD role

Clinical Clinical + demand Structure of the model is based on the 6 main types of activities that SNOD currently undertake 1. Consent related activity 2. Clinical activity 3. Theatre 4. Hospital development 5. Death audits 6. SNOD – adm activity  Triage of incoming referrals  Attendance to referrals  Approach families for consent  Clinical activity following consent, excluding theatre time  Attendance to surgery in theatre  Activity with hospitals to drive referrals and ensure compliance with transplantation policies  Audit of all deaths in ED/ICU of patients below the age of 81  Follow-up letters to donors  File closure of donors  Prepare ODC documentation for hospitals’ committees

Consideration of Options Using the findings from phase 1 of the project Consideration of all options for each task- who could perform that role? Whether each ‘role’ should be SNOD/ other new NHSBT role/ non NHSBT role (i.e. a commissioned role) Likely impact of the National referral Centre (ODT Operational Hub) on some tasks currently performed by a SNOD All role options evaluated via a workforce model including the existing SNOD role Number of roles identified during workshops at a high level Acknowledgement: Laura Hontorio Del Hoyo Assistant Director, Blood donation and Strategy, NHSBT

Role Options Modelled- Revisited Dedicated requester/ consent role Audit role Hospital development Clinical Co-ordinator Theatre role Additional Work –Developing high level role profiles –Consideration to alternative models of how staff on call are deployed to a referral –Financial modelling of all options Current SNOD role Consideration of options +/- on call Commissioned/ local options Roles in isolation of component parts

Role Options Modelled- Considerations Dedicated requester/ consent role Audit role Hospital development Clinical Co-ordinator Theatre role Investigating the viability of all the options including the current SN-OD role against many criteria

Next Steps for the Project –Evaluate the workforce modelling and feedback to staff the impact of the modelling on the options that have been considered within the project- commenced –Engage with key stakeholders in relation the potential impact of change during this period- commenced –Trial new role as pilots within specific regions- Evaluate outcomes and impact- planning phase –Take forward a paper based evaluation of potential triage interventions alongside current practice and evaluate findings- implement as appropriate- planning phase –Timelines for phase 2 completion- 31 st December 2015 –Implementation of any potential new workforce model for the SN-OD role- January 2016 onwards

Role Pilot- High level outline Workshops underway across the UK to discuss this with the SN-OD workforce Potential impact on strategy Applies the concept of fewer individuals in a consent/ requesting only role to maximise the frequency and the expertise of the requestor Supported by international evidence for increasing consent (phase 1) Work alongside the existing clinical role (from consent to theatres) Allows new role options to be modelled and piloted- develop a new consent role and further develop the clinical role of the SN-OD Developing plans for a pilot in 2 regions of the UK Split the existing SNOD into 2 roles (at the point of consent) Separating consent/ requesting activity from the existing SN-OD role

What will be the focus of the project in phase 2? A Consent/ Specialist requesting Role to be taken forward via a pilot alongside the SNOD/ Clinical Role Pilot and Implement a DCD Triage model

Thank you for your attention