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

2. 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 am
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)

3. 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

4. Optimal Service Design Workshop
Introduction &
purpose
of today

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Optimal Service Design Workshop Systematic QIPP Development
Questions?

14. Optimal Service Design Workshop
Gap analysis

15. 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).

16. 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.

17. Optimal Service Design Workshop
Outpatients

18. 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

19. 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%)

20. 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

21. 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)

22. 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?

23. Optimal Service Design Workshop
Non-elective admissions

24. 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

25. 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?

26. 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’

27. 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?

28. Optimal Service Design Workshop
Primary care prescribing

29. 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.

30. 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

31. 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

32. 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?

33. Optimal Service Design Workshop
Best / Optimal
Practice Review

34. 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

35. 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

36. Optimal Service Design Workshop Best / Optimal practice review
PainSense – managing chronic pain
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

37. Optimal Service Design Workshop
Questions?

38. Optimal Service Design Workshop
Adopt, Improve or Defend

39. 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

40. 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

41. 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

42. Optimal Service Design Workshop
Workshop feedback

43. 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

44. 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

45. Optimal Service Design Workshop
Thank You