1. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow SHIFT Project – Salfords Health Investment For Tomorrow Whole system pathways and commissioning as a dynamic approach Janet Roberts, Sylvain Laxade, Janelle Homes, Richard Freeman

2. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow What we are going to cover Making it Real What have we done? Were there problems? What are we doing now? How will we make change stick?

3. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Where have we come from and what have we done?

4. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow History of the Project Strategic Outline Case Initial hospital focus Victorian ward blocks Salfords health status Other organisations LIFT

5. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Features of the new systems Integration of health and social care Planned or elective care Unplanned or emergency care New intermediate level services New ways of managing out patients and chronic diseases

6. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow How services will change….. Acute Intermediate Primary / community Old = organisational focusNew = Pathway focus 1010 2020

7. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Service Design Groups Emergency ElectiveChronic Disease Management Diagnostic & Therapies Intermediate Care Elderly Primary Care Childrens Interface Group

8. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow User / public involvement Early principle of project Public consultation Patient focus Get it right! Requirement for planning services Methodologies

9. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Care Pathways & Service Redesign Care Pathways & Service Redesign Integrated Care Pathways are one way of implementing protocols. They express locally agreed, multidisciplinary practice, based on guidelines and evidence, where available, for a specific patient group.They form all or part of the clinical record, document the care given and facilitate evaluation of outcomes for quality improvement purposes (Modernisation Agency, 2002) The first stage of an Integrated Care Pathway development relates to the provision or mapping of the patients journey, what is to happen, where, when and by whom.This is often referred to as the High Level Care Pathways (Modernisation Agency 2002)

10. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Accessing the detail Identified a range of diseases / patient presentations & services Clinical leads Events - Energise

11. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Getting Started Clear methodology for the redesign processClear methodology for the redesign process Identification of the key stakeholdersIdentification of the key stakeholders Selection of case types based on pre set criteriaSelection of case types based on pre set criteria Development of a project planDevelopment of a project plan Inclusion and exclusion criteriaInclusion and exclusion criteria Strategies for managing the redesign processStrategies for managing the redesign process Reporting mechanismsReporting mechanisms

12. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow A Sample Project Plan Part 1:Part 1: Process Map of current patients journey and SWOT analysis against NHS PAF Part 2:Part 2: Process Map of future journey, Key proposals and the resource implications Part 3:Part 3: Potential Opportunities and Health Impact- access, outcomes, efficiency, effectiveness, patients experience. Key protocols and guidelines supporting the new journey Part 4:Part 4: Health and Social interventions and goals along the patients journey and manpower/skill mix identification

13. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow

14. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Primary Care Model A&E Model Emergency Model Theatre Model Specialty Model Intermediate Care Model Chronic Disease Model OBC Model Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

15. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

16. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

17. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

18. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Procurement Commissioning, LDPs Modernisation Development Agenda Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

19. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Technology Development PACS – Remote Health Management – ICRS – telemedicine & telemonitoring- Diagnostics & Lab Procurement Commissioning, LDPs Modernisation & Development Agenda Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

20. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Human Resource Management Recruiting, rewarding, retaining New roles, new ways of working, whole system working Technology Development Integrated patient record, PACS – Remote Health Management – ICRS – telemedicine & telemonitoring Procurement Commissioning, LDPs Modernisation Development Agenda Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Dependence Continuum Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

21. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Health Care Infrastructure Human Resource Management Recruiting, rewarding, retaining New roles, new ways of working, whole system working Technology Development Integrated patient record, PACS – Remote Health Management – ICRS – telemedicine & telemonitoring SHIFT / LIFT / Health & Social Care Partnership Procurement Commissioning, LDPs Modernisation Development Agenda Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness Social ServicesCity CouncilLife EventsLife Event & Life Cycle Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Care Continuum OBC Model Social Model Support Activities Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

22. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Health Care Infrastructure Human Resource Management Recruiting, rewarding, retaining New roles, new ways of working, whole system working Technology Development Integrated patient record, PACS – Remote Health Management – ICRS – telemedicine & telemonitoring SHIFT / LIFT / Health & Social Care Partnership Procurement Commissioning, LDPs Modernisation Development Agenda Management Systems Systems of planning, finance, quality control, etc. Scheduling, access, outcomes, user experience, efficiency, effectiveness INDEPENDENCEDEPENDENCE INDEPENDENCESEMI - DEPENDENCE Primary prevention - Osteoporosis - Falls management Early recognition - call for help - initial management Primary Care Model A&E Model Emergency Model Emergency model management 72hr stay Operation time according to condition Recovery Theatre Model Specialty Model Specialty bed Length of stay < 6 days Intermediate Care Model Intermediate Care e.g. virtual, transitional, therapy beds Chronic Disease Model Secondary prevention & chronic disease management A&E management RCP guidelines Fast track Quality & Cost - effective care Access Efficiency Patient / User Experience Outcomes Effectiveness Equity Care Continuum OBC Model Dependence Continuum Support Activities Laxade S: Creating and sustaining superior performance in health care - an adapted model of M E Porter: Competitive advantage, creating and sustaining superior performance – the value system

23. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow START Patient consults General Practitioner GP assesses needs Hernia diagnosed / suspected GP sends referral letter to hospital Consultant triages patient and informs appointments Hospital sends appointment to patient Initial outpatient consultation. Consent given. Patient put on waiting list Hospital pre-operative assessment … six, nine, twelve months later Patient attends Day Case Unit - Operation - Home on day of surgery unless clinically contra indicated Review in outpatient 4-6 weeks later, discharge to GP. Audit completed END YES Refer to appropriate agency NO

24. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow START Patient consults GP with hernia GP assesses condition and suitability for day case hernia according to anaesthetic and surgical protocol Investigations and test if necessary GP books patient into Day Case Unit operating list via direct booking on line according to the patients preference GP emails referral letter and Day Case suitability pro forma to hospital- Consent in principle Patient attends Day Case Unit Seen by Surgeon and Anaesthetist Written consent Operation if appropriate and fit- Same day discharge Review appointment with GP / a Nurse in Primary Care On line audit form completed and emailed to hospital END

25. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Goal achieved GP level. Patient presents with hip pain GP assessment using joint protocol Serious pathology suspected Refer to orthopaedic consultant immediately END Refer to appropriate agency END Hip problem suspected NO YES Refer to PCT Central Booking System for physio triage. Commence pain management Triage in primary / secondary care Patient <50 years Vascular necrosis suspected,significan t hip pain Refer to orthopaedic surgeon Identify causeTreat accordingly Patient appropriate for surgery P1 Refer to orthopaedic consultant Outpatient appointment within 4 weeks Listed for surgery via booking system Outpatient appointment via central booking system PC Stage 1 Pre-operative assessment within 2/52 of listing New Zealand score. Priority assessment/ Health Management Hip assessment. Wish for surgery YES MDT assessment Goal setting Identify address All home alterations/ modifications Surgical consent Back to primary care for goal management Admit on day of surgery, subject to anaesthetic criteria. Surgery 3/12 NO Hospitalisation. Length of stay 3/5 days unless clinically indicated Hospitalisation goals achieved Discharge home6 weeks review ? P Care 12 weeks review YES NO YES 2nd pre-op assessment + Anaesthetic assessment Treat as P3

26. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Intermediate Care needed YES Identify package of care setting, etc. Options Transitional home/ Intermediate Care/ Hospital Intermediate Care Goals met 1 year review Indefinite review via THR system Discharge Go to review system Chronic D Mang END Outcome of New Zealand Hip Score Patient improvingReview managementTreat as P3 Priority classification. Care for all Refer to community physio and OT via booking system Pain management according to pain guidelines Review New Zealand hip score in primary care 3/12 P3 Manage according to P2 Refer to Orthopaedic Surgeon Continue P3 programme Outpatient physio GP management Review 3 to 6 months Pain management if required New Zealand Score P3 P2 NO P3 P1 P2 Remain at P2Continue programmeReview in 3/12 Refer to Orthopaedic Surgeon P1 Surgical management DISCHARGE Review system END

27. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Future underpinning of Elective Care Application of the 72 hour principle An amalgam of service models as identified in OBC Focus on length of Stay underpinned by outcomes and coordination Use of a range Intermediate Care facilities Dependence on IM&T Supported by new roles and functions High S Care acuity and turnover leading to quicker access Redefinition of purpose of Secondary and Primary Care Clinical Governance across whole system Post-op review in Primary Care Linked to Social Services and City Council Life Event Model

28. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Planned Care……………. Key Change Principles emerging from the Redesign Primary Prevention and Early Detection Strategy Management in Primary Care via Joint Protocol Development and Clinical Network Informal access to Surgeons and Physicians if required Referral according to pre set criteria via Central Booking System Not all Patents need to go to Outpatient Investigations and Diagnostics in Primary Care prior to referral Surgery in an appropriate location based on Risk criteria Pre-op location based on Anaesthetic Risk Admission on day of Surgery

29. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Integrating the Redesign into the Commissioning Process The Logical Steps Process map of current service SWOT Analysis/NHS PAF Future Design Resource Implications and Economic Model Clinical Governance - Guidelines/Protocols Medicine Management Committee Professional Executive Committee Integration into LDPs/Financial Flows Directorates agenda Monitoring by Exception Integrating the Redesign into the Commissioning Process The Logical Steps Process map of current service SWOT Analysis/NHS PAF Future Design Resource Implications and Economic Model Clinical Governance - Guidelines/Protocols Medicine Management Committee Professional Executive Committee Integration into LDPs/Financial Flows Directorates agenda Monitoring by Exception

30. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Resource Implications PeoplePeople TimeTime User InvolvementUser Involvement SupportSupport PlanningPlanning Specific Needs client / patient groupsSpecific Needs client / patient groups

31. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Barriers Time »Right people – right time »Short term delivery targets v long term improvements Culture »Bureaucracy & Institutional loyalties »Adversarial approach between primary & secondary care »Silo thinking & working »Risk aversion »Professional & inter professional tension & rivalry »Limited ownership locally of overall strategy People »Resistance to change – suspicion, fatigue, cynicism, apathy »Self preservation, empire building »Fear – involving patients & carers Information »Lack of good quality / whole system information & data »Lack of shared information

32. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Overcoming barriers Skills –Energiser –Barometer –Programme Manager –Facilitator –Translator –Communicator

33. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Strengths of the process Relationship changes Energy & Enthusiasm Mutual understanding and agreements Communication & networking

34. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow What are we doing now? How will we make the change stick? Created SHIFT vision, service principles and sample care pathways Directorate / service level planning Core organisational focus Early wins Tier 2 / Collaboratives / NSFs / etc.

35. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow The challenge for commissioning How can commissioning make service redesign work?

36. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow How can commissioning help? Costs & activity Financial flows Local Delivery Plans Ongoing quality & activity monitoring

37. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Pathways & commissioning Translate pathways into separate elements with: –Costs –Locations –Expected activity –Quality measures –Quantified impact on existing services This will be the basis for commissioning redesigned services

38. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Financial flows Payments linked to activity National tariff price for each HRG Full cost implications of activity changes Regime is still developing Issue of currency & tariff for: –Mental health services –Community services

39. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Using financial flows Financial flows means Moving activity at full cost Patient choice is reflected in payments But… Need to develop mechanisms for pathways to cross between primary & secondary care

40. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Local Delivery Planning Sets out actions to meet key deliverables Prioritisation process for schemes So… Actions arising from service design must be reflected in the LDP Service design resource requirement must be subject to appropriate scrutiny and prioritisation

41. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow Ongoing monitoring Develop mechanisms and indicators to monitor: –Quality of service provided –Activity delivered –Access to services The above will be required for each part of the pathway

42. Project HIFT alfords Health Investment For Tomorrow Project HIFT alfords Health Investment For Tomorrow