commissioningsuccess NOVEMBER/DECEMBER 2015
NOVEMBER/DECEMBER 2015
commissioning
SUCCESS SUPPORTING EXCELLENCE IN HEALTHCARE
CASE STUDIES | AMBULANCE COMMISSIONING | SUICIDE PREVENTION
THROWING A LIFELINE
The trailblazing CCGs dedicated to reversing rising suicide numbers
ISSUE 18
RISKY BUSINESS
THE VISIONARIES
HEAD IN THE CLOUDS
Getting to grips with the best risk stratification tools and models out there
Expert insight into effective eye care commissioning
How can cloud computing be used to improve patient experience?
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Editor’s letter
A
CONTENTS COMMISSIONING UPDATE 04
News and updates The latest news affecting commissioning
06
Co-commissioning The myriad benefits of co-commissioning GP services
10
Suicide prevention We speak to CCGs dedicated to reversing a worrying trend COMMISSIONING IN ACTION
s the year draws to a close, how has your CCG fared? Are deepening deficits keeping you awake at night? Or are you sleeping soundly in the knowledge that clever initiatives and cost-cutting strategies are setting you in good stead for the future? For the majority of commissioners, the year has been a mixed one – and we hope that best practice case studies and analysis in these very pages have proven useful during both the highs and lows. In the run up to the Christmas break, we thought we’d pull together some of the most interesting case studies and features of the last 12 months. Whilst the way in which the national media reports on the health services can be pretty negative, Commissioning Success is all about taking a different slant and showcasing some of the superb work being done by clinicians and managers across the country. First off in this digital issue is a look at what commissioners are doing to improve upon some worrying statistics around mental health – namely the fact that, according to the Office for National Statistics, we lose around 6,000 people a year to suicide. On page 10 Alice Sholl speaks to a couple of CCGs who are thinking outside the box to reverse the trend. We’re also digging deeper into mental health care delivery by speaking to NHS England’s national clinical director for mental health, Dr Geraldine Strathdee. Limited access and a variation in standards are at the top of her list of concerns, and on page 22 she explores the role commissioners can play in improving care and highlights the work of those leading the way. Elsewhere, it’s the usual mix of CCG case studies (p12), technology insight (p34) and management advice (p44). Have a wonderful Christmas and we’ll see you in the New Year!
12
Leeds West CCG One CCG’s two-year project to improve the quality of life of children living with asthma
16
Ambulance commissioning What should commissioners consider when procuring an ambulance service?
20
Reducing A&E admissions Blackpool CCG’s innovative approach to cutting the number of unnecessary hospital admissions
22
Dr Geraldine Strathdee NHS England’s national clinical director for mental health discusses the integral role commissioners play
24
Airedale NHS Foundation Trust Waking up to the innumerable benefits of telemedicine in healthcare COMMUNITY CARE
28
Eye care commissioning Expert insight into how to ensure eye health services are focused on outcomes
32
Implementing prescribing efficiencies One programme’s mission to reduce unused medicine wastage INFORMATION AND TECHNOLOGY
34
Cloud technology How can cloud computing be used to improve patient experience?
38
Risk stratification Which tools and models are out there and how can they improve outcomes? MANAGING COMMISSIONING
CONTACT US
JESS PIKE, MANAGING EDITOR MANAGING EDITOR jessica.pike@intelligentmedia.co.uk
DESIGNER sarah.chivers@intelligentmedia.co.uk
EDITORIAL ASSISTANT alice.sholl@intelligentmedia.co.uk
DESIGNER/PRODUCTION peter.hope-parry@intelligentmedia.co.uk
PUBLISHER vicki.baloch@intelligentmedia.co.uk
CIRCULATIONS natalia.johnston@intelligentmedia.co.uk
SENIOR ACCOUNT MANAGER krystle.davis@intelligentmedia.co.uk
42
Legal insight The Public Contracts Regulations 2015 and the changes affecting commissioners
44
Conflict prevention Expert advice on how to effectively manage conflicts of interest
intelligent media solutions
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UPDATE NEWS
NEWS £2.4BN WORTH OF CONTRACTS THAT COULD FINANCIALLY BENEFIT CCG BOARD MEMBERS REVEALED CCGs in England have awarded nearly 500 contracts worth at least £2.4bn to providers in which one or more of their board members had a financial interest, the National Health Executive (NHE) has reported. The investigation, jointly led by the BMJ and The Times, revealed that 50 CCGs awarded contracts despite a clear conflict of interest being present. A total of 437 out of just over 5,500 contracts were given to healthcare providers in circumstances where one or more CCG board members had a declared interest. The probe confirmed findings of an earlier investigation by NHE that revealed nearly onefifth of CCGs have required more than half of their board members to withdraw from a meeting because of conflicts of interest. NHS England’s current rules on conflicts of interest are relatively loose, with the BMA’s GP committee chair dubbing it “too permissive”. The rules grant CCGs the freedom to self-determine whether conflicted
board members should be forced out of relevant parts of meetings, or join discussions but refrain from voting. These rules, which ultimately leave the course of action at the CCG chair’s discretion, have become the root cause for variation in conflict handling across the system – and an inevitable lack of accountability for how public money is spent. An NHS England spokesperson told the investigators: “Robust statutory guidance on managing conflicts of interest for CCGs has been published with input from the National Audit Office (NAO) and other regulators. A national audit is underway to look at how these arrangements are working in practice.” However, the BMJ is adamant that its latest investigation ultimately reignites calls to entirely ban GPs from holding board positions in a CCG if they are directors of the provider organisation it commissions. NHE has previously shown that GPs don’t have to be directors to have a vested interest in providers.
Wellbeing services for young people in Suffolk given £6m funding boost Services aimed at improving the emotional health and wellbeing of young people in Suffolk will be boosted to the tune of £6m over the next five years, the Ipswich Star has reported. The additional funding from NHS England will enable the introduction of major improvements to services, which health officials say will lead to “fundamental changes to the quality and effectiveness of services for children, young people and their families”. Improvements will include the development of a single point of access and assessment for children’s emotional health, wellbeing and behaviour referrals, a greater use of technology and digital-based therapies and more support for whole families, rather than just one child. Health officials in the county have said the successful funding bid “highlights the strong multi-agency commitment and robust transformation plans” of the local authority, CCGs and other health and wellbeing partners. Chairman of Suffolk’s Health and Wellbeing Board Alan Murray said: “This additional funding will have a positive impact on the lives of our children and young people. The key areas of focus will be to simplify how services can be accessed, with a family approach, and providing the right support at the right time and in the right place. We will also see the introduction of a specialist community based county-wide eating disorder service.” Dr John Hague, mental health clinical lead for the Ipswich and East Suffolk CCG, added: “This is excellent news and these transformation plans are a concrete example of how the whole system is working together for the benefit of those people who need young people’s emotional wellbeing services.”
04 | NOVEMBER/DECEMBER 2015
UPDATE NEWS
PLANS TO CONSTRUCT GLOUCESTERSHIRE HOSPITAL COMMUNITY UNITS UNVEILED A 74-bed community unit will be built at Frenchay and Thornbury hospitals, the Bristol Post has reported. South Gloucestershire CCG has said that it will provide 44 NHS rehabilitation beds and 30 mixed-use care beds at the new facility. The CCG originally said it would provide 68 community beds on the Frenchay site but then bosses declared they were “moving away” from the concept of a community hospital. There is an ongoing campaign in the area to save community facilities for the future, after the Frenchay site closed last year and the new £430m Southmead Hospital opened.
Now that the proposal has been made, the business case and funding for the hospital’s redevelopment is expected to be scrutinised. A final decision on the new beds is expected to be reached in March 2016. MPs Chris Skidmore and Jack Lopresti welcomed the news, saying: “As local MPs who have campaigned consistently for a new hospital at Frenchay, we are delighted. This is the culmination of a long campaign that has involved us holding debates in the House of Commons and many meetings with health ministers making the case that the area needs this hospital provision.”
‘LAST RESORT’ ANTIBIOTICS POSE GROWING THREAT TO HEALTHCARE
The use of antibiotics as a last resort has risen significantly in England during the last five years as antibiotic-resistant infections continue to grow, the Guardian has reported. Research by Public Health England (PHE) said usage of antibiotics when all other treatments have failed has risen since 2010, with the use of carbapenems and piperacillin/ tazobactam increasing by 36% and 55% respectively from 2010-14, although the rate of increase is slowing. Both are used in intensive care, transplant or cancer units against serious infections, such as pneumonia and kidney infections. “Their use, while very small, has increased in the last few years,” said Dr Susan Hopkins, the healthcare epidemiologist at PHE and the report’s lead author. “We
want hospitals to move away from these last resort antibiotics after two or three days of treatment to use more targeted antibiotics. There is a lot of work taking place to tackle antibiotic resistance and reducing prescriptions of antibiotics is just one strand of that work.” Last resort antibiotics, also known as broad spectrum drugs, are effective against a wide range of bacteria, but are more likely to drive antibiotic resistance. They are used when doctors do not know what type of infections they are dealing with. The PHE report said that overall antibiotic resistant infections continue to rise. The rate of E coli and Klebsiella pneumoniae bloodstream infections increased by 13.5% and 17.2% respectively from 2010-14.
CLINICAL CORNER BREAST CANCER DRUG TOO EXPENSIVE FOR NHS A life-extending breast cancer drug will not be routinely offered on the NHS in England and Wales because it is still too expensive, says a watchdog. According to BBC News, women in England will be able to get Kadcyla through the Cancer Drugs Fund, but the price tag per patient – £90k at full cost – is too high to widen access, say the draft NICE guidelines. NICE criticised manufacturer Roche for not making it more affordable. Roche says discussions are continuing, meaning a resolution is still possible. Kadcyla can add about six months of life to women with incurable disease. It is used to treat people with HER2-positive breast cancer that has spread to other parts of the body and cannot be surgically removed. Roche recently agreed a significant price discount with NHS England to stop the drug being taken off the Cancer Drugs Fund. But the Swiss pharmaceutical company offered a different, smaller discount to NICE for regular NHS use of Kadcyla in England and Wales. NICE says this undisclosed figure is still too high to justify against the drug’s clinical merits. NICE chief executive Sir Andrew Dillon said: “We recognise that Kadcyla has a place in treating some patients with advanced breast cancer and we have been as flexible as we can in making our recommendation. However, the price that the manufacturer is asking the NHS to pay in the long term is too high.” Any person currently receiving the treatment can continue until they and their doctor consider it appropriate to stop.
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NOVEMBER/DECEMBER 2015 | 05
UPDATE CO-COMMISSIONING
M I G H T Y OA K S FROM LITTLE ACORNS GROW
Ipswich and East Suffolk CCG was one of the first in the country to take the bull by the horns and start co-commissioning GP services. JESS PIKE catches up with chair DR MARK SHENTON to find out how this new way of working is paving the way for more joined-up healthcare across the locality oldest is Norfolk) and we also have areas of extreme deprivation within the boundary of Ipswich. A number of Ipswich wards are within the most deprived 10% in the country and about one in five children are living in poverty in Ipswich. It’s quite a broad spectrum – we have a lot of affluence, a lot of age and a lot of deprivation and poverty – it’s quite a mixed bag, really. What’s your background Mark? I’m a practicing GP at Stowhealth in Stowmarket, Suffolk and have been a partner there since 1996. What are the main health challenges there? We have a very elderly population, the second oldest in the country (the first
06 | NOVEMBER/DECEMBER 2015
align incentives and explore how we can make variations to direct enhanced services (DES) to make them more relevant to our local population. Have you been able to do that yet? Yes. One of the key things we’ve looked at has been aligning local enhanced services (LES) with national DESs around care homes, multi-disciplinary teams and national unplanned admissions.
And what have been the benefits, thus far, of co-commissioning primary care services?
And what’s next on the horizon?
It joins up what we do as a CCG so we can look more at linking services right through from prevention in public health, to general practice, to community services and into the hospital trust setting. It will help us
We’re looking at integration of care and health between social care, primary care, community services and hospital services. How do we go about commissioning for general practice’s place at the table
UPDATE CO-COMMISSIONING
And how has a new way of working impacted on workload for CCG members? It hasn’t really – we don’t see it as being an additional element but we do have to be constantly mindful of potential conflicts of interest.
within an integrated care organisation, for example? What are the big challenges? I think it’s about finding out how to incentivise the system when a big part of it sits within the hospital setting. How do you make acute and primary care more equal partners at the table? And how do we challenge the cultures that are inherent in our system whereby you’ve got a significant amount of care being paid as a block contract and a lot of money being spent on an activity basis (payment by results)? How do we bridge that payment challenge and the culture of work that runs alongside those means of delivery? Does payment by results encourage increasing activity for income? Does having a culture based on getting a fixed fee for your services throughout the year inhibit change or make it happen? How do you put the two different services together in an integrated way? These are the big challenges. And what about conflicts of interest? For us it’s about making the most out of the opportunities rather than getting tied up in knots about what a conflict of interest is. It shouldn’t be about eliminating conflicts of interest but about keeping everything as transparent as possible around decisionmaking. If you try and eliminate the conflicts of interest you take all the parties out of the room which isn’t necessarily the right thing to do. So the structure hasn’t changed hugely since co-commissioning for GP services began? We have a co-commissioning committee and no GPs sit on that. We’ve had a committee in place that deals with payments to general practice ever since we’ve been constituted and GPs aren’t involved with that.
And what impact has this new way of commissioning had on your patient population? We’ve just undertaken a major health and care review which looks at how we can work with our partners in local government and all of the assets in our local communities. We’re trying to work out how to get the system operating more effectively, given the fact that we’ve got several thousand charities in Suffolk, some very solid communities and good networks as well as good quality general practice. How do we create networks in neighbourhoods that support people and prevent them from going into crisis? It’s quite a broad review but we’re starting with a couple of localities within the county, such as one in east Ipswich, where we’re trying to pull together the neighbourhood team to work with risk-stratified patients and help manage them as they’re tipping towards crisis.
“How do you make acute
and primary care more equal partners at the table?” What are the other benefits of cocommissioning GP services? Last year we collaborated on retaining the local PMS contract arrangement – I think one practice moved to GMS but we were able to retain the value of the PMS contract locally and refresh a development framework for those practices holding that PMS contract. Examples like that show we can play a role in ensuring that the voice of our practices is heard within the local area team. And what else is the CCG working on? At the moment we’re also looking at recruiting and retaining GPs and looking at how to make general practice attractive
for recruits as well as those on the cusp of retirement. We’re currently working with our Ipswich practices and looking at how they could work together more effectively to overcome some of the problems they’ve got. It’s about maintaining interest so GPs may do a little less general practice but at least they’re still working within the general practice fold.
Dr Carl Ellson, chief clinical officer for NHS South Worcestershire CCG, explains their plans for the cocommissioning of local GP services
“We’ve already developed an eight-point plan which describes our intentions for primary care commissioning during 2015/16. A key component is the offer of a new nine month local contract, called Promoting Clinical Excellence, which focuses on frailty and the frail elderly and excellence in the management of long-term conditions such as blood pressure measurement, hypertension management and detection and management of atrial fibrillation as well as respiratory and other illnesses. The CCG sees these two things combined as the platform on which it can build. For us, the benefits we expect to see as a result of this investment include proactive, coordinated, high quality care for older adults with severe frailty, reduced morbidity and mortality in stroke, heart and kidney disease, reduction in inappropriate hospital admissions and sustainable general practice. As a CCG we want to move away from a fee-based, supply-induced demand contract to rewarding practices for outcomes; we plan on entering into an agreement that extends beyond the normal 12-month period.”
NOVEMBER/DECEMBER 2015 | 07
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ISSUE 13
So whether you’re on the board of a clinical commissioning group, participating in commissioning, a provider or interested from the side-lines, stay one step ahead of all commissioning-related news and developments. Commissioning Success will provide you with the must-have tips and tools to make a success of clinically-led commissioning.
UPDATE SUICIDE PREVENTION
Throwing a lifeline e rise in the th n o re a s e Suicid eaks to the p s L L O H S E UK. ALIC cutting these to d te a ic d e d CCGs anisations rg o e th d n a numbers look to for n a c rs e n io s that commis pport advice and su
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uicide is on the increase in the UK. It’s something no one likes to hear but it’s overwhelmingly and statistically true. According
Whatever preconceptions you may have about suicide there are clear patterns in the contributing factors that lead a person to want to take his/her own life. For example, a greater proportion of people who take
to the government’s statistical update on suicide the number of suicides has been steadily increasing since 2008 and, according to the Office for National Statistics (ONS), we lose around 6,000
their own life are male – 80% according to the latest ONS suicide figures. Suicide’s also prevalent in middle age, particularly in people aged between 35 and 50, with those in the hardest economic situations at
people a year to suicide. One can feel powerless to reverse such a bleak trend but clinical commissioners are among those who can take action for the patient populations they serve.
greatest risk. Consider the UK’s economic position over the past 10 years; during the recession suicide numbers increased as pressures upon families and individuals grew,
10 | NOVEMBER/DECEMBER 2015
particularly for those providing for a family. “When somebody loses a job it can challenge their very identity because they feel like they’re no longer meaningful,” explains Joe Ferns, executive director of policy, research and development at Samaritans. “When it comes to the psychology of how somebody becomes suicidal it often starts with a sense of defeat and then feeling trapped,” he says, and whether or not someone is able to talk about their problems, and how open or supportive the relationships around them are, makes a big difference.
UPDATE SUICIDE PREVENTION
TAKING ACTION Despite the challenging prospects for those struggling with mental health more CCGs are now dedicating their time and budgets to suicide prevention. Bolton CCG recently committed an extra £450,000 towards its mental health services and has set up multiple initiatives and crisis centres in the area to reduce suicide risk. Much of this budget has gone towards training and awareness for healthcare staff. The Papyrus Suicide Safer Communities initiative, a campaign which provides suicide awareness training, has received funding from the CCG with the aim of reducing fear and anxiety surrounding talking about suicide – actively encouraging participants to get involved with suicide prevention. Importantly, Bolton’s focus has been to ensure that as many people as possible are trained up – from frontline staff to community members. For those working closely with vulnerable people, the CCG has commissioned applied suicide interventions training in which participants learn about everything from the attitudes and beliefs that can affect a suicidal person to identifying when someone’s at risk of suicide. And then there’s ASIST – Applied Suicide Intervention Skills Training – which can involve anyone in a community from the age of 16 – and STORM training for frontline staff designed to boost knowledge and confidence among individual mental health workers. Tailoring training to individual staff is highly beneficial. Over in the Midlands, Birmingham South Central CCG has been involved in setting up GP-specific suicide prevention workshops. Enabling GPs to support a patient who may be suicidal, and to be aware of at-risk people, means that a patient’s first point of contact can prevent the situation from escalating further. Addressing mental health issues early on in primary care has also been found to save valuable funds – a scheme launched by Newham CCG, in which patients have regular check-ups with community psychiatric nurses in GP practices instead of with a hospital psychiatrist, has shown just 10% of patients relapsing and having to return to psychiatric care. It’s also good to have a strong grasp on
numbers. “Currently, the female suicide rate in Bolton is 111% higher than the national rate and this is a continuing trend,” a spokesperson for Bolton CCG says. “There are a number of risk factors: 86% have had prescribed medication, 70% have received a mental health diagnosis and 50% have been seen by mental health services in the past year.” Such information speaks volumes about suicide risk in a local area compared to the national picture. Bolton CCG recommends building a strong evidence-base by taking annual suicide audits, tracking any patterns or causes you might find and studying information at a national level. In this way you can turn information into locally meaningful recommendations. A LEARNING PROCESS Despite initiatives sparking up across the country it’s still relatively early days for many CCGs’ suicide prevention strategies so don’t forget to learn from the experts – those with suicidal thoughts have been contacting Samaritans for years. “It’s important to recognise that people often need help outside of traditional working hours,” Joe says. “There’s something really important about crisis care across a 24-hour period.” Those who do not meet the thresholds for clinical intervention can also fall through the gaps and become vulnerable, especially over holidays and weekends. In the Pennines and North Essex mental health teams have been working with Samaritans to offer such patients supportive telephone calls. After a high takeup the charity is moving on to trial the scheme with GPs and is looking at inpatient or outpatient facilities too. “We’re keen to find other trusts that are willing to come on board and we’re almost ready to expand it across the county.” In addition to using the right information be sure to target groups that are the most in need of support. It’s all well and good knowing that a disproportionate number of men take their own lives but you need to address the underlying causes. Research from Mind suggests that almost a third of men would be embarrassed about seeking help for a mental health problem; it’s important, therefore, that you make your services as accessible to men as possible. The same goes for an area of
high socioeconomic deprivation. “Whether it’s rural isolation, drug use or certain population groups, CCGs should be looking to target their work based on what the local problems are.” Suicide certainly isn’t a simple issue. But by carrying out the right analysis, you can begin to make some positive changes to the way mental health care is delivered in your area – and see the tide turn as a result.
RESOURCES The Mental Health Foundation’s list of risk factors: www.mentalhealth. org.uk/help-information/ mental-health-a-z/S/suicide/
The Samaritans’ Men and Suicide report: www.samaritans.org/ about-us/our-research/researchreport-men-suicide-and-society
Mind’s website: www.mind.org.uk
The government’s statistical update on suicide 2015: www.gov.uk/government/ uploads/system/uploads/attachment_ data/file/405411/Statistical_update_on_ suicide_acc.pdf
TOP TIPS • Have a suicide prevention lead who holds no other responsibilities • Provide 24-hour support • Ensure support can be provided as quickly as possible • Provide training tailored to those interacting with vulnerable patients • Analyse patterns and causes in different areas • Target services to those patients most at risk.
NOVEMBER/DECEMBER 2015 | 11
IN ACTION CASE STUDY
BREATHING EASY It’s estimated that 1.1million children in the UK have asthma – many of whom have poor control of their condition. EMILY HARDY talks to LAURA BROOKER, NHS Leeds West CCG’s clinical lead for children’s asthma, about their two-year project to improve the quality of life of children living with asthma in the area
A patient develops severe breathing difficulties, the clock is ticking, what are you going to do?
12 | NOVEMBER/DECEMBER 2015
00:00:30
IN ACTION CASE STUDY
WHAT’S YOUR BACKGROUND AND ROLE AT THE CCG, LAURA? I’m a children’s nurse with a background in allergy and immunology but I’ve been employed by the CCG to work specifically on this project as the clinical lead for children’s asthma. The CCG developed a business case which would implement and sustain gold standard care for children living with asthma. The clinical lead for children and maternity services and the broader team made a start on the project by going into schools and making a video that really led our work and illustrated its necessity. I started in January 2015 and we’ve grown the project from there. WHY HAS THE CCG PRIORITISED CHILDREN’S ASTHMA? At NHS Leeds West CCG we’re focusing on long-term conditions. Asthma is a chronic common condition and one in every 11 children has it. The National Review of Asthma Deaths (NRAD) – a report by the National College of Physicians – examined the circumstances surrounding recent asthma deaths and found that two thirds of these could have been avoided; this really hit home and demonstrated how important it is to standardise care and ensure all children with asthma receive regular reviews, personal asthma action plans and inhaler technique checks. Asthma UK tells us that you’re four times more likely to end up in hospital if you don’t have an action ” plan but, shockingly, only 22% of people with asthma have one! The CCG is also signed up to the Asthma UK pledge; that’s to say we recognise asthma has a major impact on health and quality of life and that people with asthma deserve great treatment from the NHS. We therefore pledged to take action to see that the asthma quality standard is implemented in our area by March 2016.
receive training in order to feel confident in supporting children with asthma during school hours. For a school to be ‘asthma friendly’ they must meet a number of requirements and the team is on hand to advise the school on how they can meet these. Requirements include having a robust asthma register, an asthma policy and an emergency salbutamol inhaler available for children to use when necessary because sometimes inhalers run out or get lost – it’s a big ask to expect children to carry one around with them the whole time. One of the schools has already had to use its emergency inhaler, possibly preventing an asthma attack. We’re using a similar model with early years services and have started working with member practices. This involves offering training for practices, setting up children’s asthma clinics after school and during school holidays, providing practices with asthma resources and ensuring practice nurses are confident in delivering personal asthma action plans and checking inhaler technique. Asthma UK recently released a report following on from the prescribing errors that were highlighted in the NRAD 2014. They’ve found that people with asthma are prescribed long-acting beta agonists without steroids which is against clinical guidelines. They also found that more than 100,000 people are being prescribed shortacting reliever inhalers, which is an indicator that their asthma is poorly controlled. As a result Asthma UK is calling for practices to review their asthma registers and call patients in for an asthma review. Some of the practices we’re working with are doing this now and we hope that more will follow suit. We’ve also put together a steering group – including schools, pharmacies and NHS trusts – which meets quarterly to discuss how to move the project forward and is really well attended!
“Asthma is a chronic common condition and one in every 11 children has it
HOW DID YOU GO ABOUT DOING THIS? The video highlighted the fact that children wanted to know more about their asthma and how to manage it themselves so we started our work in schools, talking to children, teachers and parents with the aim of making schools ‘asthma friendly’, based on a similar project that was received really well in Ealing. We wanted to make sure children understood why they were taking their inhalers, what the different ones are for and how to use them properly. We’ve started giving parents education and support around asthma and keeping their child well. Teachers and staff were also keen to
HAVE YOU HAD ANY PROBLEMS GETTING SCHOOLS ON BOARD? The schools seem very keen to engage. Time was always going to be an issue, not just with schools but with all professionals, so we’ve been amazed at the numbers who’ve attended the steering group and taken an active interest in the project. We have 90 schools in the Leeds West area and we’ve started work with seven of them already; many others asked us to come back to them in September when it’s quieter.
You dial 999.
00:01:07
NOVEMBER/DECEMBER 2015 | 13
IN ACTION CASE STUDY
“We’ve seen some really positive preliminary outcomes” HOW ENGAGED WERE THE CHILDREN IN THE PROJECT? I’ve been overjoyed to see how much the children enjoy the assemblies we host; these don’t just help children with the condition, they show the other children how they can help their friends too. We do a quiz at the end of the assembly and the children love it! It shows us that they’ve taken the information on board. If we capture children while they’re young the hope is that they’ll carry on these good habits. The school nurses have been brilliant too – they’ve really engaged with the project and have taken on the education we’ve provided; without their support this work wouldn’t be working as well as it is. Practice nurses are also keen to work with us – inviting us into their practices to support them with education and personal asthma action plans. WHAT CLINICAL OUTCOMES HAVE YOU NOTICED SO FAR? It’s still early days but we’ve seen some really positive preliminary outcomes; eight of our member practices have made children’s asthma a priority for their quality improvement projects and other practices are considering this move too. Member practices have also found that, as a result of our work to raise awareness, they’re being asked more frequently for personal asthma action plans. We’ve received feedback from children who’ve changed device and had support with their technique and have, consequently, reported improvements. And we’ve still got 18 months to go! WHAT ARE THE NEXT STEPS? We hope to expand our work into secondary schools, asking students to give their point of view on how we can best meet their needs. We’re going to be expanding our work with early years services too by providing more education for staff at children’s centres. We’ll obviously be continuing our work with schools and member practices and we want to make plans for sustainability – making sure that this work sticks. We’ve employed nurses who
work in our member practices to keep the work going in the future and, because we’ve involved the school nurses so much, we’re hoping they too will be able to take this forward, ensuring both staff and parents get the training they need. AND WHAT ELSE IS ON THE CARDS FOR NHS LEEDS WEST CCG? The clinical lead for children and maternity and our commissioning development manager for children have just told me they’re planning to look at Best Start – aiming to give every child in Leeds the best possible start in life. Watch the video at www.youtube.com/watch?v=gD6UlPOibQM
... but the ambulance is going to take 14 minutes*. *UK Government Target response time
14 | NOVEMBER/DECEMBER 2015
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IN ACTION AMBULANCE COMMISSIONING
What’s your emergency?
16 | NOVEMBER/DECEMBER 2015
IN ACTION AMBULANCE COMMISSIONING
Following news that London Ambulance Service Trust has asked CCGs for £27m of extra funding for staff and new vehicles JESS PIKE finds out what commissioners should consider when procuring an ambulance service
I
n the vast urban sprawl that is London the sight of a speeding ambulance is as ubiquitous as a malnourished pigeon or bewildered tourist. But whilst blaring sirens are a soundtrack to city life, their apparent omnipresence is no indication of the success of the current model of service delivery. In fact, it’s quite clear – whether you work in the healthcare arena or not – that the current model is not meeting increasing demand across the UK. Commissioners of ambulance services face a plethora of challenges – not only do more patients need attention but there
when it comes to making assumptions about what a private provider will be able to deliver. “Take the Alton Towers incident back in June,” he says. “There’s absolutely no way a private provider would have been able to cope with that kind of work. While the private sector is very good at delivering an excellent patient transport service they’re less successful when it comes to serious emergencies.” As a result of this the future looks bleak for public providers who may well be left to deal with the more complex incidents that private companies can’t cope with. “If you’re moving to a private
are also requirements to commission services which respond to the agenda of the local community. “Added to this, the modern paramedic needs to have a wider knowledge base and know more about the range of clinical services available in their local area,” says Carole Mattock, interim director of quality at Brent CCG (lead commissioner for the London Ambulance Service). “This situation’s compounded by a national shortage of paramedics, resulting in staff spending a longer proportion of their shift time on a job, a situation which is undesirable, as it can lead to staff fatigue, prompting some staff to leave the service.” As with any healthcare delivery model, historical and ideological barriers can be difficult to break down – and, as Kenneth Kronohage, director of special projects at Falck (trading in the UK under the Medical Services brand) points out, these can block competition to develop quality and secure the best value for money. “Countries like Sweden and Denmark, which have both private and public providers, have experienced a complete transformation of their prehospital treatment in the past 20 years. Slovakia is experiencing something similar.” With ambulance services often covering vast geographical areas, it shouldn’t come as a surprise that a ‘one size fits all’ approach just won’t cut the metaphorical mustard. “The best services will have locality managers who’ll be prepared to work with the health economy in their areas to ensure the model of delivery is most suitable for the population of that area,” says Carole. PUBLIC OR PRIVATE? Mark Docherty, director of nursing, quality and clinical commissioning at West Midlands Ambulance Service NHS Foundation Trust warns that, whilst there’s certainly room for both private and public providers, commissioners should tread carefully
or independent provider make sure they can deliver everything that a NHS contract can deliver. Anyone can provide a cheap ambulance service – but an effective, high quality service is a different matter,” says Mark. “Too often we see the private sector ruthlessly undercutting on cost and, in the longer term, it becomes an unstainable contract for CCGs because they’re just not able to deliver on the clinical aspect of the service.”
“A well-commissioned service should be at the heart of a wellintegrated urgent care system”
THE CLOCK’S TICKING Ambulance response times are so often a focus of headlines but, as Kenneth points out, they do not say anything per se about the provided service. “The times depend on both the way the prehospital system is arranged before the arrival of an ambulance and the opportunities to treat the patient in the ambulance afterwards,” he explains. “Commissioners should, therefore, define the demand for the ambulance services in relation to the other parts of the prehospital chain. There’s a need to improve prehospital scientific research in order to have more knowledge about how different prehospital systems affect things like survival rates and other indictors in order to define the true cost of prehospital treatment.” Another solution to lengthy waiting times is to increase the number of community and first responder schemes, says Carole. “Having the appropriate staffing resource available would increase the chance of response times being met, and increasing the number of vehicles will mean that patients aren’t left waiting for an ambulance longer than necessary.” For many commissioners, target response times have been the main focus – an error, according to Mark. “Look at London: providers are the worst in terms of response times but they have very good clinical outcomes when compared with anywhere else in the country. Commissioners need to start thinking outside the box – any shoddy outfit can get you to patients quickly but what will be the best overall outcome for the patient?” OVERCOMING STAFF SHORTAGES For Carole one of the all-pervading problems facing both
NOVEMBER/DECEMBER 2015 | 17
IN ACTION AMBULANCE COMMISSIONING
providers and commissioners is the shortage of paramedics nationally – there are currently 3,000 paramedic vacancies in the UK. With ambulance services across the country now undertaking
between commissioners and possible bidders is crucial, says Kenneth. “This ensures that knowledge of the bidders is transferred into the actual tender material,” he says. “The best
extensive recruitment drives, CCGs can support providers – and themselves – by supporting such programmes and encouraging their providers to undertake campaigns in the areas they service. “In addition, a number of ambulance services have introduced specialised roles (such as specialist mental health paramedics) to provide paramedics with an opportunity for continued personal development and career progression opportunities,” she says. Thinking creatively about recruitment will be vital, agrees Mark. Whilst overseas recruitment is favoured by some providers, evidence suggests this can be expensive. For Mark, a more sustainable and cost-effective option involves targeting those living in pockets of deprivation in inner-cities. “There’s a workforce there to be utilised – they just need training,” he says. “By targeting these individuals you could end up with a workforce that would be loyal instead of transient – as many paramedics currently are.”
tender material would describe the functional needs of the service wanted including quality framework conditions, environmental demands and service levels needed, but should not specify how these can be achieved. Dialogue, innovation, knowledge, experience, quality and cost efficiency should all be looked for in providers.” But whilst an integrated care model is often top of the politicians’ agenda it seems that not all commissioners are fully on board, with many looking at the cost of one part of the system without looking at costs overall. “In the West Midlands we’ve just lost the 111 contract to a private provider, but what we know about private providers and 111 is that the number of calls rooted back to the 999 service will increase,” explains Mark.
A NEW MODEL OF CARE? An integrated, joined-up approach is whole-heartedly recommended, with Carole advising commissioners to look for a provider that works in partnership with their local health economy partners and contributes to the integrated care agenda. “For an increasing number of patients the ambulance service is their first point of contact with the health service and best practice ambulance commissioning reflects that,” she says. “A well-commissioned service should be at the heart of a wellintegrated urgent care system – and should work closely with commissioners to ensure patients are treated in the care setting that is clinically most appropriate for them.” In addition to this joined-up approach a technical dialogue
“Anyone can provide a cheap ambulance service – but an effective, high quality service is a different matter” 18 | NOVEMBER/DECEMBER 2015
FUTURE GAZING So what does the future of ambulance commissioning look like? For Carole it all hinges on paramedic recruitment – and the need for more specialised training for paramedics. “We might well have paramedics who are experts in a whole range of clinical specialisms like maternity, factures or diabetes,” she says, “and there might well be more telephone triage for less critical patients in order to make sure they get the most appropriate disposition.” What’s certain is that with demand for ambulance services creeping up by about five per cent each year, commissioners are going to have to think strategically when it comes to procurement. And who knows – with the current system sliding towards crisis point, a complete model reconfiguration may be necessary in the years to come. “For people who are critically ill an ambulance service is a necessity but for those who are ambulant we may need to start thinking about different models of care,” says Mark. “Urgent care centres are one option (despite the fact that many people are opposed to them). Either way, we can definitely improve upon productivity.” For now, make sure you do your due diligence before plumping for a provider – and do tap into networks like the National Ambulance Commissioners Network for advice and expertise. The quality of emergency response in your community depends on it.
IN ACTION XXXX
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NOVEMBER/DECEMBER 2015 | 19
IN ACTION REDUCING A&E ADMISSIONS
WHY A&E? NHS Blackpool CCG’s innovative approach to reducing A&E admissions is having a positive impact on its patient population and busy A&E rooms. JESS PIKE finds out how this rather unique initiative is helping reduce pressure on a hospital at breaking point
W
hilst CCG board members will be fully aware that A&E departments
across the country are buckling under the strain of spiralling admissions, not all patients are quite as well-informed, and conveying the right messages to different patient populations about when they should and shouldn’t attend can be a mammoth task. After all, getting to grips with one’s own poor health or the poor health of a loved one can be an overwhelming challenge – our own symptoms and fears feel a millions miles away from abstract stats and figures about
20 | NOVEMBER/DECEMBER 2015
unnecessary admissions that appear in national newspapers. So what can CCGs do to convince patients to think carefully about A&E attendance?
to treat or manage their symptoms. This is estimated to have cost the local NHS a total of £842,000. Whilst avoiding unnecessary NHS
NHS Blackpool CCG, a pretty forwardthinking CCG with a patient population of 172,500, has its fair share of challenges, not least the fact that life expectancy in the seaside resort continues to be the worst in the country for men. And research into A&E admissions carried out in 2014 revealed that one in three people who attended Blackpool Victoria Hospital’s A&E department between April and September 2014 could have been treated elsewhere; of 40,000 A&E visits, 36% (14,400) of people left having received advice on how
spend is a huge driver in reducing admissions another welcome by-product involves harnessing the power of A&E staff in the most efficient and effective manner possible – which has its own impact on quality of care as well as patient experience. And, like many of her peers, Dr Amanda Doyle OBE, chief clinical officer at Blackpool CCG, knew that a timely campaign would be an effective way of altering her patient population’s mindset and undoing assumptions about the purpose (and capacity) of A&E.
IN ACTION REDUCING A&E ADMISSIONS
UNDERLYING MESSAGES “We knew a fresh approach was needed to capture public imagination and support,” says Dr Doyle, “so, working with our partners across the Fylde Coast health economy we devised and developed the ‘Think! Why A&E campaign?’, which used characters rather than real people to deliver a clear message. The use of these characters has allowed the campaign to represent individuals who are not defined by age, class, gender or ethnicity.” The animation, which is four minutes long and was launched in November 2014, is set to the tune of Village People’s YMCA and shows various characters making the decision to call 999 or go to A&E without thinking through their alternatives. The lyrics include the following rather pithy line: ‘Young man, in bed feeling unwell / With a fever. What’s wrong? He can’t tell, / So he rushes, out to his A&E / But was thatan-e-mer-gen-cy?’ “It may be quirky and light-hearted but it also has a serious message,” explains Dr Doyle. “It’s an integral aspect of the second phase of the campaign plan which aims to capitalise upon the power of social media to target a wider audience. Throughout the campaign we established the #ThinkWhyAandE hash tag and, to date, this alone has reached more than 1.23 million people.” Whilst the hash tag has helped the campaign to go viral Dr Doyle and her colleagues have also had to think carefully about other ways to get the animation seen and have used display screens in GP practices, pharmacies and health centres as well as screens in libraries, children’s centres and workplaces to maximise
exposure. But the cherry on the cake? “Well, with the support of the local council, we’re also exploring the possibility of the animation being incorporated into the Blackpool illuminations,” says Dr Doyle. “This would target the millions of tourists who visit the town every year – and we’ll also be using the animation as part of short educational sessions delivered to families in partnership with Blackpool FC’s Community Trust.”
“Praise has come from as far afield as Western Australia, with health officials over there saying they need something similar for their patient population”
A JOINED UP APPROACH As the ‘Think! Why A&E?’ campaign was only launched in late November 2014, Dr Doyle and her team haven’t yet been able to fully evaluate its impact but the CCG has been inundated with requests from other CCGs, hospital trusts, universities, housing associations and businesses wanting to find out more about how the idea was conceived and set in motion so cleverly. “Interest in the campaign has been enormous,” Dr Doyle admits, “and praise has come from as far afield as Western Australia, with health officials over there saying they need something similar for their patient population.” So what advice would Dr Doyle have for CCGs looking to dip their toe into similar waters? “Making sure we reached the right
Dr Amanda Doyle OBE, chief clinical offic er at Blackpool CCG
people in the right way with the right message was essential,” explains Dr Doyle. “That’s why we adopted a phased approach; we began with the usual mechanisms – posters and leaflets – and this, as well as digital media activity, has been very important for us and helped us to make sure all audiences are reached.” It goes without saying that the campaign has been designed to feed into Blackpool CCG’s long-term vision, as Dr Doyle points out. “It’s been devised to have longevity, so we’ll continually adapt materials and mechanisms for disseminating the message as it progresses,” she says. For any CCG considering launching a similar campaign, partnership working will be a big differentiator and will enable you to reach audiences that might, typically, be less engaged with healthcare; as Dr Doyle and colleagues will attest, campaigns like this really can make a significant difference. So what are you waiting for? Get your message out there and start slashing those admission numbers once and for all.
NOVEMBER/DECEMBER 2015 | 21
IN ACTION INTERVIEW
NO HEALTH WITHOUT MENTAL HEALTH With the fight against the mental health stigma slowly being won EMILY HARDY meets DR GERALDINE STRATHDEE, national clinical director for mental health at NHS England, to discuss the integral and complex role commissioners must play in transforming the quality of care even further WHAT’S THE BIGGEST CHANGE YOU’VE SEEN DURING YOUR 20 YEARS IN SENIOR HEALTH ROLES? I’ve seen a real transformation. We’ve gone from having a very institutional model of care to having intensive, multi-agency, multidisciplinary partnerships working in the community and supporting people to live in their own homes; mental health has become the leading out-of-hospital specialism.
22 | NOVEMBER/DECEMBER 2015
WHAT ARE THE BIGGEST PROBLEMS NOW? We still have a significant number of people who cannot get access to treatment, there’s major variation in standards and implementation across the country, and we haven’t had the same focus on primary care mental health development that other countries have. Plus, over the last 20 years, physical and mental health assessment and treatment pathways have become very separate.
IN ACTION INTERVIEW
WHAT ROLE CAN COMMISSIONERS PLAY HERE? Firstly, it’s essential that commissioners use data in order to better understand their population – to find the determinants of people becoming mentally ill and to work out what can be prevented. Next, look at the economics of mental health in your patch – how much do you spend on the adverse consequences of not having provided early intervention or mental health treatment? These problems don’t go away and have a massive impact on the whole area. Then think about how can you invest in prevention – best early start, best employment, an alcohol strategy? The fourth thing is to look at how you can increase access for people rapidly. This means providing good crisis services. WHICH CCGS HAVE BEEN PARTICULARLY SUCCESSFUL IN IMPROVING THEIR OUTCOMES FOR MENTAL HEALTH? I could point you to several. There’s the wonderful integrated perinatal team in Devon, the CCG leads in Southampton helping us think through A&E crisis care and the liaison mental health system and, in Sunderland, there’s fantastic work being done to make people more health literate, improve access to IAPS and reach out to local employers. I could go on and on. We’ve just finished a CCG mental health leadership training programme during which each of the leaders undertook an improvement project. These have fundamentally shaped and improved how we’re going ahead with our standards of care. WAS THE LEADERSHIP PROGRAMME COMPULSORY? It wasn’t, but we had a fantastic uptake and there are more CCGs asking to participate. My original dream was for the programme to give us the knowledge we needed to have our commissioning leaders develop robust diploma courses, masters courses or programmes in evidence-based, knowledge-led mental health commissioning. ARE THERE ANY CCGS NOT YET PLAYING BALL? I think it’s probably not unfair for me to say that, before this particular era, mental health services had some utterly committed commissioners who weren’t given the support they needed or senior enough positions to achieve parity of mental health commissioning; this is one of the key reasons why we have such incredible variation across the country. I would urge any CCG that doesn’t yet have an identified mental health lead to appoint one. The areas with trained, well-supported leads are changing the face of mental health. For areas without – or for those with a lead one day a week across seven CCGs – it’s a real struggle.
“I would urge any CCG that doesn’t yet have an identified mental health lead to appoint one” HOW CAN COMMISSIONERS EMPOWER SERVICES AND PROVIDERS? At the end of the day, the patient doesn’t really mind who provides the care as long as it’s utterly seamless and it works for them. However, from my experience, people with mental health problems are enormously sensitive to conflict and dissonance; they’ll pick up on any conflict in the service. If we have divisive arguments then we set back the collaborative networks by years. Role model what you promote in your patients and work together to give the people on your patch what they need. DOES CO-COMMISSIONING PROVIDE AN OPPORTUNITY TO IMPROVE THINGS FURTHER? I think co-commissioning is the way forward and incredibly important. However, people are always committed to the ‘what’ but it’s the ‘how’ – the implementation – that’s absolutely key. GPs often tell me that the greatest barrier to helping patients is not knowing where the services are. If there was one financial penalty I’d put in place it would be a punishment for not keeping details of commissioned services up-to-date on NHS Choices, the 111 directory of services and all other websites. There must be better supply chain management methods we could apply to empower GPs and reduce variation. WHAT ELSE SHOULD COMMISSIONERS BE THINKING ABOUT? Work in schools and with school nurses is vitally important. We’re also focusing on parenting – often described as ‘the statin of mental health’. It’s fundamentally important to have physical and physiological literacy, so we’re pushing for support and advice to be offered as part of maternity and perinatal services. We’re driving for people to have integrated physical and mental health assessments too. It makes sense; if you’re not mentally well you can’t get the clarity you need to stay healthy. This lack of integration is costing huge amounts of money.
WHERE CAN COMMISSIONERS GO FOR INFORMATION? Information is currently spread across several websites but we’re
ANY FINAL WORDS OF ADVICE? Focus on data, prevention, providing excellent tele-triage and telehealth, digital crisis services, reducing suicide, ways to get 40% of people with mental health problems back into employment (as opposed to the current seven per cent) and look at the vanguards
aiming to bring together a network of good practice websites so it’s easier to find. This is where enormous thanks need to go to social media; Twitter is an invaluable resource when you need to find evidence fast. Commissioners want information rapidly; they want two sides of A4 on economic modelling, for example.
and excellent models of care. And do not disinvest. There’s real tension about the pendulum swinging too far one way, but it would be wrong to neglect the most vulnerable people – many of whom have, before now, not been able to access the care they need.
NOVEMBER/DECEMBER 2015 | 23
IN ACTION AIREDALE NHS FOUNDATION TRUST
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24 | NOVEMBER/DECEMBER 2015
IN ACTION AIREDALE NHS FOUNDATION TRUST
As more commissioners wake up to the benefits of telemedicine JESS PIKE catches up with REBECCA MALIN (left), deputy director of strategy and business development at Airedale NHS Foundation Trust, to find out how clever technology is improving access to and quality of healthcare for different patient populations across the UK So what’s your background, Rebecca? I’ve been in the NHS since 2008 but prior to that I worked in technology; I started out at IBM and then moved into the airline industry – Virgin Atlantic, to be precise. At Virgin I led initiatives to design and deliver technology to enhance passenger experience and passenger flow and then, in 2008, I moved back up north and joined the NHS; since then I’ve done a variety of roles, starting out in IT, technology design and support and then latterly moving into business development and strategy. It was during this last role that I became involved in our telemedicine development at a time when we were really dipping our toes into a whole new way of working. Tell me how telemedicine at Airedale began. Well, we’re now in our ninth year and when we started out Dr Richard Pope, our medical director at the time, had seen standard video-conferencing equipment being used in other countries to deliver healthcare and was really impressed. He had a real passion for technology and seeing how technology could enhance patient experience and so he was keen for us to try it. What was the first step? In the early days we tried it in offender health; we started at HMP Full Sutton, which is in York, and we installed standard video-conferencing equipment into the healthcare wing of that prison. What benefits did you see? The more you can deliver over a video link – and we demonstrated a 50% improvement in patient flow too – the more you reduce costs, mainly because of the expense involved in transporting and escorting prisoners to and from hospital. The prisoners also express high satisfaction with the service, a lot of which is down to privacy and dignity. Where’s the privacy and dignity if you’re walking through
a hospital handcuffed and everyone’s staring at you? If we can deliver that care over video we’re enhancing the privacy and dignity of that patient… and we now provide that service to 13 prisons across England, as far south as London and as far north as Durham. And it all started at Airedale? It did, and it’s still based out of Airedale; we provide that service nationwide. Our telemedicine journey started in prison health and we work with technical partners Involve; together we deliver the whole endto-end piece. What are the cost-savings involved? Well, the lowest escort fee for a lowsecurity prisoner is around £200, and there really is no upper limit; escorting a high-security prisoner to a 10-minute outpatient consultation can involve significant security including things like police helicopters... plus, in extreme cases, they’re unable to confirm which hospital they’ll be attending so two hospitals have to be put on alert. There are some big savings to be made. What was next at Airedale? Offender health is where we started nine years ago and we then starting looking at patients in their own homes and in nursing and residential care homes. Patients in their own homes were, and still are, those with long-term conditions, predominantly COPD, heart failure, complex diabetes and those at the end of life. Last year we became part of a unique joint venture called Immedicare which enables us to provide a full end-to-end telemedicine service – clinical expertise and the technology – to commissioners. Prior to the joint venture we were finding that commissioners would procure the clinical and the technical separately: now we offer a one-stop-shop service.
So CCGs around the UK are commissioning you to do a similar thing across different parts of the country? Yes, so right now we’re live in around 220 nursing and residential care homes – as far south as Kent and as far north as Cumbria – and we have a further 113 in implementation. Overall that’s supporting somewhere between 6,000 and 6,500 residents across nursing and residential care homes across the country. How does the venture work? The engineers roll out and implement the technical piece and our nursing team here provide the clinical information and roundthe-clock care, seven days a week. Each care home will have a telemedicine device which could be a laptop or a tablet device with a detachable webcam or an inbuilt webcam. The face-to-face team here at Airedale hospital is staffed by senior nurses and they deal with any clinical issues that come through. The reason we went for the senior bands of nurse is because they’re the ones with that broader and higher range of skills so they’re able to make an immediate clinical decision. We only escalate around two per cent onto our on-call physicians in the hospital. What other services do you provide? We also provide a service across Airedale and Bradford for people in the last 12 months of life; we offer a single point of access so that person or their family or carers don’t have to navigate the health and care system. We provide them with one single phone number and we have 30 tablet devices that we give to those who can benefit from greater support in the last few months to weeks of life. The results we’re seeing are astounding. In what way? Well, you can imagine it would be pretty frightening if you were supporting your
NOVEMBER/DECEMBER 2015 | 25
IN ACTION AIREDALE NHS FOUNDATION TRUST
cy and
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family member to die at home and you woke up in the middle of the night to find them in distress. With this service you can just press a button and be connected visually to a senior nurse which makes the patients and family members feel much safer. And the feedback we’re getting from nursing and residential care homes is equally positive; in addition to some of the economic savings, and the difference it’s making to admissions and A&E visits, we’re also enabling staff to support people to remain where they’re most comfortable, which is in their own homes. Hospital just isn’t the right place for the frail elderly, particularly if they’ve got dementia. Do you have any stats in relation to reductions in hospital admissions? We worked with Yorkshire Health Economic Consortium recently on economic evaluation of care homes across Airedale, Wharfedale and Craven; the research showed that, since they’ve started using
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telemedicine two years ago, there has been a 37% reduction in hospital admissions and a 45% reduction in A&E attendances. Do you have any figures on the cost savings? Yes; as a result of the reduction in admissions of the frail and elderly there was a saving of £5.2m over two years and, for A&E, the cost saving was just short of £118,000. These figures relate to care homes across Airedale, Wharfedale and Craven; we haven’t got any national figures. Have you found more CCGs waking up to the benefits of telemedicine in recent years? Absolutely. I think with increasing demand and an ageing population the NHS is now in a position where it has to find different methods of delivering healthcare. It’s about not bringing the frail elderly in and out of hospital unless they absolutely need to be here; it’s about offering the right care to support them to remain at home. So yes, I do think commissioners are thinking more
about how to spend that envelope of money in the most efficient way possible. And what advice would you have for CCGs looking to select the right provider in terms of telemedicine? I’d point out that telemedicine is only one piece of the jigsaw; it’s not the only intervention to support people remaining at home, for example. I’d strongly encourage commissioners to look at whole-system changes: look at health and care, primary care, secondary care and community care alongside telemedicine. Consider telemedicine as one piece of the jigsaw in supporting people to remain in their own home. And what’s next in terms of telemedicine at Airedale? Going forward I think it’ll be about supporting people to set their own goals and self-care through telemedicine, which is already having a big impact in certain pockets of the patient population here.
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NOVEMBER/DECEMBER 2015 | 27
COMMUNITY CARE EYE HEALTH
THE VISIONARIES What does effective eye care commissioning look like? How can CCGs make sure the services they provide are evidence-based, patient-centred and focused on outcomes? JESS PIKE investigates
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COMMUNITY CARE EYE HEALTH
O
ne of the inescapable truths linked to society’s ageing population is that of poor eye health, something that most CCGs will be well aware of. There are now almost two million people in the UK suffering from sight loss, with age-related macular degeneration the leading cause of blindness in adults. Other significant causes of sight loss include glaucoma, cataracts and diabetic retinopathy. Unsurprisingly, these numbers only look set to rise – with a report prepared by Access Economics in 2009 estimating that the number of people living with sight loss will double to four million in 2050. A number of recent surveys also demonstrate some of the most concerning issues, as Liz Price from the Royal College of Ophthalmologists points out. “A survey of hospital ophthalmology clinical leads carried out by the Royal College in 2012 identified evidence of widespread delays to ophthalmic follow-up appointments, and reported cases to the National Reporting and Learning System (NRLS) have increased more than 20 fold between 2009 and 2013 with nearly 500 patients suffering from deterioration or loss of sight from delayed hospital appointments between 2011 and 2013.” It’s clear, then, that CCGs can play a vital part in curbing this worrying trend and stemming the numbers of people suffering from debilitating eye issues – both in terms of planning for local support and preventive services, as well as early intervention measures. As Sally Chandler, planning and performance manager for UK Vision Strategy, says, such measures can make an enormous difference to quality of life and help people with sight loss live independently. MAXIMISING OUTCOMES The UK Vision Strategy has been vocal in its calls for an effective, joined-up approach to eye health. Its inception in 2008 was triggered by the need for a framework for change to transform the UK’s eye health, enable those with sight loss to receive timely treatment and support, and to determine what ‘good eye care looks like.’
In 2011, the framework inspired UK Vision Strategy partners to develop commissioning guidance for eye care and sight loss services, which is endorsed by the Royal College of General Practitioners, National Association of Primary Care and NHS Alliance and Family Doctor Association. In March 2012, the UK Vision Strategy was awarded funding via the Department of Health to deliver a project called Commissioning for Effectiveness and Efficiency (CEE), building on the existing guidance. The aim of the CEE project was to develop effective and efficient approaches to the commissioning of eye care services in order to maximise the best possible outcomes for local communities in three CCG areas: South Devon and Torbay, Gateshead, and Bedfordshire. “The project ended in September 2014 and independent evaluation carried out by Shared Intelligence found that it successfully influenced commissioning intentions and contributed to improving the local provision of eye care services,” says Sally. “The CEE project implemented a collaborative, patient-centred, evidence-based whole systems model to commissioning that enabled eye care to be embedded as a priority across health and social care.” It will come as no surprise to experienced commissioners that a successful approach will not necessarily be easy to implement, and will require close collaborative working, extensive patient engagement, local leadership and an evidence-based, whole systems approach. For the Royal College of Ophthalmologists, there is a series of priorities that CCGs should take on board when considering their approach to eye care – they advocate evidence-based commissioning of service to optimise properly costed and resourced clinical service provision both in hospital and community settings. This includes removing arbitrary tariffs that reward new patients and disadvantage followup patients, and broadening and varying target limits for new patients to reflect the urgency and risks of particular conditions and diagnoses. Other recommendations include:
Utilising extended work-force teams that are ophthalmology led • Implementing extensive training programmes for optometrists, orthoptists, nurses and ophthalmic technicians: assessing competencies, continued professional development, appraisal, personal audit and revalidation for this extended workforce. Developing IT and communication infrastructures to manage patients seamlessly within the system Collecting data and analysis for quality assurance to identify needs at local and national levels • All hospitals to collect and share compulsory data for outcome measures, analysis and benchmarking Safety and alert mechanisms to be introduced to identify and appoint patients who are falling out of recommended review times. Improving patient awareness about the importance of follow-up appointments for chronic eye disease and eye health • Education campaigns highlighting risks of delayed follow up • Reach vulnerable groups • Educate healthcare staff. •
A TIMELY RESPONSE For Katrina Venerus, managing director of the Local Optical Committee Support Unit (LOCSU), the introduction of community-based eye care services can play a transformative part in improving eye care. “These services have really come of age with the publication of the recent NHS Five Year Forward View and radical reforms to the way the NHS delivers care,” she says. “Out-of-hospital care is a key proposal in the radical blueprint, and community eye health pathways are an excellent example of holistic, preventive care that can provide the best experience for patients and the best value for money for commissioners.” East Riding of Yorkshire CCG has proven that such steps can bring about substantial savings and free up muchneeded capacity in hospital ophthalmology outpatients clinics, as well as easing
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COMMUNITY CARE EYE HEALTH
pressure on A&E and on GP appointments: in April 2014 it commissioned a community-based service that’s being delivered for half the cost to the CCG compared to the previous arrangements when all patients with a range of eye problems were referred to the hospital eye service. “If this type of minor eye conditions service was introduced across England, the saving to the taxpayer would be in the region of £10.5m,” says Katrina.
58 CCGs have such a community eye care service in place– meaning that 39 million people are currently missing out on local care and almost three quarters of CCGs aren’t reaping the spoils of reduced pressure on secondary care, A&E and GP surgeries. Katrina urges any CCGs looking to introduce a minor eye conditions service in their local area to contact her via the LOCSU website. “The network of local optical practices also runs a bespoke software package to record patient
campaigns, such as anti-smoking,” Sally explains. “Gateshead CCG’s Eye Health Needs Assessment (EHNA) highlighted the need for a focus on prevention and early intervention, which resulted in Gateshead Public Health and the CEE project officer producing a Sight Loss Prevention Statement on behalf of the eye care action group, articulating the relationship between eye health, sight loss and other health and lifestyle conditions. Further information about the approach
The symptom-led service involves a network of 43 local optical practices and 60 optometrists providing the scheme through a not-for-profit eye care company, that contracts as a single provider with the CCG. “As a result the scheme is highly accessible in the community,” explains Katrina, “and patient feedback shows that people suffering from eye conditions really value the high-street location and the wide
outcomes,” she explains, “and this allows the LOC company to monitor performance and ensure that the key performance indicators set by commissioners are being fully met. Plus, we’ve developed a series of pathways that cover a number of common eye problems.”
used in Gateshead can be found in our CEE commissioning guidance.” Armed with the right kind of information – and taking a joined-up and collaborative approach – CCGs can make a big difference when it comes to the UK’s eye health, and can help ease the heavy workloads placed on busy clinicians across the country.
“If this type of minor eye
conditions service was introduced across England, the saving to the taxpayer would be in the region of £10.5m” range of appointment times, including evenings and weekends. Also, the proposed link with pharmacy potentially offers quick and easy access to prescriptions without the patient having to visit their GPs – patients can self-refer, so GPs are also supportive because it’s freeing up appointment time.” Hospital eye services also reap the rewards – in East Riding only 20% of cases that are serious are referred to secondary care, freeing up capacity in busy ophthalmology departments to tackle long backlogs and concentrate on the most urgent and complex cases. However, despite the clear and wide-ranging benefits of community-based eye care services, only
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JOINED-UP THINKING Sally is in full agreement that a collaborative approach will be vital, particularly as health and social care feels increased demand for services and dwindling funding. “In order to improve the commissioning of services, it’s vital that multiple stakeholders from across the health and social care system work together, in full partnership with patients and the public,” she says, before explaining more about the UK Vision Strategy’s recently launched commissioning guide (based on the findings from the CEE project that supports this approach and bringing together key learning from the three project sites accompanied by a suite of support tools). The CEE project worked with local partners and commissioners to identify the key links between eye health and sight loss and other health determinants, she says, including smoking, obesity, stroke, blood pressure, dementia, falls, emotional health and wellbeing, deprivation and inequalities. “The CEE project recognised that there was considerable potential for using eye health messages to reinforce the message of broader health promotion
THE STATS In 2009 the National Patient Safety Agency (NSPA) identified that it had received 44 reports of concerns about patient safety due to delays in appointments for glaucoma patients, 13 of which went blind The Macular Society identified that 67% of cases of age-related macular degeneration (AMD) were not meeting the follow-up times that were clinically indicated (2013) from a questionnaire to Trusts using Freedom of Information requests The 2013 RNIB document Saving Money, Losing Sight found that 41% of the ophthalmology staff surveyed in England recognised that patients were sometimes or often losing vision due to delayed treatment or monitoring (similar survey with same results in Wales, 2014).
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COMMUNITY CARE MEDICINES OPTIMISATION
Unused medicines cost the NHS an estimated £300m every year. AUSTIN CLARK finds out more about the problem and the work the PrescQIPP NHS Programme is putting in to reduce this wastage
E
ach year approximately £300m worth of prescribed medicines are wasted1. Like many contemporary healthcare challenges the problem is complex in nature and relates to cultures, systems, professional and patient education and how healthcare providers communicate. But it’s also an area ripe for great improvement if a whole-system approach is taken. Expecting any single healthcare professional group, such as GPs, to tackle this alone will not solve the problem; however, in many cases improvement can come from within established structures through better utilisation of key professional groups such as the pharmacist.
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According to those responsible for the PrescQIPP NHS Programme, which works on behalf of the prescribing community to deliver evidence-oriented resources and tools, events and webinars to support quality prescribing, medicines are the most common therapeutic intervention and biggest cost after staff in the NHS. However, due to various reasons, 30 to 50% of medicines are not taken as intended leading to wastage. Non-adherence to medicines can be both intentional – where a patient chooses not to take a medicine for a particular reason – or unintentional – such as patients being confused about their medicines or forgetting to take them. Wastage can also occur due to other factors not related to adherence such as
overordering of repeat medicines, oversupply, prescribing or dispensing errors, treatment revision, death of a patient and patients stockpiling medicines in their own home. There are also settings, such as care homes, where the problems are more widespread; the process of ordering everything on a monthly cycle and returning any unused medicines to the pharmacy
COMMUNITY CARE MEDICINES OPTIMISATION
before re-ordering the same medicines is fairly common, particularly where monitored dosage systems are used. OVERCOMING PARTICULAR ISSUES Multimorbidity, which can lead to problematic polypharmacy, is a particular issue. Patients with multiple conditions are often put on multiple medications, many of which interact with each other or have long-term safety concerns. It’s estimated that five to eight per cent of hospital admissions are due to preventable adverse effects of medicines2 and the more medicines a patient is taking the higher the likelihood of them suffering more serious adverse effects. As patients get older or deteriorate problems can worsen as the toxic effects of some medicines are more pronounced in older people. There is a need to look at prescribing in a more rational manner and to ensure that all healthcare professionals are working together when looking at the care of the individual patient. Reviewing patients with a view to appropriately ‘deprescribe’ medicines is increasingly gaining traction in the western world. In many cases the risks of taking medicines outweighs the benefits, especially in relation to polypharmacy, and intervention with a view to deprescribe can improve outcomes in terms of safety, adherence, patient empowerment, waste and also prescribing spend. Patients need to be empowered to take their medicines as prescribed through less complicated treatment regimens so that adherence can increase and health benefits improve. Savings associated with optimising medicines will not only come from the prescribing budget and it is important to identify where
interventions can release savings – for example, reduced hospital admissions. However, in order to realise this opportunity as an intervention, more time will be needed for a full medicines review carried out by appropriately skilled healthcare professionals. The national ‘medicines optimisation’ strategy highlights the pharmacist as a skilled, cost-effective and often underutilised resource within the NHS. Pharmacists are experts in medicines and locally available to support patients. Empowering this professional group, and better integrating them into the ‘house of care’ surrounding the patient, could provide great gain and support improvements around problematic polypharmacy and appropriate deprescribing. DELIVERING RESOURCES At the PrescQIPP NHS Programme medicines waste is a common factor in many of its resources and is a high priority for the
“There is a need to look at
prescribing in a more rational manner and to ensure that all healthcare professionals are working together when looking at the care of the individual patient.” commissioners it works on behalf of. As a cooperative, community programme working on behalf of the majority of the CCGs in England, it delivers a range of pragmatic, evidence-based resources, along with benchmarking and intelligence that CCGs can utilise for local delivery. Subscribers work with PrescQIPP to direct what is delivered and how it is delivered, and tackle issues such as waste and polypharmacy, enabling self-care, better patient reviews and empowerment are top of the list of requested projects. The key themes described in this article, such as medicines optimisation, are increasingly threaded through the projects
being delivered. The resources produced help commissioners plan and implement medicines optimisation projects at a local level and also support the sharing and dissemination of good practice. For example, in a recent project PrescQIPP supported the Eastern Academic Health Science Network to identify key areas where specific challenges exist around adherence and waste and to provide a platform for stakeholders to collaborate and co-create projects. The dramatically changing role of the medicines teams within CCGs and CSUs will offer many opportunities, if correctly deployed, to properly tackle adherence and waste. Those I spoke to at PrescQIPP said that in their many interactions with these teams they see the real, transformational change that can be delivered when people are encouraged to innovate and lead around the causes and not just the symptoms of medicine waste. In the last round of its innovation awards the overall best project of the year was one relating to medicines waste (‘What a Waste’ by East Staffordshire CCG – read more at www.prescqipp.info). With the right amount of support from CCG boards, medicines teams can continue to grow to become a real driver for improvement across the spectrum of medicinal care. Medicines optimisation – both as a service and a strategy – also requires investment, commissioning and support to deliver outcomes. As has been shown in this article, medicines waste represents a significant challenge for the NHS in terms of not just the cost, but also the quality and safety of the care we provide to the patient. It also represents a real opportunity for improvement that can be achieved if the right elements are in place across the system. PrescQIPP, in partnership with CCG teams, will continue to work to tackle this important issue. 1. York Health Economics Consortium. School of Pharmacy. University of London. Evaluation of the Scale, Costs and Causes of Waste Medicines. November 2010. 2. The Kings Fund. Polypharmacy and Medicines Optimisation. Making it safe and sound. 2013.
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IT CLOUD TECHNOLOGY
EVERY CLOUD HAS A SILVER LINING
Cloud computing is transforming the way businesses operate across the globe but what is it and how can it be used across the health service to enhance performance and patient experience? EMILY HARDY investigates
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IT CLOUD TECHNOLOGY
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aced with the challenge of co-commissioning primary care, CCGs and the tools they use have come under the spotlight once again. A study by Huddle, Meeting the Digital Challenge: How Well is the NHS Embracing Cloud Computing?, revealed that, despite government initiatives to drive greater use of cloud computing, many parts of the NHS are struggling to embrace this key enabling technology. According to the experts much of this reluctance stems from a lack of awareness and confidence in switching to and using the cloud. So we at Commissioning Success have been simplifying the mysterious cloud for you, bringing it back down to earth… where it belongs. WHAT’S THE CLOUD? Look up ‘cloud’ in the dictionary and you’ll find the following: ‘Cloud: a visible mass of condensed watery vapour floating in the atmosphere, typically high above the general level of the ground.’ You might be perfectly content with this familiar definition and, perhaps even proud of your ability to distinguish between a Cumulonimbus and a Stratocumulus, but it’s now time to seriously consider the potential of another sort of cloud – the omnipresent data cloud that holds a whole host of silver linings for CCGs. Storing information in a cloud-based environment simply means that your data is kept off-site and accessed using the internet, or dedicated public sector networks, rather than the hard drive on your computer or the server in your office. And no, that doesn’t mean it hovers precariously above your head in cyberspace; when you store data in the cloud it is, in fact, kept in a highsecurity building that’s firmly on the ground. “Traditionally computers in an office network are connected to a server that sits in the office environment collecting data but now there’s the option to store that data in huge, powerful servers housed in highly-secure and highly-connected data centres dotted round the country,” explains Raza Baloch, director at Into The Cloud Ltd. “These data centres have a plethora of security measures in place – such as fingerprint and retina scanning – to prevent unauthorised individuals getting in.” In addition to high levels of security cloud, computing offers flexibility – allowing you (and other authenticated individuals) to access your data, programs or applications from any location and on any device that’s connected to the internet or public network. WHAT PLACE DOES THE CLOUD HAVE IN RELATION TO COMMISSIONING AND HOW CAN IT HELP CCGS IMPROVE PATIENT CARE? • Collaboration across a complex network A cloud system can mobilise strong collaborative relationships between CCGs and healthcare providers such as the local authority, GPs, local hospitals, mental health services and adult social care. CCGs can simplify the management of these different relationships by designating a central place – a cloud – to share resources, collaborate on
“Only 66% of NHS staff are aware of cloud computing” documents and hold discussions. While some CCGs consist of just a handful of practices, larger groups can include 50 or 60 GP surgeries alone. Collaboration and the ability to share documents – both internally and externally – are integral to a CCG’s success. “Cloud computing is seen as a key component of improving collaboration between agencies and departments – in particular, how sensitive data is managed, shared and secured across the entire public sector,” explains Alastair Mitchell, co-founder and CMO of Huddle. “However, we’re in a position where almost half of NHS employees still routinely post hard copies of documents to each other or rely on insecure USB flash drives,” he says. “NHS employees rightly view themselves as staunch guardians of highly sensitive and confidential material; the way in which ‘collaboration’ happens in the NHS today is anachronistic – it’s hugely inefficient, rampantly expensive and worryingly unsecure.” • Supporting governance and transparency Conflicts of interest are expected to arise more frequently as CCGs take on an extended role in primary care commissioning because GPs will have a role in both delivering provision and commissioning it. Cloud collaboration tools are closely aligned with the needs of CCGs here because a central cloud workspace supports transparency, ensuring the latest versions of important documents are always accessible to those authorised to see them. Furthermore, some cloud platforms contain committee room functionality and secure workspaces specifically designed to enable decision-makers to collaborate between meetings. • Go green, work remotely and free up estate With the NHS under consistent pressure for cost and carbon efficiency, estate rationalisation and mobile working are becoming a prominent part of CCG strategy. The cloud will eventually enable CCGs to become building-free and turn rooms full of servers into wards full of beds. • Using data to make better commissioning decisions CCGs currently struggle to make use of real time population health data. One of many reasons for this is the cost of storage. However, CSUs are starting to get around these challenges by using the cloud – working with CCGs and GP surgeries to achieve ‘Accredited Safe Haven’ status and utilise the six million anonymised patient records for population health analysis purposes. This data, and the analytics generated, allow commissioners to make better informed decisions with reduced risk in order to address the specific service needs of the region.
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IT CLOUD TECHNOLOGY
A WHOLE HOST OF SILVER LININGS • No more office server: The server and PBX in your office take up space and, because they require cooling and power, eat up precious energy resources too. • More memory: Cloud storage means you’re no longer constrained by the spec of your computers; you can access data and software on any device. • No maintenance required: Cloud systems are continually updated and maintained meaning you can avoid time-consuming software updates, costly repairs and IT support visits. • Improved security: Data in the cloud is housed in highsecurity buildings and there are safeguards and controls available to limit who can access what within your cloud. • Remote working: Connect to the cloud anywhere. Data can be inputted and accessed anytime, anywhere and on any device. • Save money: Cloud computing services can be more economical than hard drives; because they’re priced on an opex model there are no huge start-up costs.
WHAT’S THE CATCH? Your cloud service is only as good as your network and connection. “If you don’t have a good internet connection you’re not going to be able to operate a cloud-based-server or hosted telephony,” Raza warns. “To ensure full quality of service it’s absolutely paramount you have an excellent internet connection in place. This doesn’t necessarily have to involve a costly outlay; data connectivity has become a commodity so it’s not as expensive as you might think.” THINKING ABOUT TAKING THE LEAP? We’ll all move into cloud computing sooner or later. As Raza says: “It’s just a matter of time; the next three to five years are going to see a huge explosion in cloud service adoption.” However, owing to fears and concerns over data security, many NHS workers remain cautious. But this isn’t another “NHS IT gone bad” story, says Alastair. “This is about the challenge of change management in a massive and complex organisation. It’s about how NHS executives and IT leaders can intervene, turn the tide, and help
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“Almost half of NHS employees still routinely post hard copies of documents to each other or rely on insecure USB flash drives” their colleagues achieve the NHS’s potential and meet the vision for flexibility, integration and efficiency as set out in NHS England’s Five Year Forward View.” It’s human nature to question what we cannot see and to approach radical technology with trepidation but, rest assured, this isn’t unchartered territory. Cloud computing is an innovation as significant as the internet or computers (or even the wheel!) and, sooner or later it’s the path that all businesses will take. As the technology matures the potential for functionality will expand too. Finally, a reason for England’s 209 CCGs to be cheerful; a tangible solution to a number of frustrating day-to-day problems during this highly crucial phase of their development.
HUDDLE’S FINDINGS: • Only 66% of NHS staff are aware of cloud computing, the lowest among public sector workers • Just one third of NHS employees are confident using cloud services – 27% are not confident and 36% have never used cloud computing • Security concerns (81%), time and effort to switch (74%) and lack of expertise to install systems (72%) are the major barriers to cloud adoption in the NHS • More than 96% of NHS staff share information among internal and external teams as part of their work • Despite 87% of NHS staff viewing the security of their organisation’s information as ‘very important’ the most common way, after email, in which staff share information is by posting hard copies (47%), using couriers to deliver physical documents (25%) and relying on USB flash drives (20%).
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NOVEMBER/DECEMBER 2015 | 37
IT RISK STRATIFICATION
Securing a risk stratification system to suit your population and its growing needs is no easy task. EMILY HARDY explores the tools and models available to CCGs and decodes the procurement process so you don’t have to
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PUTTING YOUR FA I T H I N DATA
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IT RISK STRATIFICATION
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s the nation ages, and the prevalence of long-term conditions increases, the need to comprehensively interpret and analyse the information that describes populations and the individuals within them has never been greater. In a bid to emulate the success of American and Swedish health models UK health commissioners have employed various risk stratification tools and models to help them get a handle on their data. These varying tools allow CCGs to move away from crisis avoidance towards a more preventive way of working by moulding health data into actionable business intelligence and insight. Basic set-ups use aggregated and analysed primary or secondary care data to assist CCGs in identifying the most vulnerable and at-risk
rate. While it’s been traditionally employed to reduce emergency admissions, CCGs now have the option of building a predictive modelling system that can be used to prevent a broad range of problems before they’re even diagnosed. According to Dr Mark Davies, medical director at MedeAnalytics, reducing hospital admissions is the crocodile closest to people’s canoes at the moment but this shouldn’t be all that CCGs are focusing on. “Concentrating solely on hospital admissions profoundly misses the point. It would be a tragedy if a CCG were to buy a system for one particular purpose and then decide they want to focus on something else; they run the risk of wasting an awful lot of time and money in the long run.” Dr Davies encourages CCGs to use multiple data sources so as to build an ‘information architecture’ which will allow
The industry’s key players and leading experts tend to agree on this point. Consultant Stephen Sutch says: “When looking into models, look out for good descriptors and markers that will help you understand your whole population. A lot of tools concentrate on highlighting individual problems but these really only have a single purpose. Using hospital admission lists or GP data to look at the top one per cent of the population at risk is just firefighting; sometimes GPs come back and say: ‘You’ve just produced a list of people we already know about’.” He argues it’s most critical to identify people with emerging health problems, particularly when addressing and encouraging self-management. “For self-management we need to get to the next five to 20% of the population and use the analytics to commission broad-
patients, helping them to reduce unplanned hospital admissions in the process. Those tools and models, which incorporate a broader sample of data from multiple sources can guide CCGs in allocating care across the whole population in order to make precious funds go further and provide preventive solutions for the long term – averting problems instead of having to cure them. These more complex, predictive modelling systems can help CCGs analyse finances and accurately measure progress. It’s up to CCG board members to select and invest in the most appropriate and value-for-money model for that area’s specific care needs. Is there a system to suit everyone at a price to match, and how much should CCGs be prepared to invest? With a myriad of models and suppliers to choose from and continuous changes and updates in the governance of risk stratification – not to mention legal considerations – choosing to run with risk stratification can be a risk in itself. Without knowing the ins and outs of what’s available you may struggle to make a fully informed decision. So, on the off-chance that data analysis isn’t your specialist subject area, we’ve attempted to make it all a little simpler for you…
them to accurately target interventions of any kind and develop a complete range of services to benefit the whole population. Wayne Parslow, general manager at MedeAnalytics, adds: “The traditional notion of getting basic data based on attendance and procedure information – from GPs and hospitals – is not suitable for the world that we are now rapidly moving into, which requires commissioners to take account of all kinds of data.”
scale education programmes and wider interventions that prevent their health problems from emerging in the first place.”
MORE THAN JUST HOSPITAL ADMISSIONS Risk stratification is evolving at a furious
MULTI-MORBIDITY The highest risk individuals are not necessarily the most vulnerable and CCGs can benefit greatly from knowing where the most vulnerable people sit. For this reason, Stephen recommends using a system that will give you an understanding of principles such as multi-morbidity. “It’s all very well looking at your big chronic issues such as diabetes, cancer and so on but then there’s a core of the population that have all of these in common; realising that disease clusters in individuals is an incredibly key concept. You’ll want a risk stratification system that helps you understand issues such as multimorbidity as well,” he says. The model you employ will form the foundation of your data analysis. Considered by many to be ‘the most flexible’ model is the Adjusted Clinical Groups (ACG) system authored by Johns Hopkins University. Chris Morris, principal analyst at NHS South, Central and West Commissioning Support Unit, predominately uses the ACG system because, he says: “The system supports multiple functions: case finding, population profiling, resource management and, potentially, resource allocation. The system also provides an anonymised but detailed
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IT RISK STRATIFICATION
record set that supports commissioning analysis such as disease prevalence, population segmentation and case-mix adjustment to understand variation.” Other models include the King’s Fund Combined Predictive Model, the Nuffield Trust’s Recalibrated Combined Predictive Model and United Health’s RISC tool. However, as Dr Davies says: “I don’t think people should be specifying a model if they’re looking to build a risk stratification system that’s bespoke to their CCG. It’s about running the NHS with your eyes open and identifying the cohorts you need to access.” TIPS FOR PROCUREMENT Alan Thompson, senior consultant at ACG System International, recommends, first and foremost, engaging with local GPs with the ultimate aim of gaining permission to use their data. “Most risk stratification tools rely on the data from GP practices. Engaging with many hundreds of GPs is a difficult task so you can use the body which represents them locally – the LMC. If you can convince the LMC that what you’re trying to do will benefit patients then persuading GPs to come on-board becomes a much simpler process.” He also suggests working with the LMC on developing your information governance and data security mechanisms. “Ensure you have the necessary engagement with those who will ultimately use the risk stratification tool to identify patients,” adds Chris, because, “… the best tool in the world is still useless if people don’t believe in it or won’t use it”. GETTING THROUGH SECURITY It’s the responsibility of information governance professionals and advisory groups to ensure data is shared in a safe way that maintains people’s confidentiality. Legislation ‘section 251’ allows commissioners
40 | NOVEMBER/DECEMBER 2015
with a well-defined purpose to process particular data. However, if a CCG then wants to ask a different question or investigate a new population group, they’re required to go back to the advisory group for permission all over again. “Information governance can be tricky to navigate,” admits Alan. “The guidance that’s out there is neither black nor white; by necessity it’s very grey and people’s interpretation varies considerably. On a continuum, you’ve got information governance professionals at one end who say you can’t do anything with the data, for example, and then people at the more pragmatic end of the spectrum who understand the benefits of using integrated data sets to support the care of
“The best tool in the world
is still useless if people don’t believe in it or won’t use it” the population.” Alan suggests seeking information governance advice from multiple sources and adds: “The best information governance people I’ve worked with say that it should be an enabler not a barrier.” IS RISK STRATIFICATION COSTLY? According to Steven, risk stratification is at its most costly when it’s used for a single purpose; this is partly because getting the data in the first place can be the most difficult and
expensive task. “Getting hold of the data is where 80% of the effort lies,” he says. However, he argues that the investment makes much more sense when you also use risk stratification for planning, performance, benchmarking and putting preventive measures in place. Dr Davies says: “If you’re asking CCGs to compare costs the key message is to make sure they’re comparing apples with apples. It’s a very simple thing to run some numbers through an algorithm for a relatively simple data set and come up with some numbers. It’s a very different thing to provide a business intelligence information architecture that allows you to provide services across your population. It’s really important that CCGs align their business intelligence ambitions with their strategic ambitions – embedding business intelligence throughout. If CCGs go in with a narrow question they’ll get a very narrow short-term solution that, in the long term, will cost them more money.”
IT XXXX
NOVEMBER/DECEMBER 2015 | 41
MANAGING COMMISSIONING LEGAL INSIGHT
GET WITH THE REGS
T
After much debate throughout the public sector, the Public Contracts Regulations 2015 (‘the Regulations’) came into force in February. MARK FITZGIBBON from Hill Dickinson identifies and explains the key changes that NHS procurement and commissioning practitioners should take note of
he public procurement laws – established to regulate the purchasing by public sector bodies of contracts for goods, works or services – have been updated and, as you’ll be aware, the Public Contracts Regulations 2015 (replacing those from 2006) are now in place to regulate procurement commenced on or after February 26 2015. So what’s new? HEALTHCARE SERVICES FOR THE PURPOSES OF THE NHS The commissioning of healthcare services for the purpose of the NHS has been excluded from the Regulations until April 18 2016. However, this exclusion does not apply to non-health services procurements, thereby creating a two-tier system for the short term. PART A/PART B The distinction between Part A and Part B services has been removed and replaced with a new classification: Social and other specific services. Where such services are being procured above a value of £625,050, a contract notice must be used to advertise the opportunity. However a light touch regime will apply. Equally significant is the removal of the catch-all ‘other services’ category; the presumption being that services not falling within the light touch
42 | NOVEMBER/DECEMBER 2015
regime will be subject to the full scope of the Regulations. THRESHOLDS The Regulations clarify that the higher ‘subcentral contracting authority’ threshold of £172,514 does apply to Foundation Trusts and CCGs in public services procurements. However, NHS Trusts and Welsh NHS Bodies will continue to apply the lower threshold of £111,676.
“Implementing new
procurement requirements is a great place to start” NEW PROCEDURES The Innovation Partnership Procedure has been introduced for use where an authority has identified a need for an innovative product, service or works that cannot be met by purchasing products, services or works already available on the market. A new Competitive Procedure with Negotiation has been implemented with pre-conditions for use that are aligned with those for the Competitive Dialogue Procedure. CODIFICATION OF CASE LAW Various procurement principles, previously enshrined in case law, have now been
incorporated within the Regulations. This includes Teckal (the in-house exception), Pressetext (material variations to a contract) and Hamburg Waste (public/public shared service arrangements). TURNOVER THRESHOLD LIMIT To afford small and medium-sized enterprises greater access to public contracts, a cap on turnover has been introduced as a selection criterion. An authority cannot require a tenderer to have a minimum yearly turnover that exceeds twice the estimated contract value (over its life). WHAT HAS STAYED THE SAME? The processes for other procurement procedures are largely unaltered. The listed changes are intended to make procurement simpler and quicker, reduce the risk of challenges and promote best practice. However, in a climate of a new administration, tighter NHS budgets and complex commissioning, legal challenges will still be a real risk for many. Commissioners should review their decision-making processes and assure themselves that they’re making as robust decisions as possible. Understanding and implementing these new procurement requirements is a great place to start. Mark Fitzgibbon is a partner at Hill Dickinson
MANAGING COMMISSIONING XXXX
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For more information contact us: jessica.pike@intelligentmedia.co.uk NOVEMBER/DECEMBER 2015 | 43
MANAGING COMMISSIONING CONFLICTS OF INTEREST
CONFLICT PREVENTION THE LOWDOWN A mammoth part of the lay person role involves identifying and negating conflicts of interest that arise during the commissioning process. EMILY HARDY investigates how, during the early stages of primary care co-commissioning, CCGs can effectively manage the vested interests of board members
D
espite categorically denying the claim Devon CCG was, in March this year, accused of a conflict of interest (COI) in its decision to award a contract worth £100m to Royal Devon and Exeter Foundation Trust. The country’s largest CCG was accused by Northern Devon Healthcare Trust of being “automatically skewed” and “biased” in their process to commission the three-year community services contract. Failure to correctly manage COI can significantly damage the integrity of a CCG’s decision-making processes, jeopardising the public’s trust and the confidence of patients, providers, taxpayers and parliament. Now, owing
44 | NOVEMBER/DECEMBER 2015
to the introduction of the optional cocommissioning of primary care, the waters are murkier than ever. While this move is anticipated to solve major complications in the sector it’s also set to cause a few too – particularly when it comes to COI. NEW, STRONGER GUIDANCE According to NHS England the increased possibility that GPs will find themselves part of a decision-making process to ‘potentially commission to their own benefit’ exposes CCGs to a greater risk of COI, both real and perceived. Chris Naylor, senior fellow at The King’s Fund, agrees: “It is important to recognise that COIs exist not only when a member practice gains an actual benefit from a commissioning decision but whenever there
is a potential for them to do so, or when an outside observer might perceive a risk of impaired judgement. Co-commissioning arrangements mean that these situations are likely to arise more often.” In acknowledgement of these developments NHS England, in consultation with national stakeholders, has shone a light on COI management and strengthened its guidance on the issue. In Next steps towards primary care co-commissioning, Ian Dodge, national director for commissioning strategy at NHS England, says: “In order to harness the benefits of co-commissioning, yet guard fully against the risks, we have developed robust new and transparent arrangements for managing perceived and actual conflicts of interest.”
MANAGING COMMISSIONING CONFLICTS OF INTEREST
and then proceed as normal with the meeting. That’s just the start. Equally, you don’t want to risk being overly cautious and exclude someone from an area of work they might make a valuable contribution to. There are other ways to manage things.” According to Oliver a common method is to allow a knowledgeable – but openly conflicted – person to participate in a discussion but not to participate in the final decision-making process. “All the cards are on the table so the clinician is able to share her/his knowledge but they don’t get a vote. This is a good middle path.” SPOTTING INTERESTS “People assume COI is only about financial interests,” says Oliver, “but this isn’t the case. If clinicians have done a lot of research on a particular condition they may well find themselves keen to commission an
“If you don’t take any
reasonable steps to find out your partners’ interests it’s not going to look good”
In its updated guidance NHS England stipulates that CCGs must create “decisionmaking committees” with a lay chair and with lay and executive members forming a majority, rather than GPs. However, there remains growing concern about removing clinicians, who have invaluable and expert knowledge to contribute, from decisionmaking processes in organisations that are supposed to be clinically-led. KEEP CLINICIANS IN CLINICAL COMMISSIONING “First things first,” says Oliver Pritchard, partner at law firm Browne Jacobson. “It’s not a problem that COIs arise. Because of the way CCGs have been set up – with GPs as major contributors to decisionmaking – conflicts are inevitable. It’s
inherent in the whole structure; it doesn’t mean you’ve done anything wrong. Also remember that GPs are fiercely proud of their professional integrity and reputation,” Oliver adds. “They’re not moaning about the bureaucracy – it’s quite the opposite; they want to protect themselves against any accusation of bias. We don’t see loads of cases where GPs are deliberately and brazenly trying to influence the decisionmaking process in their favour.” Given that COIs are “inherent” and “inevitable”, and that GPs want to know how to protect themselves, Oliver says CCGs need to do more than just identify potential conflicts. “What’s important is how you manage COI – which is the bit that lots of people forget! It’s not enough to declare COIs, mark them on the register
initiative for this over something else.” And it’s not just members’ interests you need to consider. According to Oliver, a grey area for CCGs is the disclosure of GPs’ fellow practice partners, practice managers and reception staff’s interests. “Does every GP on a CCG board need to make it their business to know the interests of their fellow partners – what shares they hold, for example? Most CCG policies require you to declare the interests of the partners in your practice but don’t go beyond partners and practice managers. If you don’t take any reasonable steps to find out your partners’ interests it’s not going to look good but, if you genuinely aren’t aware of something, then how can you be expected to declare it? You have to make a judgement call.” KEEPING ON TOP OF IT ALL Jenna Tsai, associate at Hill Dickinson, stresses the importance of robust record keeping: “Records of decisions made by the CCG should always be kept as an audit trail. The CCG should, as a matter of routine, include within that record whether there was any COI (actual or perceived) declared as part of those records. Where there is such a conflict the record should include who was conflicted, their position, the nature of their interest, when it was declared and how, plus the steps taken to prevent that conflict affecting the decisionmaking process,” she says.
NOVEMBER/DECEMBER 2015 | 45
MANAGING COMMISSIONING CONFLICTS OF INTEREST
“Make routine consideration of COI easy,” adds Jenna. “Include it as a standard agenda item, send regular reminders to governing body members to reflect on whether the register of interests needs to be updated and include it as an automatic prompt in any new procurement or other decision-making exercise.” In line with NHS England guidance Neha Shah, senior solicitor at Hempsons, advises CCGs to have an effective and robust governance system in place. “This will ensure commissioners maintain a register of interests, keep clear records of the steps taken to manage a COI and engage with a range of possible providers on service design. There should be clear statements about the standard of conduct expected of individuals and this system of governance should be documented in CCGs’ constitutions and supporting policies and procedures. In addition, there must be procedures in place for whistleblowing and appropriate external oversight in relation to breaches of CCGs’ COI policies,” she says. DON’T BE PUT OFF: ASSISTANCE IS OUT THERE According to Dr Beth McCarron, BMA
46 | NOVEMBER/DECEMBER 2015
“Failure to correctly manage
COI can significantly damage the integrity of a CCG” executive and commissioning lead, the BMA has been heavily involved in trying to ensure that COI issues are addressed and ameliorated as much as possible. Specific and “very clear” guidance around COI with co-commissioning is accessible on the BMA website and the GP Commissioning and Service Development Subcommittee is in the process of developing a checklist of questions that CCG boards can ask to make sure every potential risk of COI has been uncovered before a service is commissioned. “NHS Clinical Commissioners also have a checklist and we will be working more with them,” she says. “The other interesting thing on the horizon is the Multi-speciality Community Providers (MCP) model,” adds Dr McCarron. “CCGs may find that the whole issue of board members having a pecuniary interest is diluted as GPs federate and groups of practices join together to provide services; they’ll be making contracts with
groups of practices instead.” Some CCGs, including Vale of York, are considering swapping GPs with their neighbouring groups as a way to safeguard against COI without muting the voice of general practice. Dudley CCG has set up a separate committee to take on delegated commissioning and, across London a number of CCGs have formed a collaborative commissioning collective. Howard Freeman, chair of Merton CCG which forms part of the South West London collective, said having a single committee across several CCGs “means there is a wider pool of GPs to make decisions”. For Dr McCarron it’s vital to address COI so that CCGs don’t become averse to the idea of co-commissioning. “General practice has had no new investment since 2004 and there is no more flex,” she says. “In my view it’s absolutely vital that CCG boards make the very difficult but very necessary decision to invest in primary care because, at the moment, general practice is absolutely stifled. What we really don’t want to see is disinvestment in primary care or reluctance to co-commission because CCGs are concerned about COI.”
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