Innovation in Healthcare

Innovation

in Healthcare

Innovationin Healthcare

For page turning technology visit: www.innovationinhealthcare.org

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Rapid access to evidence-based information you need to support local care decisions

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Finding better ways to deliver healthcare O2 health is helping NHS Trusts and other organisations to improve the delivery of healthcare, while meeting some tough budget demands.

We’re working together to understand the needs of patients and their care teams. Then delivering the technology that meets them.

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A dynamic coalition NAPC and NHS Alliance will provide a collective voice for clinical commissioners, says Michael Sobanja, CEO of NHS Alliance and Clinical Commissioning Coalition steering group member

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How reducing variation improves quality and value The QIPP Right Care workstream develops tools to help the NHS get better value from the money it spends on planning healthcare for local populations

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How NHS Improvement helps its health partners deliver the QIPP agenda

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Delivering major breast surgery (excluding reconstruction) as a day case or a one night stay

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Atrial fibrillation: detection and optimal management in primary care

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Research is the route to innovation

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Clinical research is a key factor in healthcare innovation, but it needs to be higher on the NHS agenda argues Dr Jonathan Sheffield, chief executive of the National Institute for Health Research, Clinical Research Network

Managing the transition in healthcare commissioning The development of Clinical Commissioning Groups (CCGs), provides both an opportunity and a challenge to GPs

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Healthworks, Birmingham/Sandwell Pathfinder are being built from scratch by new federations of GPs who do not yet know each other well

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CARE UK: Delivering Innovation Dr Mark Hunt, Managing Director of Health Care at Care UK, examines the role of independent providers in meeting the challenges faced by NHS commissioners

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Optimising warfarin monitoring – a novel approach?

Stroke management and prevention are major clinical priorities for the NHS, as stroke is the third largest cause of death in England, at a cost of £2.8 billion

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Chronic obstructive pulmonary disease: improving home oxygen services 36 Acute stroke services: a network approach to the use of telemedicine North East Essex GP Commissioning Group This is the rich variety of primary care, as it is meant to be How virtual healthcare can improve how we treat the ageing population and those with chronic illness Richard Rees-Davies, managing director, EMEA at Intel GE Care Innovations

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Not just hype The National Institute for Health Research Stroke Research Network has eight Hyper-acute Stroke Research Centres across England that provide a joined-up serivice of quality care with pioneering monitoirng and research

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One plan to reduce four harms The QIPP Safe Care workstream has developed ‘harm free’ care, which it hopes will get NHS staff thinking differently about patient safety

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Innovations in sexual health provision: technology’s role in tackling inefficiency and supporting service development 45

A problem shared is a problem solved

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Innovative microbiology services for the 21st Century Philip E Luton, business development and marketing manager of the Health Protection Agency explains the support and services the agency can offer

Technology can help healthcare be more efficient and give patients a better experience. O2 Health is ready to help organisations get the best out of it A picture of health New multi-media technology means GPs, patients and consultants can meet and talk through treatment without having to be in the same room, or the same city

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Baywide, Torbay “I’m living the future – and it works,” says Dr Samantha Barrell, a GP in Brixham, a busy fishing town and holiday centre at the southern end of Torbay in Devon

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Commissioning mental health pathways A project overview by Carole Green, Project Director, Care Pathways and Packages Project (CPPP); Ian Smyth, Chair, Pharmaceutical Mental Health Initiative (PMHI); Miranda Stead, Director, Mednet Consult

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The power of touch: using touchscreen technology to engage patients 55 Patient engagement goes much further says Mark Worger, Business Development Manager, Elephant Kiosks

Contents

Innovate to survive The prime role of clinical commissioners is to improve the population’s health. Innovation and redesign will be their tools, says Michael Dixon, chairman of the NHS Alliance

Reduce referrals, save money and improve patient care… …by implementing heart failure and DVT testing with cobas h 232 • Selected as ‘commercially available with NHS evidence to support adoption’ by iTAPP* in support of the QIPP† agenda1

The cobas h 232 system is simple, providing accurate cardiac decisions in just 12 minutes, so that: - hospital referral can be reserved for patients who really need it 2,3 - appropriate treatment can be given without delay NT-proBNP testing - is recommended by NICE4 - could save more than £20m-£30m across the UK per year5 - could avoid up to 61% of echoes and 46% of cost6 • Only around 40% of people aged ≥45 years referred with suspected heart failure have the diagnosis confirmed7

D-dimer testing • SIGN guidelines state that a clinical decision rule (CDR) and negative D-dimer test can safely be used to exclude a diagnosis of Venous Thromboembolism8 • Using D-dimer testing and a simple clinical decision rule can reduce the need for hospital referral for DVT by almost 50%9

For further information, phone 0808 100 99 98, email burgesshill.cardiacpoc@roche.com, or visit www.roche.co.uk * Innovative Technology Adoption Procurement Programme † Quality, Innovation, Productivity and Prevention.

Roche Diagnostics Ltd Charles Avenue Burgess Hill RH15 9RY United Kingdom Company registration no: 571546

References: 1. www.imsta.ie/node/350 [Accessed 22nd July 2011].

2. Wu A et al. National Academy of Clinical Biochemistry Standards of Laboratory Practice: Recommendations for the Use of Cardiac Markers in Coronary Artery Diseases. Clin Chem 1999; 45: 1104–1121.

3. Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost 2005; 94: 200–205.

4. NICE Clinical Guideline No 108. Chronic Heart Failure. National clinical guideline for diagnosis and management in primary and secondary care August 2010.

5. www.cumberland-initiative.org/about/health-successes-using-modelling [Accessed 19th July 2011].

6. Goode KM, Clark AL, Cleland JG. Ruling out heart failure in primary care: the cost-benefit of pre-screening using NT-proBNP and QRS width. Int J Cardiol 2008; 130(3): 426–37.

7. NICE Commissioning Guide. Heart Failure service for the management of chronic heart failure. March 2010.

8. SIGN National Clinical Guidance No 122. Prevention and Management of Venous Thromboembolism.

9. Büller HR. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med 2009; 150: 229–235.

KMHIS – a commitment to Green IT at the heart of healthcare Kent and Medway Health Informatics Service is an NHS organisation providing IT services to health, social and third sector organisations How GE is rethinking the role of technology to address the UK’s healthcare challenges Michael Smeeth, Director of Healthcare Infrastructure for GE, explains how GE’s technology can help the NHS create efficiencies, new services and meet carbon emissions goals Why the NHS needs to get up close and personal Chief Executive Ian Gillespie, from Vanguard Healthcare Solutions Ltd, discusses the implications of the Health and Social Care Bill with regard to clinical commissioning groups and mobile solutions, and suggests it is not a question of ‘them and us’ but a collaborative approach between the private sector and the NHS required to find cost efficient answers

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A lifetime of good oral health Trisha Rawsthorne, professional education manager for Philips explains why preventing periodontal disease is vital to patients’ health

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Innovation in other health economies Mainstream telehealth support is a new approach that is positively helping significant numbers of patients with chronic diseases around the world says Giles Tomsett, managing director, of Healthways Europe

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A complete system for producing autologous cells for use in regenerative medicine 83

Exploiting the results of remedi, the EPSRC Innovative Manufacturing Grand Challenge in Regenerative Medicine, this project is creating an automated production system for the regulated manufacturing of cellular therapies Amit Chandra, Centre for Biological Engineering, Loughborough University NHS Alliance The NHS Alliance invited GP consortia to submit brief statements about what they are achieving at local level, including innovations they have made to deliver a better service to NHS patients. This section includes a selection of what they said

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How volunteers can help the professionals deliver better community healthcare 93 Pathfinder Healthcare Developments CIC specialises in finding innovative ways to bring health services to hard-to-reach patients The Who’s Who of commissioning Over 2,000 healthcare professionals gathered in London’s Olympia in June for the launch of the definitive event in primary care commissioning

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Contents

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Innovate to survive The prime role of clinical commissioners is to improve the population’s health. Innovation and redesign will be their tools, says Michael Dixon, chairman of the NHS Alliance

To date, sadly, these have been in short supply. Witness, for instance, the reduced spending in primary care compared to secondary care, when the rhetoric is that we must move services from hospitals into the community. Witness too the ongoing debates between commissioners, who want to limit demand, and some frontline GPs, who feel oppressed by what they see as draconian measures. Dawn raids on primary care funds and aggravating frontline clinicians with arbitrary quotas are imperfect solutions.

Indeed, they should be solutions of last resort.

Instead, a total commitment to innovation and breaking down obstacles should be the first task of every Clinical Commissioning Group (CCG). Our new clinical commissioners will need to adopt a “can do” attitude towards innovation in three specific areas of care.

First, they must take a new leading role in moving traditional hospital services, where appropriate, safe and cost effective, into local communities. That will mean more diagnostic tests available locally, more acute elderly ill being looked after in the community and the treatment of long-term disease with traditional outpatient services being moved out of hospital. In future, for instance, if someone has a deep vein thrombosis then diagnosis and treatment should all be possible within a patient’s own GP practice and community.

Meanwhile, the new commissioners will also need to ensure that when high tech care is required in hospital, it can be provided as cost effectively as possible.

Second, the new clinical commissioners will also need to redesign community services

themselves. That will require better integration of services (such as district nursing and practice nursing, where appropriate) and using new technology (such as the home monitoring of vulnerable patients) to maximise the benefits of community care and reduce calls on secondary care.

The new war cry of CCGs needs to be “innovation, innovation, innovation!”

Third, there are many areas of care, where we need to reduce the input from expensive professional care altogether. This means enhancing the ability of patients to self care, improve personal health and find new ways of encouraging whole communities to better care for themselves. That great untapped seam of NHS goodwill, which sees the nation’s rich effectively subsidising the health and care of the nation’s more needy should now be reflected in a “new ethos” encouraged by the clinical commissioners. This would see the central “gift” from taxpayers translated into a much greater mutual responsibility on the part of local people and their clinicians to “co-produce health” wherever possible and reduce the costs on the system. Without such social engineering happening at local level, the concept of a “National” Health Service will become unsustainable.

Innovation inevitably faces blocks. Some of these will originate from the interest of those clinicians and managers, who benefit from the system staying as it is. There will also be blocks

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from another group of clinicians and managers, who recognise the need for innovation but see it as unaffordable. This is where our new commissioners will need to be really innovative.

They will not be able to pay the double costs of providing old services, when new ones are introduced. They will not have the luxury of introducing important health initiatives that may not be realised in improved health outcomes for five or ten years. They will need the wisdom of Solomon to devise ways of innovating rapidly, while meeting all the shortterm goals imposed on them. It is a challenge but it is also a magnificent challenge.

Primary care has always delivered, when it has been allowed to. GP practices have a reputation for adapting rapidly. The roots of clinical commissioning lie many years back with GPs, who wanted to make a difference.

With innovation, we now need to reignite the spirit, passion and sense of adventure that fired the commissioning movement. The new war cry of CCGs needs to be “innovation, innovation, innovation!” The first question on the lips of anyone visiting a CCG will need to be: “How are you changing things”.

NHS Alliance is delighted that Innovation in Healthcare is joining us as a partner and champion of innovation and radical redesign.

Julien Wildman is fired by the passion of someone, who has been treated by the NHS and knows how it could be done better.

Clinical commissioners must be fair to patients and staff alike, but their solid commitment must be towards making health and services better. That is, they will need to innovate to survive!

Online pageturner www.innovationinhealthcare.org

A dynamic coalition NAPC and NHS Alliance will provide a collective voice for clinical commissioners, says Michael Sobanja, CEO of NHS Alliance and Clinical Commissioning Coalition steering group member

The Coalition The National Association of Primary Care (NAPC) and the NHS Alliance have come together to form a coalition to support clinical commissioning. Both organisations have a heritage going back many years drawing upon GP Fundholding, Locality Commissioning and Total Purchasing Pilots established in the 1990s and more latterly Practice Based Commissioning.

Both wish to provide a collective voice for clinical commissioners going forward – why?

The context here is to recognise that clinical commissioning brings together fiscal responsibility with clinical responsibility and welds the two together in the interests of patients and the public. The NHS faces enormous challenges in the coming years and only by bringing these two key elements together can it survive and prosper. At a recent meeting of clinical commissioners organised by both organisations, four pillars were identified upon which the coalition would move forward. These are: »» The need for Clinical Commissioning to focus on Public Health »» The need to avoid over centralism in the system »» The need to maintain local flexibility »» The need to ensure collective working locally.

Let’s look at these. Firstly, the need for Clinical Commissioning to focus on Public Health. »» Previous health reforms have placed an

emphasis on effective and efficient healthcare but not necessarily sufficient focus on health improvement for the population as a whole. Benefits arising from healthcare must be identified but may fall outside the healthcare system, for instance by allowing individuals to remain in employment, or to return to employment. »» Similarly, all provision of healthcare has an opportunity cost – the commitment of resources to one patient means that those resources are not available to others. This wider view of the purpose of the system – improving health and not just healthcare may also call for investment in education, housing or other “wider determinants of health”. »» Clinical commissioners must be able to leverage health improvement both by improving health care and by influencing others, for instance through Health and Wellbeing Boards locally.

Thirdly, the need to maintain local flexibility »» Some direction from the centre is legitimate and appropriate. It should be confined to the “what” (for instance national priorities) and not the “how” – the means of delivery. An example of this would be the necessary freedom for local commissioners to determine from where and whom they secure commissioning support. These decisions must stay local and may differ from place to place. In short, one size doesn’t fit all.

Secondly, the need to avoid over centralism in the system. »» The proposed new system gives great power to the National Commissioning Board – it is imperative that this does not lead to too many decisions being made centrally which would effectively hamstring local commissioners as they need to reflect local needs as well as national priorities.

That is why NAPC and NHS Alliance have come together to form a coalition. To provide a collective voice to further these principles, and to ensure that this voice is heard, in parliament, government, the Department of Health and its agents. To provide a means of developing and sharing good practice amongst clinical commissioners. And finally, to ensure that the public and our patients both receive the healthcare that they deserve.

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And fourthly, the need to ensure collective working locally. »» Health and social care should be integrated at the point of delivery. This requires collective working both across primary care and with colleagues in secondary care. Commissioning may be described as Co-Mission-ing. And Clinical Commissioners should be the glue in the system.

INNOVATION IN HEALTHCARE

How reducing variation improves quality and value

The QIPP Right Care workstream develops tools to help the NHS get better value from the money it spends on planning healthcare for local populations. Here, the workstream’s co-lead Phil DaSilva explains the success of the NHS Atlas of Variation, now in its second year of publication.

When I joined the QIPP programme early in 2010, my team and I were tasked with helping PCT commissioners get maximum value out of the way they planned and paid for healthcare while driving the quality of that service to new heights. Our response was to develop the first NHS Atlas of Variation which used existing data to highlight differences in outcomes in 34 clinical topics, broken down by PCT. The health economy warmly welcomed the Atlas and it immediately became an essential tool for commissioners.

NHS West Cheshire used the Atlas to help its commissioners understand what they spent their money on and what value they got from it. Using the Atlas, West Cheshire compared its expenditure with that of similar organisations with the same population needs. It discovered it was spending more than £2.5 million pounds a year on some areas, such as musculoskeletal conditions,

than in similar PCTs. The reason for this was a higher rate of hospital outpatient appointments in West Cheshire for musculoskeletal conditions compared to other PCTs, which managed up to 80% of referrals in a community setting. This knowledge led them to systematically review all programmes and this benchmarking work enabled the PCT to identify efficiency opportunities, reduce outpatient appointments and move more services from the acute sector to primary and community care. Using the data also helped the PCT put in place better primary prevention strategies, which will reduce demand in the future.

The results are impressive and really add up and, most importantly, will improve the quality of care for many patients. For instance, using the Atlas to introduce an equitable threshold for varicose vein treatment could save £238,000 a year.

Increasing the efficiency of prescribing statins could save £400,000 a year. Identifying patients with high blood pressure that could signify a raised risk of a stroke could save £1.37 million in emergency stroke admissions.

Since then the Health and Social Care bill has moved commissioning centre stage by proposing Clinical Commissioning Groups,

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Phil DaSilva, Right Care workstream co-leader

reporting to an independent NHS Commissioning Board. This makes our work even more relevant than before and Right Care is continuing to inform positively commissioning decisions with a second Atlas of Variation and, soon to come, a suite of themed atlases looking at specific conditions or disease pathways.

The second Atlas of Variation contains new maps covering a new range of commissioning decisions. Each map drills down by PCT area to show the clinical outcomes achieved by the commissioning spend for a range of programme budget categories. We chose these categories after engaging with a wide range of stakeholder groups including national clinical directors and their teams, third sector organisations and public health observatories.

Our aim in publishing our Atlases is to stimulate, within all levels of the NHS, a search for unwarranted variation. We all want an NHS that puts patients at the heart of what it does by maximising health outcomes and minimising inequalities.

I hope the Atlases can play a role in assuring the future of an NHS where these brave ambitions can be achieved.

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How NHS Improvement helps its health partners deliver the QIPP agenda Who We Are NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke services.

The organisation demonstrates some of the most leading edge improvement work in England, which supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements to over 250 sites across the country as well as providing an improvement tool to over 1,000 GP practices.

NHS Improvement was formed in April 2008, bringing together two existing national improvement programmes – the Cancer Services Collaborative (including Diagnostics) and the Heart Improvement Programme. It also extended its work to create a three-year Stroke programme within existing resources.

Its current work programme is defined through the Department on behalf of the NHS in the key policy areas of Cancer, Heart, Stroke, Lung and Diagnostics and forms part of the NHS Medical Directorate led by Sir Bruce Keogh.

What we do »» Demonstrating the practical application of quality improvement and service redesign, with a track record of delivering quantifiable improvement »» Leading improvement work in primary,

community, secondary and tertiary care »» Providing clinical engagement and leadership by working with over 50 clinical leads »» Aligning with policy direction, providing a bridge between national strategy and local engagement and implementation, often through clinical networks »» Demonstrating skilled expertise in a full range of quality improvement tools and techniques including high level Lean and Six Sigma, plus utilising experience from across the healthcare sector as well as commercial knowledge gained at Toyota, GE, Aviva, Boots and private healthcare »» Showing measurable results from concept to delivery »» Working in partnership with leading charities, professional bodies, Royal Colleges and other associations ensuring

The QIPP section of the NHS Improvement website which includes 200 good practice examples. Visit www.improvement.nhs.uk/qipp

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INNOVATION IN HEALTHCARE

NHS Improvement’s tools and techniques, combined with its expertise and experience, could be applied to other service areas to support delivery of the five key domains NHS Improvement’s framework for service improvement that there is a strong alignment to research, patient-facing organisations and third sector work.

and stroke networks) »» Advisory and development work (service improvement training for clinical and managerial staff)

NHS Improvement’s tools and techniques, combined with its expertise and experience, could be applied to other service areas to support the delivery of the five key domains within the NHS Outcomes Framework 20112012 and priorities within the Operating Framework 2011-2012.

It is committed to continue delivering quality improvements that are clinician-led and patient-focused to enhance patients’ outcomes and experiences.

How we do it NHS Improvement applies a framework for service improvement and clinical pathway redesign to ensure a consistent and systematic approach to its work.

The work falls into five key categories: »» Long term programmes of work to support delivery of a key national priority (Stroke Improvement Programme) »» Bespoke improvement work, which is time limited (review of seven day services across England) »» Tailored support to assist delivery (working with SHAs to implement primary angioplasty) »» Establishment, development and support of clinical networks (cardiac

It utilises the following approach as part of any service improvement work: »» Proof of principle: Piloting and testing new ways of delivering services – redesign and quality improvement (usually a 12 month duration) »» Testing wider applicability of pilots: Prototyping new service models, innovations and improvements (usually a 12 month duration) »» Spreading and disseminating learning and innovation more widely (a two year plus duration).

Practical support for the delivery of QIPP Delivering the Quality, Innovation, Productivity and Prevention (QIPP) challenge successfully will be key to delivering £20 billion of savings across the NHS by 2015.

NHS Improvement’s approach to system improvement aligns closely with the QIPP agenda and over the past year more than 200 good practice examples have been identified across the country. These are now showcased on the QIPP section of its website, www.improvement.nhs.uk/qipp.

Examples can be viewed by specialty (heart, lung, cancer, etc) or across the patient path-

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way – primary care, referral, diagnosis, treatment, aftercare and end of life care. In addition to the case studies, there is also useful information and tools. Since last summer the site’s pages have been viewed 25,000 times.

NHS Improvement’s leading edge improvement work with partners across the country has been recognised on a number of occasions during the past year by NICE and it now has six case studies that have been commended on the NHS Evidence website.

Most recently its work on developing the one day/one night stay breast surgery model and computer modelling on the potential impact of serum natriuretic peptide blood tests to GPs practices, have joined commissioning for stroke in primary care, the optimal detection of atrial fibrillation and cytology 14-day standard for test results and its work as part of the enhanced recovery programme.

In addition to its contributions to the nationally-renowned NHS Evidence site, NHS Improvement continues to encourage the identification and scoping, development, piloting, prototyping and spread of best practice through the Improvement System2 – a comprehensive online resource to support shared learning. It provides service improvement tools and resources, practical guidance, case studies, useful contacts and signposting for further information.

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Sharing the learning NHS Improvement has captured the latest learning and innovative thinking on a range of healthcare topics and disseminated this knowledge during the past year through a number of channels. These have included: »» Review workshops with clinicians, cancer survivors and representatives from a range of NHS organisations and third sector partners »» Social marketing training session for those working in cardiac rehabilitation »» Sponsorship and facilitation of FiLM (Frontiers in Laboratory Medicine) 2011 a forum where global influential leaders

address the key challenges facing laboratory medicine »» A collaborative event jointly-led and designed by GPs looking at the challenges facing those working in the new commissioning landscape, particularly around commissioning a stroke service »» A website, which was accessed by 106,000 unique visitors and 154 countries and territories »» An e-seminar on heart failure end of life care which attracted 100 participants and is being explored further to help support stakeholders facing resource and financial challenges in the current climate

Involving public and patients Engaging the public and patients in its activities is one of NHS Improvement’s core principles in the way it works. It is committed to designing and delivering health and care services around the needs of patients and carers and now has a new section on its website showcasing this partnership approach. The patient experience website supports people working with patients and carers, offering easy to access engagement resources, examples of good practice and links to useful information including personal accounts from patients of their conditions and explanations of how work involving NHS Improvement has helped improve their lives.

Most recently it worked in partnership with the Stroke Association to co-produce Community Voice events around the country designed to hear the experiences of stroke survivors and carers.

Following successful testing the trademarked ‘Discovery Interview™3’ innovative approach is now used by a number of specialties in the UK health system to improve care by understanding patient and carer experiences and by gaining insight into their needs. They are based upon a philosophy that puts patients and carers at the centre, and values listening to their experiences as a way of gaining insight that is unavailable elsewhere to stimulate “It is critical that we continue to innovate for our patients as we design the health and care system of the future, ensuring we improve the quality of care for our patients, while making historic levels of financial savings to reinvest in frontline services.

NHS Improvement working with and through clinical networks has been proven as an effective and productive model and it ensures that positive learning is spread more widely across the system.”

Sir David Nicholson KCB CBE, chief executive of the NHS in England

For further details the work of NHS Improvement visit: www.improvement.nhs.uk

NHS works closely with the clinical community and employs clinical leaders across a number of specialist fields

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Delivering major breast surgery (excluding reconstruction) as a day case or a one night stay Aim: In 2007, NHS Improvement Transforming Inpatient Care Programme as part of the Cancer Reform Strategy (2007) and recently the Improving Cancer Outcomes Strategy (2011) redesigned the breast are surgical pathway (excluding reconstruction) with the working hypothesis that: “Streamlining of the breast surgical pathway could reduce length of stay by 50% and release 25% of unnecessary bed days for 80% of major breast surgery (excluding reconstruction).” »» Why should major breast surgery be an inpatient procedure? »» It’s a relatively short operation »» Low post operative pain »» Patients can mobilise, eat and drink early »» Rare post operative events »» Patients want to return to normal life as quickly as possible.

The Problem: 2007 Baseline Hospital Episode (HES) data and local process mapping indicated that there were significant geographical and clinical practice variations.

The length of stay for breast surgery across England ranged from 0 to 7 days. Variation in clinical practice including the use of wound drains, seroma drainage preoperative assessment, admitting on the day of surgery, anaesthetics, analgesia and patient information were factors contributing to extending the length of stay for patients.

The Evidence: Breast cancer is one of the most commonly diagnosed cancers in the UK with approximately 40,000 new cases of female breast cancer and approximately 300 male breast cancer cases per annum.

Hospital Episode Statistics (2007/8)

provided a baseline indicating that there were 52,371 elective admissions for breast surgery (cancer and non-cancer) but only 25% of these are referred as day cases. The average inpatient length of stay was 3.15 days equating to 123,038 bed days.

Working with patient forums and breast charities, patients stressed the importance of “getting back to normal” as soon as possible and not wanting to stay in hospital.

“Sitting around in beds” increased their anxiety. Patients welcomed and supported the redesign of the pathway. The service improvement approach and the redesigned pathway demonstrate clear and improved QIPP outcomes.

The Project: A systematic service improvement approach was applied covering four phases:

Phase

Year

Service Improvement Methodology

1

2007

Baseline the current situation

2

2008

Testing out the idea, innovation: Proof of Principle

3

4

NHS Coverage

Outcomes Significant variation in practice. Length of stay, quality, clinical practice. Range length of stay 0-7 days

7 NHS Hospital sites

Identified early benefits and potential underpinned the hypothesis

2009

Prototype:Testing transferability and confidence of the improvement

25 test hospital sites

Pan Birmingham Cancer Network population 1.8m identified a potential saving of £1m across the network. Pathway spread across the West Midlands 15 PCT’s out of 17 the best quartile (short length of stay, CRS 2nd Annual Report 20098). Sandwell and West Birmingham Hospital now provide 94% of all breast surgery (excluding reconstruction) within one day (NHS Consolidation report July 2010)9

2010/12

Spread, Adoption, Adaption, Diffusion. NHS Improvement Spread Framework

13 Clinical Spread networks (72 hospital sites) 41% coverage across England

30% of Breast Episodes LOS 0 Days 30% 1 night stay 12% 2 days

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Patients are now able to have breast surgery (excluding reconstruction) as a day case or one night stay instead of having to spend up to five days in hospital.

British Surgery, the Association of Breast Surgery and is supported by Breakthrough Breast Cancer.

“We have pleasure in endorsing this; it looks like a fabulous piece of work that ticks every box with our own promulgated ethos of a planned pathway and evidence based care that not only improves quality, but also efficiency of care.” President Elect, British Association of Day Surgery (2011) This work has also the awarded the winner in the Pfizer Excellence in Oncology Awards (2011) for ‘Best Oncology Service Improvement’.

0-7 days (2007, Hospital Episode Statistics (HES). Currently (2011) around 42% of breast surgical procedures have length of stay (LOS) = 0 days and a ‘day case’ ranging from 6 to 12 hours. A further 30% have LOS of one night only, (2010/11 HES provisional). The overall mean LOS has reduced by 56%, exceeding the original working hypothesis. Improving the quality of the pathway has brought about efficiency benefits and length of stay continues to be reduced to around a mean 1.33 days (2011 provisional).

It is innovative in terms of changing and challenging practice from traditional inpatients to day case, inspiring and empowering other healthcare professionals with the clinical knowledge and evidence to change and to challenge traditional practice, eg use of drains, supporting the development of a clinical evidence base. It is also innovative in terms of getting patients better sooner and returning to normality.

If all patients with length of stay of more than one night were converted to the day case or one night stay breast surgical pathway, the potential bed days that could be saved could potentially be 40,000. Bed days for breast cancer have reduced from the baseline by 50,329 (41%) with most of the reduction due to shorter lengths of stay for episodes longer than a day; although the increase of short stays (zero or one day) has contributed. The proportion of patients not being admitted the day before surgery has increased from 69.6% (2006/7) to 94.6%.

Productivity: The ‘day case or one night stay breast surgical pathway’ continues to be spread and adopted across England. Good progress has been made – 72% of breast surgery patients across England now benefit from the pathway, this number continues to increase indicating that and 85% is achievable, exceeding the original hypothesis. There has been a gradual shift in the overall length of stay for patients The traditional inpatient pathway had a range of length of stay from

Prevention: Patients’ safety is improved as delivering major breast surgery as a day case or one night stay reduces the risk of hospital acquired infection; reduced intervention will be required (wound drains and seroma drainage); a change in anaesthetics reduces side effects such as nausea, vomiting and pain; pre-operative robust clinical and risk assessments identifies patient suitability for the day case or one night stay breast model.

Quality: Clinical quality was improved, resulting in patients getting better sooner. There was no evidence of increased re-admissions, re-operations and complications.

The new pathway promotes setting patients’ expectations and informed decision-making pre-operatively, earlier mobility, the avoidance of unnecessary controlled analgesia, opiates and associated side effects, thus enhancing the patient’s recovery. Patients have evaluated the pathway positively.

Innovation: The day case or one night stay breast surgical pathway has been recommended as best practice by NHS Evidence in supporting the spread of knowledge in the NHS. It has also been endorsed by the British Association of

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Atrial fibrillation: detection and optimal management in primary care Aim: To reduce the number of strokes related to Atrial Fibrillation (AF), by improving the detection and management of patients with it.

The Problem: AF is a major predisposing factor for stroke with 12,500 strokes annually thought to be directly attributable to it.

Warfarin reduces the risk of stroke by 50-70%.

NICE estimate that 46% of AF patients who would benefit from anticoagulation are not currently receiving it.

The Evidence: »» AF is common and affects over 600,000 patients in England (1.2% of the population) »» The annual risk of stroke is five to six times greater in patients with AF. »» Evidence of under-detection and sub optimal management of AF is compelling »» For primary prevention, the number needed to treat (NNT) to prevent one stroke is 37 »» It is estimated that between 4,500 and 8,000 strokes per year may be preventable through improved services and optimal management. »» The estimated total cost of maintaining one patient on warfarin for one year, including monitoring, is £383 »» Based on the NNT ranging from 25-37, the cost to prevent each AF related stroke is between £9,500 and £14,000 »» Efficiency and productivity are increased through the reduction in acute admissions to secondary care and bed days saved.

A GP using the GRASP-AF online tool which helps to optimize the management of patients with atrial fibrillation

The Project: Eighteen priority projects were piloted and developed resources for improved detection and management of AF. A tool (GRASP-AF) was developed to help GPs audit their risk assessment and management of patients with AF (see www.improvement.nhs. uk/heart/af). Since the tool was developed in October 2009, almost 1300 GP practices have used GRASP-AF and uploaded their data to CHART Online, an online facility where they can benchmark their data against that from other practices, both locally and nationally.

The Risk Assessment and Stroke Prevention for Atrial Fibrillation (GRASP-AF) Tool is a query and risk stratification tool available for use with all GP clinical systems in England that: »» Identifies all patients on your AF register »» Calculates a CHADS2 and CHADS-VASc score for all »» Highlights patients with a CHADS2 and CHADS-VASc score greater than 1 and not on warfarin »» States whether patients are currently on warfarin or aspirin (or both) »» Detects recorded reasons for NOT treating with warfarin »» Can show graphs of warfarin use and reasons for not prescribing against CHADS2 and CHADS VASc scores »» Has a comprehensive ‘advice sheet’ »» Gives you a comprehensive ‘dashboard’ view of the data

detection and management of patients with AF in primary care.

Innovation: Primary Care Trusts, Practice Based Commissioners and General Practitioners apply evidence-based learning, accessing tools, resources and education programmes developed for use in primary care to improve quality outcomes and quantifiable return on investment. This underpins a national drive to improve the management of patients with AF, and reduce their risk of stroke through sustainable changes to practice.

The Guidance on Risk Assessment: Each year, NICE estimate that appropriate anticoagulation of patients with AF could prevent a further 7,100 strokes at an additional cost of £63.5 million. The National Audit Office Progress in improving stroke care report estimates that in 2008-09 the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion.

The use of this tool demonstrates clear, improved QIPP outcomes:

Prevention: Safety: Improved detection of AF through opportunistic pulse palpation; improved quality outcomes for patients with AF through optimal management to reduce the risk of stroke. Effectiveness: Cost effective treatment for AF, reduced risk of stroke and avoidance of significant health and social care costs; improved productivity through a reduction in admissions and bed days saved.

Patient experience: prevention of avoidable mortality and morbidity; the prognosis of patients who suffer a stroke as a result of AF is particularly poor.

Quality: Improved quality outcomes for patients with AF and reduced health and social care costs by reducing the risk of stroke through service improvements to improve

Implementation of the GRASPAF tool is supported by NHS Improvement (Heart) and the cardiac and stroke networks. See www.improvement.nhs.uk/heart

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97% of the public think the NHS should support research into new treatments Ipsos MORI poll June 2011

Commissioned by the Association of Medical Research Charities, the Breast Cancer Campaign, and the British Heart Foundation

The chance to take part in clinical trials matters to patients.

It’s what the polls tell us, and it’s what patients and their families tell us too.

Which makes it all the more surprising that many NHS professionals don’t have a clear picture of their Trust’s involvement in clinical research, and their performance on research delivery.

The NIHR Clinical Research Network can give you that performance picture - and provide financial and practical support to increase your Trust’s engagement in clinical research.

To find out how many patients have accessed clinical trials in your Trust, and how we can help you to increase your research offer to patients, visit our website: www.crncc.nihr.ac.uk/nhs-performance

Tel: 0113 343 2314 Web: www.crncc.info@nihr.ac.uk Supporting research to make patients, and the NHS, better

Research is the route to innovation Clinical research is a key factor in healthcare innovation, but it needs to be higher on the NHS agenda argues Dr Jonathan Sheffield, chief executive of the National Institute for Health Research, Clinical Research Network

There is no question that the health service is facing challenging times. As the population ages, the NHS will have to respond to an ever-growing demand on its services whilst at the same time making efficiency savings on a major scale. In these circumstances it is more important than ever that clinicians and service managers get a clear picture of the most effective and efficient treatments for patients.

The way to do this is through carrying out evidence-based clinical research.

Clinical research has always been part of the remit of the NHS, right from its very inception, and the delivery of clinical studies remains at the heart of the NHS constitution and government health policy today. In addition, carrying out high quality clinical trials is one of the major ways for NHS Trusts to deliver on the quality, innovation, productivity and prevention (QIPP) agenda, so one might assume that taking part in clinical studies would be high on every Trust’s agenda.

Unfortunately, this is not always the case.

Whilst it is true that 97% of NHS Trusts do engage in some level of research activity, for some Trusts this can mean just one or two patients participating in one or two studies, rather than an institution-wide commitment to driving innovation and service improvement through clinical trials. So why isn’t innovation through clinical research more embedded in the day-to-day life of the NHS?

The reason may be that innovation is a problematic concept in a health service which must operate in difficult economic times. Innovation is seen by some Trusts as potentially expensive, as it carries the risk of low return, as well as the potential for high gain. Given current economic pressures, it is therefore understandable that NHS Trusts tend to focus more upon productivity – the reduction of “unknowns”, and the promise of budget savings – than they do on innovation through research, where outcomes are not guaranteed.

However, streamlining current practices can only deliver so much, and using clinical trials to drive innovation and service improvement is vital, if the NHS is to meet longer-term challenges.

A number of august bodies, the Academy of Medical Sciences amongst them, have called for a culture change in the NHS, so that clinical research is both high profile and high priority. This is going to require a concerted effort on many levels if it is to be achieved.

One organisation that is working to this end is the National Institute for Health Research Clinical Research Network. Sponsored by the Department of Health, the Clinical Research Network is responsible for recruiting patients into several thousands of clinical trials in NHS Trusts across the whole of England, and last year helped more than half a million patients to benefit from participating in research studies.

The Clinical Research Network is helping to encourage research culture within the NHS by publishing information about the number of studies each Trust delivers, the number of their patients who have taken part in a trial, and the length of time it takes NHS Trusts to give permission for clinical trials to go ahead. By making this information openly available to NHS

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Trust Boards, healthcare professionals and the public, the Clinical Research Network hopes to encourage Trusts to pay more attention to their research performance, make research a Board-level issue, and create an imperative for Trusts to increase their commitment to innovation through more research activity.

But it isn’t only about motivating the NHS community to pay more attention to research.

Patients too have a role to play and a recent survey indicates that they are more than willing to play it. According to a recent Ipsos MORI poll, commissioned by the Association of Medical Research Charities, 72% of the public would like to be offered opportunities to be involved in trials of new medicines or treatments if they suffered from a health condition that affected their daily life. The Clinical Research Network is currently working on a toolkit to help patients to ask searching questions about the number of opportunities they have to participate in clinical trials locally, and the ease with which they can find out about what is available. The hope is that as patients become more demanding about individual care pathways, and the treatment possibilities available to them, we will see participation in clinical research becoming more of a standard option – the norm rather than the exception.

For information on NHS Trust research performance, visit the NIHR Clinical Research Network website at: www.crncc.nihr.ac.uk/nhsperformance

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Not just hype The National Institute for Health Research Stroke Research Network has eight Hyper-acute Stroke Research Centres across England that provide a joined-up serivice of quality care with pioneering monitoirng and research

Last June the National Institute for Health Research Stroke Research Network launched eight Hyper-acute Stroke Research Centres across England providing patients with round-the-clock access to clinical research into breakthrough stroke treatments. One year on and the future looks bright for hyperacute stroke research.

When a stroke strikes the first few hours are critical. Early access to specialist treatment – known as ‘hyper-acute’ stroke treatment – can improve a patient’s chances of recovery. Over recent years a number of NHS Trusts have developed dedicated ‘fast response’ stroke units capable of providing specialist ‘clot busting’ therapies within hours of onset. This

has had a major impact on stroke treatment, but until now there has been limited means to undertake research in this vital area.

Hyper-acute Stroke Research Centres are changing that by increasing research capability and capacity. The centres are staffed by multidisciplinary research teams, including clinical stroke specialists, research nurses, radiographers and interventional neuroradiologists, who provide out-of-hours cover in evenings and at weekends to ensure that any patient suffering a stroke can take part in pioneering research at any time of day.

The Manchester Hyper-acute Stroke Research Centre is based at the stroke unit in Salford Royal Hospital, an area covered by the North West Stroke Research Network, which is managed

by Judy Ford. She explains how the research capacity has increased and the impact it’s had so far: “For example, before the centre was launched we had three part-time research nurses covering Monday to Friday, 9am to 5pm. Since then we’ve recruited more nurses, specifically with out-of-hours responsibilities. By November last year we’d achieved 7am to 7pm cover.

Now we have 7am to 9pm cover and we’ve introduced an on-call rota until 11pm, seven days a week. So if a Doctor identifies a patient for a study and gives them a patient informa-

Early access to ‘hyper-acute’ stroke treatment can improve a patient’s chance of recovery

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tion leaflet they know that a research nurse will follow it up.

“It’s already had an impact on the confidence of the clinical staff who are beginning to feel that research is embedded into care, rather than something extra. In terms of recruitment the figures speak for themselves. In the seven months before our out-of-hours service was in place we were recruiting on average just three patients per month to all hyper-acute, acute and sub-acute studies. Since November last year, when we began out-of-hours cover, that number has almost quadrupled to 11.2 patients per month.”

The study that has benefitted most from the new arrangements in Salford is the SOS study.

The average monthly recruitment at Salford was previously one patient per month. That figure rose to six per month once the centre was up and running. The Salford team even managed to recruit patients on both Christmas and New Year’s Day. Sarah Pountain manages the SOS study. She reports that the study recruitment pattern has changed, not just in Salford, but across the country: “We have definitely noticed an impact on outof-hours recruitment. Before the Hyper-acute Centres were in place, recruitment largely took place Monday to Friday, but since then patients have been recruited every weekend.

This puts us in good stead to meet our 6,600 recruitment target. But there are other studies that will also benefit; I think the research centres are having a positive impact across the board.”

This would certainly seem to be the case at the Nottingham Hyper-acute Stroke Research Centre where 2010/11 overall recruitment levels have increased by 34% compared to the year before. Diana Havard, senior research nurse for Trent Stroke Research Network, describes the changes to the research infrastructure in her region: “It took until late autumn last year to get our full out-of-hours service in place but our nurses are now available to screen and recruit patients from 8am to 8pm during the week, and 8am to 4pm on weekends.”

Similar arrangements have been put in place at all the centres, which of course is great news for stroke patients. Brian Ward underwent out-of-hours ‘clot busting’ treatment before

agreeing to participate in a study at Adden brooke’s Hospital where the Cambridge Hyper-acute Stroke Research Centre has been established.

He says: “Having a stroke was a petrifying experience. I was so grateful for the speed of the treatment and the quality of care that I received. The research that I took part in looked at how the brain heals and re-wires itself round the damaged parts after a stroke.

It’s only by doing research like this that we can hope to improve treatments for other stroke patients in the future.”

We have definitely noticed an impact on out-of-hours recruitment Hyper-acute Stroke Research Centres have also been set up in Stoke-on-Trent, Newcastle and at Kings College, University College and St Georges’ Hospitals in London. Although the centres are relatively well spread across England, it’s important to make sure that the benefits are available to all patients – and the Network is uniquely placed to do just that.

Jo McCormack is West Midlands Stroke Research Network deputy manager and lead nurse for hyper-acute stroke research. She explains how: “Our Network area has three large Trusts; Birmingham, Coventry and Stoke-on-Trent.

All three are able to deliver hyper-acute studies, but the Hyper-acute Stroke Research Centre is based at the stroke unit in Stoke-onTrent. Despite that, we consider the region as a whole where access to hyper-acute studies is open to all patients for equality of opportunity and continuity across the region. So we’re putting ‘hub and spoke’ models in place – firstly around Stoke, then Birmingham and Coventry. This means that smaller sites can refer patients to take part in hyper-acute studies – who can then be repatriated to their local hospital. Secondly and just as important, we’ll make sure that the knowledge, learning

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and experience gained at the Stoke centre is disseminated to improve stroke care across the region.”

Dr David Sandler is a consultant physician in Elderly and General Medicine in Birmingham.

He recognises that the Network has an important role to play: “In Birmingham we don’t have the additional funding to become a Hyper-acute Stroke Research Centre and there has been concern about funded centres becoming isolated pockets of research activity. But being affiliated with the Stroke Research Network has already improved patient access to research no end in our region, which is important for stroke patients as individuals and stroke services on the whole. The Network has completely changed the way research takes place and I have no doubt that it will be key in ensuring equality of access to hyper-acute research for all patients and also in distributing the learning from the Stoke centre.”

Since it was set-up in 2006 the Stroke Research Network has already doubled the number of patients taking part in stroke research. So what further developments should we expect?

Professor Philip Bath is the Network’s associate director for Industry and the Clinical Lead for the Nottingham Hyper-acute Stroke Research Centre. He looks to the future: “The Hyper-acute Stroke Research Centres have opened up an area of research that couldn’t easily be addressed before. We now have the required research capacity and capability and the early signs seem to show that it’s working. This puts the UK in a unique position to deliver this type of research to target and on time. That’s fantastic news for commercial companies – in fact the centres are already generating interest – so that’s even better news for patients. With the development of these centres our aim is for the UK to become a world-leader in hyper-acute stroke research and for more effective treatments to be available to all UK stroke patients.”

For further information on the Stroke Research Network, contact: jo.spencer@newcastle.ac.uk or visit: www.crncc.nihr.ac.uk/about_us/srn

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One plan to reduce four harms Dr Maxine Power, Safe Care workstream leader

The QIPP Safe Care workstream has developed ‘harm free’ care, which it hopes will get NHS staff thinking differently about patient safety. This ambitious programme aims to deliver care that is defined by the absence of pressure ulcers, falls, venous thromboembolism and catheter line infections

by December 2012. This initiative aims to improve patient safety, and in doing so, make significant efficiency savings.

The QIPP Safe Care workstream has been led

by Dr Maxine Power since January 2010. Dr Power and her team have developed a range of products to help NHS staff improve patient safety. Explaining the reason the workstream has been so successful Dr Power says, “Patients are at the heart of everything we do. They inspire us to change. We are committed to improving their experience of healthcare and protecting them from harm.”

Safe Care aims to effectively deliver ‘harm free’ care to all patients and does this with one plan, which can be implemented at local level and integrated easily with existing workflow and routines. There has been a lot of improvement in patient safety in recent years so this is not about starting again, it’s about building on what teams already have in place.

So where does ‘harm free’ care start?

The first driver towards ‘harm free’ care is developing a leadership and safety culture. In all clinical teams leadership is everyone’s responsibility. Safety leadership doesn’t just rest on the shoulders of one person, it is the role of everyone to drive the plan forwards. So Safe Care encourages engagement of clinical and non clinical teams in the work. This will involve working across specialisms and not allowing organisational or geographical boundaries to get in the way of improvements to patient safety.

The second driver towards ‘harm free’ care is about getting clinical care to be 95% reliable.

Safe Care recognises that it is the improvements that teams make in a small number of key processes, which are delivered in a highly reliable way, that will deliver the outcome of ‘harm free’ care.

Measurement of harm can be done in many ways, such as monitoring adverse events, case note review and point of care audits.

Each of these approaches has its merits and pitfalls. The big challenge for safety leaders is to understand these different sources of information and what they say about their systems. In response to requests from front line staff, Safe Care developed its own measurement tool: the Safety Thermometer.

Developed for the NHS by the NHS as a point of care survey instrument, the Safety Thermometer allows teams to measure harm and the proportion of patients that are ‘harm free’ during their working day, for example at shift handover or during ward rounds.

The NHS Safety Thermometer provides a ‘temperature check’ on harm and can be used alongside other measures of harm to measure local and system progress.

Finally, the third driver is to revisit the supporting architecture. Staff in every successful organisation find that they need to re-visit their support systems, such as training, education and policies, when they first start on the journey towards delivering ‘harm free’ care.

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For more information please visit www.harmfreecare.org

A problem shared is a problem solved Technology can help healthcare be more efficient and give patients a better experience. O2 Health is ready to help organisations get the best out of it

A 40% drop in no-shows for outpatient appointments. Community health workers spending 33% more time with patients.

Midwives spending 50% less time on admin.

These are results anyone in healthcare would be proud of. But would you associate them with O2? They’re one of the country’s top telecoms companies. They’ve put their name to England rugby and one of London’s major live venues. But health?

Absolutely. All those results are down to pioneering work O2 Health has done with NHS partners. Together, they’ve found ways round some of the toughest problems facing a health service that has to do more for less. They’ve found more efficient ways for healthcare workers to do their jobs. They’ve given patients a better experience.

They’ve done it with technology. But the thinking about how to get the most out of the technology matters just as much. And so does working with clients as partners, not just suppliers.

Problem-solving partner O2 Health’s managing director Keith Nurcombe explains: “The most important thing is understanding what patients and their carers need. We have as many healthcare experts as technology specialists in our team, so that helps us build an effective partnership.

When we talk to healthcare organisations we ask them to tell us what they want to achieve.

Then we design the technology around that need and help implement it to make the change real and sustainable. Technology is just an enabler of change.”

O2 Health’s work with NHS Rotherham shows partnership in action. The trust already had much of the technology, but they didn’t know how to get the best out of it. So O2 Health’s team started by talking to community health workers, who were struggling with laptops they’d been given to help them cut down on admin. They were supposed to type patient records straight into a central system instead of doing it again back at the office. But some were still writing up paper records or going back to base after shifts to save information onto desktop computers.

The O2 Health team ran workshops, then joined district nurses, school nurses and intermediate care workers in the field to see how they worked. It soon became clear they’d only been shown how to use the central system. They didn’t know how their laptops could help them do more, like communicate with each other or schedule work. So O2 Health and the trust worked together on an action plan to piece things together and train everyone on the full range of what the technology could do.

Watching people at work also showed that paper records still mattered to patients, so digital pens were brought in to help workers

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create them at the same time as an electronic version for their systems. Since the project, intermediate care clinicians alone spend 33% more time with patients. Everyone spends less time travelling and information flows better between staff and patients, and staff and management.

A single point of contact Designing technology is one thing. Getting it up and running is another. ‘Sometimes different technologies work alongside each other and there’s more than one supplier.

On paper, that could make things complex.

But we manage the whole process and keeps things as simple as possible for clients. There’s only one point of contact,’ says Steve Lawson, O2 Health’s head of marketing.

Community midwives in Portsmouth are now free to spend more time with mothers-to-be thanks to a combination of digital pens and BlackBerry smartphones. Keith Nurcombe explains: “We developed the system with our digital pen partner. It’s halved the admin that comes out of each midwife appointment.

Before, they made notes, gave a copy to the patient and then typed the same information into a computer back at the hospital. The new set-up means the information goes securely into the system straight away. So they only have to write it once.” The trust estimates that the pens will help make efficiency savings of £220,000 a year.

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Digital pen and paper, as used by Portsmouth Hospitals NHS Trust

Working smarter Working more efficiently means working in different ways, not just relying on technology.

Portsmouth Hospitals NHS Trust discovered that when it faced up to a second challenge.

More than 3,000 people a month were missing outpatient appointments and there was pressure to cut waiting times. The trust could have spent money on extra clinics. But money was tight. So they brought in a reminder system. That meant patients were more likely to get in touch to cancel instead of just not turning up. And it meant the trust could fill the vacant slots instead of watching them go to waste.

No-shows have dropped by 40% since April 2010, since the system went live. And waiting times are down, too.

There was just one snag. Paper reminders were expensive and time consuming. So O2 Health helped the trust bring in a new automatic system where every clinic sends out reminders by text or voice message. Patients who get the texts can cancel by text too. No-shows have dropped by 40% since April 2010, when the system went live. And waiting times are down, too. Spurred by the success, the trust is using texts for other things, like reminding people with diabetes to take their insulin or reminding women to come in for breast screening.

What mattered was changing processes before the technology came in, says Mandy Mugridge, project manager for outpatients:

“When people say that technology doesn’t work for them, it’s because they haven’t looked at how you’ve got to work differently.

When you do, the technology supports what you’re doing.”

Better for patients As well as boosting efficiency, O2 Health is helping to make patients’ experience of healthcare better. Nurcombe says: ‘For the NHS, face-to-face contact is the most expensive and difficult to provide. For patients, it’s the most disruptive. In the future, technology will mean it’s only for the patients who need it most.’

Here in the present, O2 Health is launching a new service called Side by Side, which means patients don’t have to travel to hospital to see consultants. Instead, thanks to video technology linked securely to data networks, they only have to go as far as their GP’s surgery. There, a video screen connects them to the consultant and lets them see their scans, x-rays, test results or medical notes.

The three can then discuss treatment options, all without needing to travel long distances for a face-to-face meeting.

Sharing knowledge As well as developing what Keith Nurcombe calls “pockets of good practice” and working in partnership, NHS organisations want to share knowledge. So O2 Health has created

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a Centre of Excellence to make it happen. So far three organisations have offered clinical resources and expertise to pilot new ways to give different types of care. O2 Health will be channeling much of its own investment through the Centre of Excellence partners.

“For us, it’s a great showcase for what technology can do. There’s nothing more powerful than other health organisations hearing it from our Centre of Excellence partners,” says Steve Lawson.

He adds: “I’ve been amazed by the appetite of some of the partners to speak to each other about what they’ve been working on and, in some cases, struggling with.” So a key part of the Centre of Excellence is to give the partners as many chances to network as possible through regional events where they can showcase what they’ve done. Another priority is to get a balance of partners in acute and community care and mental health, and in cities and rural areas.

Keith Nurcombe says: “The NHS knows it needs to change. We can listen and understand their challenges and then work together to find answers. But the NHS has to be prepared to look beyond how it has traditionally worked and push the boundaries.

Our partners have shown that there are organisations out there who are ready and willing to do just that.”

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A picture of health New multi-media technology means GPs, patients and consultants can meet and talk through treatment without having to be in the same room, or the same city

The GP shows the patient to their seat and switches on a screen. So far so normal. But moments later a consultant appears on it – followed by the patient’s scans, x-rays, case notes or test results. Then the three talk through the options for treatment, going through all the information in real time as easily as if they were in the room together.

The equipment runs on a standard PC and broadband connection, yet the information is secure enough to protect the privacy of the consulting room.

The patient’s been spared a possibly lengthy journey to hospital. The only travelling they’ll have to do is for treatment itself. And the clinicians have saved time too. They’ve been able to look over the data together and swap opinions securely without having to leave their offices. What used to be a time-consuming process can be over in minutes.

And the best part? This isn’t the stuff of Tomorrow’s World. It’s just been launched by O2 Health and it’s called Side by Side.

From exceptional to mainstream Side by Side has had an extensive trial in the

Western Isles, where the benefits are especially welcome. For people living there, seeing specialists means a flight or a ferry crossing to the mainland. And the trips are often cancelled because of bad weather, piling on more inconvenience for the patient and more expense for the NHS trust.

Western Isles medical director James Ward says: “The opportunity Side by Side offers is very significant. We have technology that patients and doctors are familiar with – computers – combined with an application that opens up the video technology we use only in certain circumstances. It promises to make the video consultation mainstream, as opposed to exceptional.”

More time to work Ward adds: “Also, it lets consultants spend more time doing what they’re best at. All our consultants see the benefits to their day-today work and the potential benefits to patients, and they’re hungry to get involved.”

Dr David Rigby, Western Isles NHS lead clinician for CHD and Stroke, is impressed: ‘It’s very easy and intuitive to work with. The

system rings like a normal phone and when I answer it the screen turns on and brings up a video image. As long as the computer’s linked up to my software systems, it’ll be able to link into case notes as well as the intranet and internet, and I can share all those images at the touch of a button while still seeing the video image and hearing the person at the other end.”

It’s not just patients and clinicians in remote areas who will benefit. Even in cities, consultants travel between 20 and 40 minutes for face-toface meetings with colleagues, meetings that could now happen without them leaving their desk.

Everyone wins The system is one of a string of O2 Health innovations. They promise to make the NHS more efficient and help resources go further, as well as giving patients a better experience.

Portsmouth Hospitals Trust has cut patient no-shows for hospital appointments by 40% with a simple text message reminder service.

And community midwives can spend more time with patients thanks to the digital pens they’re now using.

In Bradford and Sheffield, O2 Health has worked with 30 nursing homes to find a better way of treating the wounds that can develop with slow-healing conditions. Nurses are using mobiles to take pictures of wounds, they then upload the images to an NHS server, and using digital pens to record symptoms.

Specialist nurses study both, then phone or email the nurses in the homes with instructions for treatment.

Over the internet Dr David Rigby discusses case notes with the patient and a consultant

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Baywide, Torbay “I’m living the future – and it works,” says Dr Samantha Barrell, a GP in Brixham, a busy fishing town and holiday centre at the southern end of Torbay in Devon.

Dr Barrell, known to everyone as Sam, is the chair of Baywide, a GP commissioning consortium that is already taking increasing strategic control over how NHS money is spent along this picturesque stretch of Channel coastline. But she is also Clinical Director of commissioning for Torbay Care Trust, the body that for a little while longer retains statutory control over the local NHS budget.

Dr Barrell is not the only Torbay GP and Baywide consortium stalwart to lead a double life. Dr Viv Thorn, a Torquay GP, is the care trust’s medical director. And Dr Liz Thomas, another Torquay GP, is chair of the trust’s clinical advisory group, a multi-disciplinary forum providing clinical guidance and advice to the organisation. Together the three women are able to use the powers of the old regime to try out the opportunities that the new arrangements can bring for their 149,000 patients.

That gives them more of a sense of the future than most GPs in England.

Dr Barrell explains that their unusual professional journey started when the previous government launched an initiative in 2006 known as Practice Based Commissioning. It encouraged GP practices to group together to look at how NHS services were organised locally and to recommend improvements. In Torbay the GPs formed three zones, covering Brixham, Paignton and Torquay. As an incentive, they were told they could spend part of any savings they could make, to benefit their patients.

Dr Thorn says: “Each zone got resources, but it was pocket money – not enough to employ someone for a year. And it was non-recurrent.

So we decided to amalgamate, to pool our savings and have a more powerful voice in dealing with the care trust.”

The GPs agreed to form a company to conduct dealings with the trust. Gradually the trust’s senior executives came to see the value of the GPs’ insights. The care trust is a integrated care organisation that combines the powers of a primary care trust and an adult social services department. Under the government’s plans, it will continue to commission social care in a community services provider organisation after NHS commissioning passes to the GP consortium.

Dr Thorn says: “Under the old system, managers of the care trust contracted with the hospitals with little clinical input. Now we have clinicians involved in every commissioning decision, to focus on money and patient quality. We are now leading clinically in partnership with managers. We have the authority to make decisions. It has been a steep learning curve. We have had to learn how the commissioning process works and the pressures within the system and the negotiating skills.”

There was already a lot of work happening in producing referral guidelines using the Map of Medicine as a template. There are now nearly 100 care pathways in place and this helps the GPs check if their referral is appropriate. However this scheme was voluntary and the introduction of audit within the GP commissioning incentive scheme has really cemented the culture of thinking about the appropriateness of referrals against the care pathways. The work that GPs and consultants had done in forming care pathways has created a much better and closer relationship between primary and secondary care.

The pace of change at local level accelerated after the change of government in 2010 and publication of a white paper on reform of the NHS. “Pre-white paper we had a mana-

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gerially-dominated system with little clinician input. Post-white paper we have a much more clinician-dominated system with partnership working with managers,” says Dr Barrell.

The balance of power has also changed at the clinical commissioning groups that bring together GPs and hospital consultants. In the past in some groups the consultants would outnumber the GPs by about eight to one and so the hospital viewpoint invariably predominated. Now there is equal representation and an agreed dashboard of performance, finance and quality indicators that allow both sides to examine the experiences of patients and work out improvements. The long-term aim is to create an integrated NHS budget, allowing consultants to work in the community without damaging the hospital trust’s financial position. Dr Thorn says: “We have improved diabetic primary care and referrals to hospital are down 40%. That could be a huge disincentive to the hospital but if we were all working from the same pot of money, we could bring consultant expertise out into the community to further improve care and the patient experience.”

The GP consortium is also having a huge effect on the professional behaviour of its own members. With in-house performance monitoring and expertise it can ask difficult questions about whether GPs are making unnecessary referrals to hospital or prescribing medicines that cost more without offering significant extra benefit.

Once every three months, each GP has to audit five hospital referrals made by another GP in the practice and the results are discussed in a practice meeting. The practice then feeds back to the consortium their findings and these are then evaluated and shared

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with relevant redesign groups. Practices also get a monthly data pack with data on referrals, emergency admissions and A&E attendances. Results are starting to show. From April to December 2010 there was a 4% reduction in elective referrals, compared with the same period in 2009 – demonstrating a significant change from previous patterns of increasing referral rates.

Dr Charlie Daniels, vice-chair of the consortium, says: “We have had to start working supportively with the outliers to enable them to deliver to the best of their abilities.”

Dr Barrell adds: “We don’t want a referral management system with someone else doing it to us. And we don’t want to alienate practices by being punitive. So we are supportive to encourage practices to improve or understand better their referral activity. Our incentive schemes are based partly on how much progress is being made, not on the level they are at. Just the fact that you are comparing them is important. Nobody wants to be in the bottom quarter.”

Other successes include an obesity project that is now in its third year. Similar initiatives elsewhere in England have had difficulty in retaining people who start on a weight reduction course. And weight loss results have usually been mediocre. After four courses, Baywide’s figures show retention rates of 80% of people attending twice a week for six months.

Between 60 and 80% achieved their target weight loss of 5-10% of total body weight. And exit polls showed very high rates of patient satisfaction. The Baywide scheme used practice nurses to identify patients to come on the course. They already had a close relationship with the patients, often lasting over many years. Sonia Lake, a nurse practitioner who is a member of the Baywide consortium board, says: “Each place cost £500 and we were offering them for free. We needed to be able to gauge people’s commitment before giving them a place. We could think this through from a clinical perspective. That wouldn’t happen in a PCT-only scheme. Also there is something important about the relationship with doctors.”

They have also commissioned a one-year community pilot Alcohol Admissions Avoidance scheme for patients who had a high alcohol consumption resulting in regular hospital attendance. This on evaluation achieved a reduction in A & E attendances by 76%, ambulance activity reduced by 85%, admitted bed days reduced by 89%, overall hospital tariff reduced by 92%. Supported community based detoxification reduced the rate of elective and non-elective admissions and there was a high level of client and relative/carer satisfaction with scheme.

Many of the advances being made by Baywide depend on personal relationships – among GPs and between GPs and other professions in primary, secondary and social care. For example, a recent development bubbled up from interaction between GPs and community pharmacists. They observed that patients with long-term conditions, GPs and pharmacists were all inconvenienced when prescriptions for different medicines ran out on different dates. A new scheme will allow the pharmacist to alter the length of prescriptions to synchronise the dates and get retrospective approval from the GP. Karen O’Brien, an independent community pharmacist, and Dr Jo Roberts, a GP in Paignton, say: “As far as we know, this is the first time anyone has tried this approach.

It shows what can happen when consortia are given space to innovate.”

But if Baywide thinks it is doing well, why does it need legislation to change the rules? Dr Barrell says “the old system denied clinicians the absolute authority to clinically decide priorities to improve the quality of patient care.

There was not a clear defined role for clinicians to be integrally involved in commissioning decisions. That is why GP consortia need statutory powers and that is why patients will benefit when we get them.”

She adds: “The GPs in Torbay have always been proactive and enthusiastic in their approach towards commissioning. However, the environment for such an approach was not initially conducive and this became the catalyst for establishing Baywide, affording us a more robust and powerful forum from which to conduct constructive relations with the trust.”

Part of the picturesque stretch of Channel coastline, Brixham harbour

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Managing the transition in healthcare commissioning The development of Clinical Commissioning Groups (CCGs), provides both an opportunity and a challenge to GPs. The opportunities are: »» Being able to control the majority of NHS resources and thereby to extend their responsibility for the care of their patients; »» The movement of the commissioning of healthcare from a general management exercise in financial assurance to a health assurance tool driven by clinical need; »» The ability to show that, as generalist clinicians, they understand the needs of their patients and can commission care to meet their needs more efficiently than PCTs, can make better decisions and can manage the local healthcare system more effectively, too.

These opportunities cannot be ignored and we believe that, if it can be done safely, they should be grabbed.

quickly and in such a way that ensures sustainability beyond the authorisation process, timetabled between April 2012 and 2013.

The transition from a general managementled system to a clinically-led one, to improve clinical efficiency and through that to improve quality and outcomes for patients and value for the taxpayer, is not going to be easy, however.

One way to plan and deliver such a transformation is to map a programme of activities onto a ‘maturity model’ such as The Thinking People’s CCG Commissioning Capability Maturity Model (see below).

New leadership and operational skills are going to have to be developed, new organisational models will need to be explored, and new partnerships will be required throughout the local health economy – and all this needs to be done

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Such models should incorporate existing national and regional leadership and development programmes with local diagnostics and transition plans, and all these should feed into a programme of work that is designed and delivered, with ‘help’ as required, by local clinically and operationally-experienced

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leaders, subject matter experts and facilitators.

At the end of the day, they must own this programme – transformation is only successful if it is not done to you but by you.

In addition to leadership development, specific strategic, managerial and operational models will need to be explored in depth; tools and techniques will need to be embedded and deployed, and specific outputs (such as constitutions, policies, procedures, stakeholder management and communication plans, clinical pathway designs and financial management dashboards) will need to be developed and delivered, integrally to each respective module, as part of a tailored programme for each CCG according to their current level of ‘maturity’.

The desired outcome of such programmes is to have authorised CCGs by April 2012 (without conditions) equipped with the skills and stakeholder networks necessary to begin to work ‘in shadow’, while building organisations capable of taking on fully authorised commissioning responsibility by April 2013.

support available when they need it, framed in a language that they understand, and relevant to their stage of development.

The support available from The Thinking People Group, which blends clinical with academic and experienced programme management and business change expertise, is designed by experienced healthcare professionals and supports a clinicallydirected programme to help CCGs deliver their vision – to meet the challenge, grasp the opportunity and demonstrate that they deserve the confidence of every citizen.

If you feel that you could benefit from a no-obligation, no-nonsense, discussion with someone from the Thinking People’s Team, please contact the group managing director, Martin Roots: e-mail martin@ thethinkingpeople.com.

Boards, leaders, and individuals should be supported by a combination of knowledge transfer, coaching, mentoring, guidance and

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Healthworks, Birmingham/ Sandwell Across England many of the GP consortia that have gained pathfinder status over recent months were a consolidation of alliances that had existed for years. Particularly since 2006, family doctors and other healthcare professionals have forged strong relationships while working on Practice Based Commissioning – the last government’s limited attempt to give GPs influence over the design of NHS services. It was only natural that many of them would carry these ties forward into the new world that is being ushered in by the coalition government’s healthcare reforms.

Other pathfinders, however, are being built from scratch by new federations of GPs who do not yet know each other well. One such is HealthWorks in the West Midlands. Its leaders are creating a consortium out of practices that fall within different Primary Care Trusts (PCTs) and different local authorities. The GPs have a vision for improving the service for patients that transcends the boundaries that a past generation of administrators decided to draw on a map.

HealthWorks is an amalgamation of two GP groupings that were successful in their own right, but isolated from each other. One was in the Heart of Birmingham Teaching PCT’s territory and it looked to Birmingham city council for progress in the integration of health and social care. The other was in Sandwell PCT and Sandwell metropolitan borough council.

They had little to connect them except for one massively important fact. When patients from either group needed secondary care, their nearest option was one of the hospitals run by Sandwell and West Birmingham Hospitals NHS Trust. Together the two groups of GPs, with a combined list of about 120,000 patients, had a good chance of redesigning the services that the trust delivered.

Dr Nick Harding, a GP at Handsworth Wood medical practice and clinical director of commissioning at Heart of Birmingham, is the leader of HealthWorks. He says: “There were a number of like-minded practices in the hospital’s catchment area. I knew Dr Niti Pall [one of the leaders of the Practice Based Commissioning initiative in the Smethwick and Oldbury area of Sandwell.] She knew a lot of the GPs. We spent some time discussing how big a consortium would need to be to have a meaningful influence on the hospital trust.

“What we wanted to do was redesign pathways to make the service better for patients. It should be in the right place, at the right time and ideally more based in primary care than in secondary care. The question was how big you needed to be to have a voice that the secondary care trust would be interested in listening to. The answer was that our 15 practices should come together in HealthWorks.”

Its successful application for pathfinder status said: “Our practices have consistently delivered recognised leading-edge extended primary care … collaborating with PCTs to deliver initiatives across a wide range of health and social care priorities.” Successes included: »» Design of culturally and linguistically appropriate clinical services; »» Pan-Birmingham specialist services for substance misuse and zero-tolerance; »» Britain’s first nurse-led contract for Personal Medical Services; »» The third highest patient satisfaction scores in the country; »» Bringing hospital services out into the community, including dermatology, rheumatology and orthopaedics.

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The application said HealthWorks practices have a sustained track record of close engagement with Birmingham and Sandwell councils. “As a pathfinder consortium, in the first six months, we will work to engage closely with social care and public health teams to define routes forward that add widespread value to services, including the development of the first patient-centred pathways and resource collaboration to connect with underserved and hard-to-reach priority groups.”

Other early initiatives would include: »» Identification of “at risk” populations among member practices and initiation of targeted interventions within available resources; »» Promoting a clinically-led, transformational model of commissioning with active engagement from all member practices; »» Engagement with non-medical health professionals; »» Developing means for better understanding patients and the public, to embed patient experience and satisfaction into the local commissioning agenda.

Just before the Bill completed its committee stage, the consortium held one of a series of organisational development days at the National Metalforming Centre, close to the northern end of the M5 in West Bromwich.

About 50 GPs, practice managers and PCT representatives who attended were invited to explore what the consortium might mean for themselves and their patients. It was clear they were on a steep learning curve.

The meeting was led by Vincent Sai, vicepresident and managing director of Aetna UK, a British offshoot of the American insurance giant, which commissions healthcare for 36 million people. He said: “We know what

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commissioning is about because we do it and we do it in a big way.” After introducing his audience to ways in which commissioning can transform services to achieve real change for patients, Mr Sai asked the doctors and practice managers to think about fundamental questions. Why were they forming a consortium? What did they want to do? He gave them a list of options to discover what might be their main motivation for joining. An overwhelming majority said it was to improve patient care. But setting that aside, what might be their second motivation? The most popular answers were to make money and to go along with the Government’s reforms because there was no other choice. When asked to revote on

their main motivation, a few more admitted that it was to make money. Across England, it will be the interplay of these motivations that determines what the new system will deliver.

Dr Harding said GPs should be realistic about the limits to the legal powers they would gain if the Health and Social Care Bill passes on to the statute book in the form it completed its committee stage in the Commons. Many doctors wanted to use commissioning to bring about transformational change in the NHS. “GPs may think they will be able to change everything once they become the commissioners. But they will find there are certain rules they have to abide by unless we get a clear

decision by the Government on what we can and can’t change.”

For example, European tendering laws currently apply to any redesign of a service with a value of more than £100,000 over three years. Most services that GP consortia will want to change are likely to cost more than that threshold. They will find they have to go through a formal tendering process. Dr Harding says: “The system favours giant provider organisations and makes it hard for any new provider to enter the market. For the commissioner, it is burdensome in time as well as money. It takes six months to do anything and the cost is high.”

GP consortia may also struggle with the NHS’s idiosyncratic version of contract law.

Dr Harding says: “There are laws and there are NHS-type rules. One NHS body is not allowed to sue another NHS body. That sounds fair enough: you don’t want public money spent on two opposing sets of lawyers. But the consequence is that it becomes extremely difficult to change anything. You can start something new, but it is difficult to stop paying for the old.

“In our area, GPs have been trying to change commissioning for district nursing and health visiting. But the contract does not allow us to redesign the service in the way we want. It will be interesting to see the first GP consortium that takes on a secondary provider legally.

I think the consortium will not get what it wants. Lawyers will get involved and people at the consortium will be under powerful pressure to back down.

That doesn’t mean we won’t try to make the best of it, because we will.”

“GPs must not think that commissioning is like a bicycle in perfect working order that they can climb on and steer in a different direction.

As things stand, they are about to inherit a penny-farthing. The Government would do us a favour if it were to use the pause for reflection on the Bill to engineer a better machine.”

We want to make the service better for patients

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CARE UK: Delivering Innovation Dr Mark Hunt, Managing Director of Health Care at Care UK, examines the role of independent providers in meeting the challenges faced by NHS commissioners Given the amount of administrative work, decision making and budget planning facing commissioners over the next twelve months, innovation in service delivery may be far from the top of the agenda.

centres, urgent care services, clinical assessment and treatment services (CATS), diagnostics and offender health services, we have in-depth experience of how to bring fresh thinking to the challenges facing the NHS.

designed and operated by Care UK, employs a multi-disciplinary approach to provide fast track, consultant-led first line assessment and treatment to patients across the region via three sets of mobile units.

However, there is a distinct window of opportunity for commissioners to implement new ways of delivering care that will lead to long-term patient satisfaction, either through the way a service is provided, or the development of proactive, preventative care.

Taking time now to re-examine patient demand, and how this is managed through existing and currently underdeveloped care pathways, could pay dividends in the future.

What we do is combine a deep understanding of patient needs, local knowledge, highlydeveloped management expertise and clinical excellence to design and deliver services that achieve real innovation and patient results. These results pave the way for future commissioning models.

Ongoing evaluation of patient demand for services offered through CATS is carefully monitored and reshaped accordingly to meet demand. Clinical time is maximised for specialities that see the highest levels of need and administrative support is shaped accordingly. Patients benefit from a responsive and tailored care pathway following their referral from a GP.

There are some great examples of innovation already in existence, which are transforming patient experience as well as delivering cost savings for commissioners. Shifting care away from hospitals will continue to play an important role in delivering cost savings, shortening waiting times and increasing choice for patients.

As commissioners from across the country convene at the NHS Alliance annual conference in Manchester towards the end of this year, one of Greater Manchester’s best examples of innovation in practise will be right on their doorstep.

Greater Manchester NHS CATS Greater Manchester NHS Clinical Assessment and Treatment Service (CATS), which is

By examining the challenges that led to the commissioning of services within Greater Manchester, the innovative model that was implemented, and the positive results being generated for both commissioners, patients and the GP community, it is clear that CATS could be a model for similar services across the country.

Care UK’s Approach At Care UK, we work in close partnership with the NHS across more than 50 contracts to deliver quality services that generate significant benefits for the NHS and the patients we serve.

As a leading operator of independent sector treatment centres, GP practices, NHS walk-in

Mobile clinics bring healthcare to areas that were poorly served by existing NHS facilities

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State of the art clinics provide services across five core specialities

The challenge Managing the volume of people being treated in hospital outpatient departments across the North West was a major challenge facing the region’s healthcare authorities.

For patients referred by their GP for a consultant appointment, the only real option was to attend a clinic based within a hospital.

This naturally was resulting in huge pressure on hospital outpatient departments, with massive workloads for clinical and administrative staff. Patients often had to wait a long time for appointments, with some taking over the ideal NHS 18-week target from GP referral to outpatient appointment. A static, hospital-based pathway also meant that patients often had to travel quite a distance from their home to receive treatment, and had to take time off work or arrange childcare in order to make an appointment.

Compounding this challenge were the pockets of the region that were either poorly served by existing NHS services, or had a very low take up of its services – often due to the location and inaccessibility of available appointments.

In short, the service available to patients was inflexible, overstretched and at risk of affecting patient recovery times.

In 2007 the North West Strategic Health Authority issued a tender for providers to develop and implement an effective solution to relieving the burden on outpatient departments. The tender stood out as an opportunity to reshape referral-based patient pathways to alleviate pressure on hospitalbased services and staff.

An innovative, mobile solution With significant experience in delivering innovative solutions, Care UK was well placed to take on the tender. It was a challenging brief that would require innovative thinking and a completely new approach to traditional service delivery.

Having initially considered a static site solution, we quickly understood that the costs involved in the infrastructure and staff support for an extended hours service would not enable us to deliver a valuable solution. A mobile solution had to be the way forward.

The CATS main units include two five-trailer multi-discipline mobile clinical units plus separate MRI or CT units. It provides services for patients across five core specialities including urology, ENT, musculoskeletal, gynaecology and general surgery.

Additional on site diagnostics also include X-ray, DXA and ultrasound services. There is also a third unit which is a dedicated procedure unit used for endoscopic procedures and some general surgery.

Each of the main units has five consulting rooms with dedicated gynaecology and ENT rooms, plus integrated X-ray and ultrasound rooms and a multifunctional therapy and treatment area. Each unit is completely self supported and visits a rotation of seven sites across Greater Manchester including Denton, Longsight, Stretford, Salford, Bolton, Rochdale, and Oldham. These are all areas where traditionally the NHS had seen a low uptake of healthcare services, largely due to the socio-economic make up of the local communities.

The seven-year contract would be delivered on behalf of 10 Primary Care Trusts (PCTs) across Greater Manchester, and needed to deliver a fast-track, accessible service that would mean patients are seen sooner, attend fewer appointments and complete their care pathway in a shorter timeframe.

Each unit has five consulting rooms with dedicated gynaecology and ENT rooms

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The clinic’s integrated services allows treatment to be received on the same day and over fewer appointments

tract, we will continue to invest in maintaining and developing the high quality of services and care provided at CATS. To ensure patient care remains at the highest quality, Care UK operates to very strict standards and objectives, which are specified as part of the contract. We monitor performance very closely in partnership with the 10 PCTs to ensure that the service is delivering to these objectives and offering value for money to the local NHS.

Patients are referred to CATS by their GP, or can ask to be referred to the service for the treatment that they require. CATS patients can, in one session, potentially have their appointment with a consultant, receive an X-ray or other diagnostic tests and, if appropriate, move on to undertake their first session of treatment. This makes the process much faster and much more convenient.

Patients can also be referred on to a hospital if necessary.

Appointments are consultant-led, bookable by referrers through Choose and Book, and a dedicated patient management centre (PMC) based in Manchester City Centre delivers the triage process and other customer service functions including booking transport, telephone appointments, arranging investigations and diagnostics.

Investing in a long-term commitment

Care UK made a major financial investment into CATS to ensure its success – initially through the purchase of the mobile units and investing in a robust infrastructure and clinical framework. CATS has received significant ongoing investment. The next phase of this investment will involve adding an additional endoscopy unit to double capacity in order to meet demand.

Earlier in 2011, two dedicated administration units were constructed to serve CATS, each employing eight staff and enabling the discharge administration to be processed onsite and on the same day as a patient’s appointment. Throughout the duration of the con-

Our objectives relate to treatment times and quality measures. For example, we aim to have triaged all patients within 48 hours of accepting a referral from their GP and to have completed their episode of care within 56 days (unless further procedures/treatment is applicable).

Strength of the model The innovative approach of the CATS model offers a range of tangible advantages for healthcare commissioners and patients alike: »» Flexibility: Clearly the mobile nature of the service offers huge advantages for the North West PCTs. The units can be strategically located to deliver care where it is needed most and more time can be spent in locations requiring additional support. The mix of appointments can also be varied to meet local demand.

For example, we have been able to adjust the appointment mix across the Greater Manchester locations to offer more musculoskeletal speciality appointments in exchange for fewer gynaecology and urology »» One stop clinics: CATS enables consultants to deliver a ‘one stop’ clinic including consultant appointment, assessment and procedure in one visit for specialties such as vasectomy and minor lumps and bumps. This delivers a much shorter pathway, and also increases appointment slot availability and the volume of patients a consultant can see in each clinic »» Direct listing: Direct listing enables CATS to provide a first appointment, diagnostics and a pre-operative assessment in one visit. The patient is

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then placed directly on to the theatre list for a partner hospital. The NHS is saved the costs of an additional outpatient appointment and CATS is able to add value to conditions that still require hospital-based surgery »» Cost-effective tariff: CATS offers a bundled tariff following a GP referral to include integrated clinical assessment and treatment, incorporating diagnostics and pre-operative assessment (POA), rather than separate charges for each appointment and treatment required for each patient throughout their journey.

The joined up approach, together with the convenient locations and extended hours means the number of patients that do not attend (DNAs) is reduced »» Low risk solution for the NHS: The capital outlay and balance of risk for the mobile service is borne by Care UK and not the local NHS.

Challenges Introducing a model that has such huge differences to the accepted ‘traditional’ patient pathway has naturally brought about many challenges.

Negotiations involving up to 10 PCTs and the Strategic Health Authority were complex, but it was important that all stakeholders were able to ensure their requirements were met by the solution offered by Care UK. We continue to work closely with PCTs across Greater Manchester to provide a clear view on performance, service provision and uptake across their regions.

The concept of visiting a mobile unit, often housed on a car-park or open ground was totally new to patients, and required plenty of information and guidance to assure patients that the healthcare they would receive was of excellent quality and comparable to that within a traditional hospital environment.

Patient feedback has indicated that any apprehension is quickly quashed upon entering the state-of-the-art units, meeting our friendly, professional staff and receiving a fast-track, high-quality level of service.

Direct marketing to households across the PCT locations, advertising on local public transport vehicles and hubs, and proactive awareness campaigns to promote services such as urology and vasectomy, have continued to build a positive profile of CATS across Greater Manchester.

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Shifting GP behaviour away from a traditional model is not something that can simply change overnight, and we’ve taken a longterm strategic approach to educate GPs about the service and its benefits and to encourage referrals on a long-term basis. We had planned for an initial ramp up period while both patients and GPs became aware of and accepted the service as a viable and beneficial option for healthcare.

Delivering results To date over 120,000 patients have been referred to CATS, averaging at over 1,300 patients per week across the seven locations.

The service employs 53 consultants and over 200 full time clinical and administrative staff.

Our latest patient survey highlighted: »» 97% of patients surveyed would recommend the service »» 95% of patients rated the service ‘excellent’ or ‘very good’ »» 84% of patients had complete confidence in the service »» 96% of patients rated excellence in respect and dignity The service enables patients to receive treatment over fewer appointments. Almost 60% of patient episodes are completed in one appointment. The average appointment frequency for CATS is 1.63 visits versus over 3.3 for Greater Manchester Hospitals (Civil Eyes Research, June 2011). Currently 98% of A patient survery found that 95% of patients rated the service as ‘excellent’ or ‘very good’

all patient journeys are completed within 8 weeks, which is far shorter than the 18-week time frame of the traditional NHS route.

The best advocates of the service are patients, and we have many positive testimonials:

“Would recommend the service to anyone” Retired Salford resident, John Clarke, asked his GP to refer him to the Greater Manchester CATS unit in Salford for a painful shoulder.

He’d been suffering from a trapped nerve in his shoulder muscle, which was causing severe pain when he moved his arm in certain ways.

He went the CATS mobile unit in Salford where a consultant gave him a thorough examination and a series of exercises to do to ease the pain. He was referred for an X-ray, which he had at the Bolton unit, before being referred for an operation at the Salford Royal Hospital.

John said: “I was very impressed by the service. The staff were incredibly thorough and professional and I was seen and treated far more quickly than I expected.

“I feel fortunate to be so close to such a fantastic service and would recommend it to anyone.”

“Impressive speed of service” Janice Marcroft was referred to the Greater Manchester NHS CATS mobile units in Rochdale for acute pains in her feet, which felt like uncomfortable electric shocks. As Janice is diabetic, it was important for the symptoms to be treated very quickly.

Following a visit to her GP, Janice visited the CATS units for a scan on her feet, and to discuss the results and treatment with a consultant. She was impressed with the speed of getting the appointments arranged and the friendly, courteous staff.

“At first you are a little taken aback by arriving at a set of trailers for your appointment, however the service and staff are extremely professional,” Janice explained.

Janice had three sessions of physiotherapy and ultrasound, also delivered by CATS, and has been pain free for 18 months. She has been so happy with the service that both her daughter and husband have also chosen to be treated by the CATS service.

Re-purposing the model Those in charge of commissioning future models of healthcare will have to consider new ways of thinking, in order to deliver high-quality services that provide better outcomes for patients, relieve current pain points within pathways and support a more preventative, proactive healthcare strategy.

CATS is an innovative mobile service, which was commissioned to bring healthcare closer to patients and address health inequalities across the region.

The development, implementation and refinement of CATS has been a major, longterm project for Care UK and the PCTs involved, which has seen significant investment, both financially and culturally, as we work together to integrate new healthcare pathways into ‘accepted’ procedures for patients and GPs alike.

It is to the credit of the NHS, and particularly NHS North West, that they have had the vision to commit to a service that addresses previous inequalities in healthcare provision, offers an innovative solution to easing the burden on traditional hospitals and improves the patient experience.

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Optimising warfarin monitoring – a novel approach?

Stroke management and prevention are major clinical priorities for the NHS, as stroke is the third largest cause of death in England, at a cost of £2.8 billion1

Atrial fibrillation accounts for some 14% of all strokes, and is both under-diagnosed and under managed with respect to optimal anticoagulation therapy2.

With the arrival of novel oral anticoagulants into the market, questions are being asked and guidelines are being written to identify the place in management for not just these agents but also existing medications, such as warfarin.

With mounting user experience of these new agents across the globe, and delays in NICE guidance on dabigatran, the emerging approach across the UK is that of ensuring that warfarin is used to its optimal potential ahead of considering new oral anticoagulants3.

One of the areas of recommendation to investigate is that associated with time in therapeutic range (TTR), with 65% or more being recognised as the optimal level of anticoagulation control4. The other undoubtedly

is ensuring that patients are offered warfarin rather than aspirin when stratified according to the NICE guidelines.

In that respect there are two strategies, amongst others, that are being considered to optimise TTR within localities around the UK. These are not novel as posed in the title of this article if one looks at the literature, however in clinical practice they can often be only partially implemented into care pathways for stroke prevention in atrial fibrillation.

Strategy 1 Optimising TTR at a ‘centre’ Time in therapy range data at an organisational level, can provide a good indication of how the service is performing against the 65% ‘standard’. For example within a commissioning group of several practices comparisons can be made across the practices with respect to local implementation, with considerations been given to frequency of appointments,

staff turnover, training of staff, patient education including compliance and frequency of monitoring. Some focus of attention in some or all of these areas, and no doubt others, could lead to service improvement.

A key support tool that can be of huge benefit is that of computer decision support software (CDSS), essentially a management tool for capturing patient anticoagulation management history, with the output being a guide dose and follow-up appointment. Most importantly the reporting functions within CDSS, will provide both individual centre and patient TTR data.

Strategy 2 Optimising patient TTR There will be potentially many reasons why a patient may have a sub-optimal TTR, however some general perspectives without knowing the details of specific patients could include education, compliance, missing appointments or feeling disempowered by the system.

Often patients that embrace a self-care approach tend to improve their levels of control5,6 through increased self-awareness and a greater sense of responsibility.

There are over 15,000 patients that selfmonitor their INR within the UK whereas the numbers are closer to more than 10 fold in countries such as Germany, that lead to the

Computer decision support software captures a patient’s anticoagulation management history and suggests a guide dose of warfarin

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Despite the commercial availability of the technology, the number of patients in the UK selfmonitoring INR is well below that of Germany

Innovation for Technology, Productivity and Prevention (iTAPP) identifying coagulation self managing as a technology that is “commercially available but with limited NHS evidence to support adoption”. Maybe now is the time to recognise the strength of data from Heneghan et al, The Lancet 2006, GarciaAlamino et al, and The Cochrane Library 2010 (see bibliography, below). The clinical data shows the ability to achieve 85% time in therapeutic range for those patients self-monitoring.

With consideration to these ‘novel’ approaches warfarin monitoring can be optimised to over 65% for many patients, that could meanwhile allow more appropriate and affordable use of new oral agents in those not able to reach 65% after pursuing such strategies.

1 Anticoagulation for atrial fibrillation, A simple overview to support the commissioning of quality services, NHS Improvement-Heart, 2009 2

Heart and Stroke Improvement – Commissioning for Stroke Prevention in Primary Care – The Role of Atrial Fibrillation, NHS Improvement, 2009

3 UKCPA Position Statement on the introduction of new oral anticoagulants for stroke prevention in atrial fibrillation, July 2011

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4 Wallentin et al; Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial, The Lancet 2010 5 Heneghan.C et al, Self-monitoring of oral anticoagulation: a systematic review and meta-analysis, The Lancet 2006 6 Garcia-Alamino JM et al, Selfmonitoring and self-management of oral anticoagulation (Review), The Cochrane Library 2010

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Chronic obstructive pulmonary disease: improving home oxygen services Aim: To ensure that recommendation 14 of the consultation on a Strategy for Chronic Obstructive Pulmonary Disease (COPD) (2010) which stated: ‘All people with COPD and hypoxaemia should be clinically assessed for long-term oxygen therapy and reviewed at regular intervals, and existing home oxygen registers should also be reviewed’ is being implemented and to determine whether adequate monitoring measures are in place to record and review the patients need for home oxygen therapy.

The Problem: The Department of Health (DoH) estimates that approximately 30% of people in England who are prescribed oxygen as a form of therapy either derive no clinical benefit from its usage or the oxygen that is prescribed is not used as effectively as it could be. Additionally, data from a preliminary review displayed a clinical variation with many of the Primary Care Trusts (PCTs) not undertaking the quality clinical assessment required and not regularly reviewing the patients need for long term home oxygen usage. This could increase the potential for the delivery of poor-quality care and also does not make best use of valuable resources.

The Evidence: Home oxygen therapy is provided to about 85,000 people in England at a cost of approximately £110 million a year.

The demand for services is steadily increasing and there are areas where the quality, efficiency and value for money of services can be increased as well as improving outcomes for people with COPD. The Project: Since July 2010, NHS Improvement-Lung has worked with a number of clinical teams across England as part of the DoH Respiratory Programme in order to address the clinical variation with regards to

respiratory care witnessed within England. Its aim has been to support the development of patient centred, evidenced based and clinically led services by identifying and sharing innovative ways to reduce variations in care, and improve the quality and experience of patients with COPD by utilising the improvement techniques and methodology within NHS Improvement.

The project teams made extensive use of the British Thoracic Society Home Oxygen Services Standards and early drafts of the Department of Health Good Practice Guide. In addition to this, the project teams have also utilised the work of the National Institute for Health and Clinical Evidence (NICE) and IMPRESS to inform the thinking.

The respiratory teams who embarked on improving their respiratory services had to consider staff competency levels, assess and review location settings, give guidance on correctly documenting and interpreting diagnostic results, give guidance on accurately prescribing oxygen and provide the patient with written information regarding their oxygen therapy.

Work with twelve pilot sites demonstrates clear improved QIPP potential outcomes: Quality: Placing an emphasis on the assessment of clinical need and ongoing clinical review provides an opportunity for healthcare professionals to more comprehensively inform and educate patients about their condition. In addition, if home oxygen therapy is deemed appropriate then this interaction also facilitates patient education about equipment use, risk and their own responsibilities as regards the safe use of oxygen at home.

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Innovation: The learning, presented in the form of practical case studies from the NHS Improvement-Lung project sites has been captured within the Improving Home Oxygen Services: Emerging Learning from the National Improvement Projects publication. The following are two examples from the pilot sites that highlight the improvement work in relation to clinical pathway redesign and the measurable effects documented within the use of home oxygen.

Milton Keynes PCT Community Services and Milton Keynes Hospital set about reducing previously highlighted variations in health inequalities and the usage of oxygen for patients at home. Analysis work revealed that the patient experience varied depending on who prescribed their oxygen, with a two tier oxygen service in existence and little integration of primary and secondary care across the oxygen pathway. Using a ‘spend-to-save’ style initiative to support the redesign of the home oxygen therapy pathway through service mapping and installing process audits, protocols were jointly developed with clinical teams and the implementation monitored by the COPD administrator.

The resulting service significantly transformed the care of patients on home oxygen within Milton Keynes, with newly initiated respiratory oxygen patients first subject to a formal assessment and within dramatically improved financial control. In order to sustain and enhance the benefits of this improved service, and to address outstanding areas for improvement, the multidisciplinary team applied to take part with NHS ImprovementLung and were accepted on to the programme in the summer of 2010. The project aim was to enhance the existing care pathway, improving ambulatory oxygen assessment and

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the development of a quality patient questionnaire of pre and post use of patient information literature to monitor the patient’s experience. Since the patient’s pathway has been redesigned, a review was carried out in respect to short burst oxygen therapy patients in January 2011. It has predicted a £6,000 cost saving has been encountered and a further saving of £13,000 with regards to ambulatory oxygen prescribing.

Sherwood Forest Hospitals NHS Foundation Trust and NHS Nottinghamshire County Community COPD Team jointly enrolled with NHS Improvement-Lung in on a 12 improvement project to improve oxygen prescribing upon hospital discharge. An analysis of oxygen patient data revealed inequities in the current system, where at least 50% of patients have the therapy prescribed without referral to the oxygen assessment service, whilst the other 50% receive an evidence-based, gold standard service. The project aimed to increase the GP uptake of direct access to oxygen assessment services. It also introduced a standard pathway for patients discharged with oxygen following admission. Since the interventions have been in place the cost savings recognised by the improvement work to date has resulted in a projected saving of £24,209 per annum.

The re-categorisation consisted of reducing hours of usage, reducing oxygen flow or removal of supply without the loss of the quality of care delivered.

established home oxygen services who implement oxygen usage reviews and therapy optimisation. On a national scale, the work complements the DoH estimated gross savings of up to 40% for each PCT. The expected future outcomes in these project sites will be a minimum of £600,000 in relation to prescribing expenditure. This will be achieved through therapy rationalisation, list cleansing, avoidance of inappropriate prescribing and the withdrawal of clinically unnecessary therapy.

Prevention: The quick-win cost savings that are achievable within the usage and control of

home oxygen is obviously attractive to commissioners but more established teams are also attempting to ensure sustainable financial management by educating GPs about the assessment of formal assessment.

To find out more about the learning and improvement work underway with Improving Home Oxygen services and to access the latest publication go to www.improvment.nhs.uk/lung

Productivity: According to a recent analysis carried out by the DoH, the potential savings that could be achieved nationally could reach £45 million a year by focusing on quality and productivity within the home oxygen service.

This would be through the use of an established home oxygen service and oxygen register review, which would incorporate a formal clinical assessment of the patient. The cost saving figure is equivalent to £300,000 per Primary Care Trust (PCT) or a potential gross national saving of up to 40%.

The improvement work specifically within the use of home oxygen services has demonstrated that the annual total spend across nine NHS project sites can be reduced by a minimum of £600,000. This applies for both new and £45m could be saved nationally on home oxygen services based on the minimum reduced spend of £600,000 across the nine NHS Improvement project sites

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Acute stroke services: a network approach to the use of telemedicine Aim: To improve access and outcomes for acute stroke patients by implementing a technological solution to the geographical challenges of a patient’s location at the time when expert clinical opinion is required.

Problem: The provision of expert clinical assessment and diagnostic image review in the acute stroke episode is often variable due to the patient being admitted to a hospital site that is remote from where the consultant has their base or place of work, or where it is not possible to have specialist onsite 24/7.

Protracted journey times in transferring either the patient or the consultant between sites in order for early intervention to be delivered hampers successful outcomes for the acute stroke patient who may benefit from thrombolysis treatment within a short time window. Geographical challenges meant that referral for those needing regional neuro intervention was taking up to 60 minutes in some localities. For those needing advice only, this journey was unreasonable. A network approach to providing acute stroke care was clearly required. In some areas this was successfully overcome by consultants working collaboratively to provide covered rotas, including out of hours. However, this alone, was not sufficient to provide a sustainable solution as it often required a few experts covering large areas with compensatory rest required during episodes of heavy on-call sessions.

The Evidence: »» There are approximately 150,000 strokes per annum and these account for 53,000 deaths each year in the UK – making stroke the third most common cause of death in England

»» Stroke accounts for 9% of deaths in men and 13% of deaths in women in the UK »» At lease 450,000 people are disabled as a result of stroke in England »» Stroke costs the economy £8 billion per year in England alone »» Stroke patients occupy 20% of all acute hospital beds and 25% of long term beds »» Approximately 13% of strokes occur in people under retirement age The Project: A number of stroke networks and acute trusts have addressed the issue of acute stroke service provision by piloting IT solutions to the problems encountered by treating patients over remote or expansive geographical locations. In response to the obvious clinical desire to address this problem, the teams were also urged by the quality markers (QM) set in the National Stroke Strategy (2007): QM7–urgent response; QM8–assessment; QM1–working togethernetworks, so that patients with suspected acute stroke receive an immediate structured clinical assessment from the right individual.

Therefore, the projects in each area centred on: »» reducing delay in patients receiving treatment »» delivering care closer to home (patient’s local hospital) »» ensuring the process is safe with good governance arrangements in place »» embracing proven best practice »» providing cost effective care 24 hours a day 7 days a week Local drivers also included: geography, capacity, workforce, sustainability, passion and quality.

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Using digital real-time video and audio capture and transfer through telecarts and laptops all with either bespoke, WLAN, HD or N3 connectivity, a network IT solution was found to negate the geographical challenges of providing a sustainable acute stroke service across a region. Some of the projects went through four identifiable stages to implementing this approach: modelling, development, feasibility and pilot study.

Others just implemented and made adjustments along the way. A financial set-up cost was incurred across all sites to offset against ongoing savings in sharing of out-ofhours on call costs for consultant staff, and the potential for medium and longer term savings including reduced length of stay and decreased patient dependency.

The use of telemedicine across the East of England, Lancashire and Cumbria, Surrey and Sussex stroke networks and East Kent Hospitals NHS Trust demonstrates QIPP outcomes: Quality: Immediate access to a stroke consultant 24 hours a day, seven days a week ensures that decisions on patient assessment, diagnosis and management can be made without delay. The skill mix is maintained at each stroke unit by the sharing of best practice between hospitals. The same ethical, professional approach is maintained as if the consultation was taking place face-to-face.

Innovation: Patients remain at their local receiving hospital and assessment is made remotely with expert clinical decision-making afforded by the use of teleradiology over the telestroke network. Use of telemedicine solutions for stroke has obvious advantages

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The use of telemedicine can help to negate the geographical challenges of providing a sustainable acute stroke service across a region

in improving access to treatment in rural locations. The use of telemedicine can facilitate 24/7 delivery of thrombolysis in the delivery of a telestroke service. This is a technological solution to a clinical project.

The roll-out of telesolutions is currently being explored in: rehabilitation classes, neurosurgery, intensive care, dermatology, A&E advice and rapid response ambulance services, while there is also the potential for virtual clinics to be run across all sites – including weekend ward rounds.

Productivity: The direct benefits of telemedicine are that it is very simple and fast to set up – ensuring that technology is used to support the professionals in their clinical rota arrangements regardless of location. This saves time for both the patients and their clinicians. All patients are assessed by a consultant within minutes so that alternative diagnoses can be reached and management instigated without delay. Images are seen in real time and confidence in the appropriateness of recommendations for the therapy or management are afforded by ‘live’ interaction.

Prevention: Education of the public in the likelihood of spotting the acute phase of stroke onset has been afforded by the FAST campaign. Patients, relatives and carers and healthcare professionals alike are now more aware of the symptoms of an acute stroke and are knowledgeable of the importance of getting early intervention to prevent poor long term outcomes. The use of telemedicine to seek expert opinion very quickly reduces mortality and will improve the patient’s quality of life.

For further information on telemedicine being used as a technological solution to a clinical network problem please visit: www.improvement.nhs.uk/stroke Stroke patients occupy 20% of all acute hospital beds

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North East Essex GP Commissioning Group Patients entering the Primary Care Centre on Turner Road in Colchester may be heading for the GP surgery for a consultation with the family doctor. Or they may be on their way to the walk-in clinic that deals with minor injuries and offers emergency contraception and smoking cessation advice. The modern, state-of-the-art building close to the town’s General Hospital also contains a 20-station dialysis unit, four dental surgeries for people with special needs, a chronic disease management service, podiatry and a child development centre. This is the rich variety of primary care, as it is meant to be.

But MPs and peers considering the Health and Social Care Bill may be more interested in what happens on the second floor of the centre, where the patients rarely go. It provides office accommodation both for NHS North East Essex, which is the Primary Care Trust for the area, and for the fledgling North East Essex GP Commissioning Group, a pathfinder consortium that is due to take full control of the local NHS budget when PCTs across England are dismantled in 2013. The two organisations share the same space and, to a surprisingly high degree, they share the same views about how the NHS should be run. In some parts of the country the leaders of GP consortia may be itching to get rid of the managers in their local PCT, but in North East Essex they hope that many will remain colleagues for years to come.

Dr Shane Gordon, a Colchester GP, is the consortium’s joint chief executive. He says: “We have achieved a lot through the close cooperation of local primary care clinicians and the PCT managers. It’s that partnership that is really at the heart of good commissioning. It’s not one group or the other doing it all. It’s a partnership between the people who manage

the demand for healthcare [the GPs] and the people who understand the complexity of the system [the managers.]”

The North East Essex GP-led consortium is the product of a merger of Practice Based Commissioning (PBC) groups in Colchester and Tendring, which have been shaping services for patients since 2006. They organised 30 redesigns of medical pathways including cardiology, gynaecology, dermatology, ophthalmology, musculoskeletal care and pain management. The PCT allocated £1.5m a year for the GPs to directly commission services. It also gave them considerable discretion over out-of-hours care, a £3 million initiative to improve access to psychological therapies and a £1.5 programme to give people health checks. Gradually, the GPs gained increasing influence over other parts of the PCT’s £500m-plus budget.

Dr Gordon says: “Around the country there were very few areas that managed to make the PBC model work. That was because PBC groups had no statutory power and so there was no obligation on PCTs to devolve commissioning responsibility to GPs. As a result, the boot was on the wrong foot.

“In North East Essex we [the GP leaders] went to the PCT and said: ‘we know you have a job to do and we want to help.’ That led to us building a relationship of genuine partnership.

Rather than seeking to replicate or displace the PCT, we were able to influence what it did.

So we never got into a dispute about counting beans. The outcomes that we both wanted to achieve were better services for patients and better use of resources. We concentrated on how to deliver those improvements without getting stuck on what the Government said the rules were for PBC.”

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Dr Gordon believes that this cooperative approach helped the PCT pull off the trick of balancing the books while making improvements for patients. One example was the GPs’ scheme for providing treatment in the community for carpal tunnel syndrome, instead of sending patients to hospital. It cut costs by 30%, reduced the waiting time for treatment to an average of six weeks and achieved a 98% satisfaction rating among patients.

But if the relationship between GPs and the PCT is so good, why do the North Essex GPs think there’s any need for legislation? Dr Gordon says: “The Bill has given a new impetus to the PCT to make sure they are engaging with the local GPs in every bit of commissioning. The risk in the previous arrangement was that it was relatively marginal to the overall business of the PCT. We were commissioning around the edges of the PCT’s work, whereas what we are getting into now is deeper engagement in the big, chunky services. A lot of the work we did before was on planned care. Now we are getting involved across a wider range of hospital services, community services and urgent care.”

Dr Gordon’s view of the NHS reforms is informed by the positions he holds at many levels in the health service. He still spends one day a week in the surgery with his patients.

For two days a week he works for the GP consortium and is among the GPs who now form a majority on the executive board of the PCT. For the remaining two days of the working week, he works at an even higher level of the NHS superstructure as associate medical director for NHS East of England, the region’s Strategic Health Authority.

From this multi-level perspective, he says: “The Bill does two key things. First, it makes GPs

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responsible for the health of the local population as a whole, not just the patients in front of them at any given time. Second, it puts the boot on the right foot. Previously it was PCT managers who were responsible for delivering the outcomes of the NHS and the engagement of clinicians in that was optional. What the Bill does is make the clinicians responsible for the outcome, while the managers become the facilitators, the people who grease the wheels.

“Our style is not to come in heavy and say: you are doing it wrong. The PCT has done a pretty good job and we feel we can add some value to that and continue to bring innovation and drive. As GPs we will spend much of this year learning as much as we can about the business the PCT does. We want to get a clear idea of how to be an intelligent customer of commissioning support.”

Dr Gordon is wary of the blandishments of consultants in the private sector who claim to have the solution to every problem. He says: “We recognise there is much in the organisational memory of the PCT that we value highly.”

He thinks that it is right for GPs, as generalists, to lead a commissioning consortium

and form the majority of members of its main board. Other generalists should have a seat at the table, including nurses and representatives from the local authority’s Health and Wellbeing Board. But, in Dr Gordon’s view, it would be entirely wrong for hospital consultants or therapists to be involved in taking the key strategic decisions about meeting the health needs of his consortium’s 320,000 patients.

Which of the hospital’s 70 specialties should be represented? Which of the allied health professionals should have a seat at the table?

Should it be the pharamacists, the dentists, the podiatrists or any of the other professions that play an important role, but have a particular interest in claiming a share of resources. If all these interests had a seat, the commissioning board would be unwieldy; if only a few, its representation might be unfair. The advice of specialists would be invaluable when it came to making decisions about their individual specialisms, but they were not needed at the strategic stage.

Dr Gordon says: “In our area, we have big problems of health inequality. There is a 13-year gap in the average life expectancy in different parts of our patch. We have to satisfy the particular needs of transient populations in our seaside towns. We have to decide how

to spend limited resources to make the biggest difference for our population. That requires an understanding of public health, knowledge of the services we offer and an understanding of how things could be different. If we had all the specialisms on the board there would be a bunfight. For setting the strategic priorities we need people with a generalist perspective, not the specialists who shout the loudest.”

Should the government specify the proportion of non-GPs that it would be right to have on a commissioning consortium board? Probably not. Each consortium should find the right answer for itself. “But if you want GPs to own the problem of population health, you need to have GPs in the majority. Otherwise they will crawl back to their practices and say: it’s nothing to do with me. If that were to happen, you would have missed the opportunity presented by the Bill, which is to get GPs to take responsibility for population health.”

So GPs should be in control, but they should use their new powers with humility. Dr Gordon says: “The media like to portray us as arrogant, but I don’t see any evidence for that.

This is about us trying to do the best possible job for our patients in a spirit of humility and seeking to add value rather than to replace expertise that is already there in the system.”

And what does he say to patients who think doctors should get on with doctoring and concentrate on the job for which they have been expensively trained? Dr Gordon recalls his early years as a GP when he wanted to send patients to the hospital for an ultrasound test.

There was a waiting list, causing a delay of 8-10 weeks. Often the symptoms worsened and the patient had to be admitted to hospital for investigation. That was hugely more expensive for the taxpayer and more distressing for the patient. It was a nonsense, but in those days the GP could do nothing about it.

By taking control of commissioning, they can now do more. Dr Gordon concludes: “In my surgery I can make a difference for one patient at a time. Now, operating at the level I do, I can make a difference for thousands. That is how I sleep more easily at night.”

13-year gap in average life expectancy

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How virtual healthcare can improve how we treat the ageing population and those with chronic illness Richard Rees-Davies, managing director, EMEA at Intel GE Care Innovations The recent media scrutiny of the private care home industry and the proposed NHS healthcare reforms have put a spotlight on the issue of how we care for the elderly and those living with chronic illness. Figures from The Office for National Statistics show that over the last 25 years the percentage of the population aged 65 and over increased from 15% in 1985 to 17% in 2010, an increase of 1.7 million people1. By 2035, 23% of the population is projected to be aged 65 and over2.

Combined with the figures of the number of patients with chronic illnesses, estimated at 15 million people in the UK3, it is clear that there will be unprecedented demand for NHS services. For the sake of future generations we need to plan how we will care for these important groups in society.

The challenges facing healthcare professionals are huge; not just an ageing population, but

also the rising cost of medical care, increased demands on healthcare professionals’ time and reduced resources due to government funding reductions.

It is estimated that those with at least one long-term condition account for 80% of GP consultation time and 60% of hospital bed days4. To put the challenge facing the health service into financial perspective, in a recent article in the Daily Telegraph, Secretary of State for Health Andrew Lansley suggested that on current trends, £230 billion will need to be spent on health by 2030 compared to the £103 billion which is spent now5.

Telehealth This leaves the UK with an extra £127 billion to find. Even the most drastic efficiency savings will find this difficult to address, and whilst the economy continues to struggle there

is little prospect of new funding coming from the government. The NHS must find new ways to deliver quality care.

Technology can be used very effectively to modernise the NHS, simultaneously making efficiency savings and improving care for patients. It can help patients to take a more active role in the care and management of their condition, which in turn helps them to feel more in control of their situation.

Just this month the NHS announced that it is revising the blood pressure guidelines in the UK and Wales6. Patients thought to have high blood pressure should have the diagnosis confirmed at home, according to new guidelines. Predictions suggest that this move will save the NHS £10.5 million a year and will also help avoid misdiagnosis and unnecessary prescriptions. We must welcome these changes and look at other areas in the NHS that can be modernised with similar technology.

One solution that could help frontline health professionals manage their time and resources more efficiently is virtual care co-ordination.

Virtual care co-ordination allows doctors and nurses to monitor the care and treatment of their patients remotely. It is particularly valuable for the elderly and those with illnesses that can often result in lengthy spells in the hospital such as diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart failure (CHF). The software is installed with healthcare professionals in hospitals, GP surgeries or community nurse centres, and in Cutting clinic visits: new software allows patients to update doctors from home

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patients’ own homes on a dedicated device (eg a PC or laptop) to encourage a two-way dialogue between both, and the sharing of updates on the condition of health to help keep patients independent and not needing to spend as much time at hospital or clinic.

Recently Lord Crisp, former head of the NHS, argued that in the future the only real way to fund the NHS was to treat older people and those with long-term conditions at home or in the community rather than in expensive hospital wards.7

Video conferencing There are several important functions that make virtual care co-ordination technology so versatile. The video conferencing capability means that doctors and nurses can see their patients and have face-to-face dialogue with them as often as necessary. This means that the patient does not need to travel to hospital or a doctor’s surgery for a check-up, which is both time consuming, costly and also tiring for the patient. Having a conversation over video conferencing can put a patient’s mind at rest if he or she has noticed a deterioration in their health, but is unsure whether a visit to the hospital is necessary.

Remote monitoring The technology can also connect to blood pressure monitors, glucose meters, pulse oximeters and weight scales, helping the patient conduct their own tests and easily transmit vital information about the status of their condition from the comfort of their own home. This helps give the healthcare professional data they need to assess a patient’s condition. By allowing a patient to share this information more easily from home, they will feel that their illness is less of a hindrance to day-to-day life , and will be happier as a result.

Virtual care co-ordination follows best practices from third party healthcare organisations in how nurses and doctors should interact with and provide education to their patients.

It proactively involves the patient in the process, engaging him or her through video conferencing and other conversational capabilities such as surveys and education.

on record8 saying that the roll-out of broadband working at 40Mbps or faster would enable the wider user of telehealth to help patients stay connected to carers from the comfort of their own homes. Lansley estimated that if 1% of consultations could take place in the home, the NHS could save £250 million annually9.

These are very significant budget savings.

Clinical commissioning groups With around 150 Primary Care Trusts moving to around 600 GP commissioning groups there is a concern that this will make it harder to deploy advanced telehealth technology.

For economies of scale, larger deployments are advantageous as the cost per unit is less.

The Whole System Demonstrator project, which is trialling in Cornwall, Kent and Newham will hopefully produce a set of guidelines that will make it easier for clinical commissioning groups to prescribe the technology to their patients. This is particularly important in areas with higher-than-average incidences of chronic disease.

Patient benefits The benefits are numerous. It helps patients to stay more independent, it reduces the stress of travelling to and from hospital for routine check-ups and it also gives their carers peace of mind. Intel-GE Care Innovations™, a new joint venture from Intel and GE that develops virtual care co-ordination solutions, worked with the NHS in Central Lancashire from June 2010 to June 2011 on a pilot programme using its Care Innovations™ Guide to help reduce the number of hospital readmissions for patients with long-term conditions. The pilot had positive results with the senior community nurse involved in the programme commenting that “the Guide has helped us utilise our resources in a different way and supports early detection, proactive intervention and the development of the patient’s understanding of their condition”.

healthcare

The senior community nurse found that her patients and their carers liked using the technology as more regular contact enhanced their relationship. In addition, nurses felt that it had also helped them to use their resources in a different way, supporting early detection and proactive intervention, which improved the care they gave patients with long-term chronic illness.

Fortunately, this kind of technology is very much on the agenda for helping the NHS to manage budgets and time more efficiently.

The Health Secretary, Andrew Lansley, went

Of course, there is another benefit of virtual care co-ordination that will also help address issues we face with an ageing population.

Looking to the future of

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Healthcare professionals are confronted with similar challenges caring for the elderly as they are when treating those with chronic illnesses.

Quite often both groups of patients will feel isolated from the community. Their care givers might be under more pressure for their time, with finances being tighter than ever before.

Funding adult social care for an ageing population puts a considerable additional demand on budgets. Research from the Organisation for Economic Co-operation and Development suggests that the ageing population will force the UK to spend an extra £80 billion each year on pensions, long-term care and the health service over the next four decades.

Virtual care co-ordination technology can play a positive role in both reducing the cost of care through increasing nurse and doctor productivity and improving the quality of care by increasing the number of check-ups, providing early detection, allowing for early intervention and permitting patients to stay within the comfort of their own home.

Healthcare must exist outside the four walls of the hospital and within homes and communities so that the ageing population and those with chronic illness are not neglected or isolated. By implementing technology that helps people to live independently for longer we can reduce the financial burden on the NHS whilst providing more comprehensive care.

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1

The Office for National Statistics, ‘Ageing, fastest increase in the oldest old’, www.cardi.ie/publications/ ageingfastestincreaseinthe‘oldestold’

2

The Office for National Statistics, ‘Ageing, fastest increase in the oldest old’, www.cardi.ie/publications/ ageingfastestincreaseinthe‘oldestold’

3

Innovation Unit, ‘Managing long term health conditions in the NHS’, www.innovationunit.org/blog/201105/ managing-long-term-health-conditions-nhs

4

Innovation Unit, ‘Managing long term health conditions in the NHS’, www.innovationunit.org/blog/201105/ managing-long-term-health-conditions-nhs

5

The Daily Telegraph, ‘Health Secretary Andrew Lansley: funding crisis threatens the NHS’, www.telegraph. co.uk/health/healthnews/8551392/Health-Secretary-Andrew-Lansley-funding-crisis-threatens-theNHS.html

6 BBC Online, ‘Blood pressure guidelines revised in England and Wales’, www.bbc.co.uk/news/ health-14629425 7

Nigel Crisp, 24 Hours to Save the NHS - the Chief Executive’s account of reform 2000 to 2006

8 The Office for National Statistics, ‘Ageing, fastest increase in the oldest old’, www.cardi.ie/publications/ ageingfastestincreaseinthe‘oldestold’ 9 OECD: huge elderly care bill threatens family ties, www.telegraph.co.uk/news/politics/8501333/OECDhuge-elderly-care-bill-threatens-family-ties.html

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Developing technology for those that need it

NHS in numbers

most

To highlight the pressure that the NHS is under, in a typical day, NHS Direct receives 18,000 telephone calls, 835,000 people visit a GP, 50,000 use accident and emergency departments, and 94,000 people are admitted to hospital as an emergency.

The Times, ‘Managing change presents biggest challenge to the NHS’ http://www.thetimes.co.uk/tto/business/industries/publicsector/article3101574.ece

The Care Innovations™ Guide grew out of a decade of research with seniors, healthcare professionals, and family caregivers, and is now being used throughout EMEA and the US The Guide offers virtual care co-ordination, connecting older adults with their care providers through video consultations, customised health sessions, and multimedia education

Ageing population in numbers

It can be customised to deal with any chronic, long-term illness such as diabetes, congestive heart failure, or chronic obstructive pulmonary disease.

The fastest population increase has been in the number of those aged 85 and over, the ‘oldest old’. In 1985, there were around 690,000 people in the UK aged 85 and over. Since then the numbers have more than doubled reaching 1.4 million in 2010. By 2035 the number of people aged 85 and over is projected to be 2.5 times larger than in 2010, reaching 3.6 million and accounting for 5% of the total population.

The Intel-GE Partnership – bringing together two brands to make a different to healthcare

Intel’s Digital Health Group and GE Healthcare’s Home Health Division joined forces to form Care Innovations, a new company creating technology-based solutions that give people the confidence to live independently. Working together they specialise in three core areas: disease management, independent living, and assistive technologies. The partnership of these two internationally-renowned brands is hugely significant for the future of healthcare technology. With the combined expertise of Intel in the computing world and GE in all things healthcare, the brands are devoted to finding ways of making the lives of patients and elderly easier.

Patient case study One NHS patient trialling the technology in Central Lancashire explained how the Guide helped him to manage his COPD: “My illness was getting progressively worse year on year. I couldn’t play in the park with my grandchildren or go out socialising as much as I used to. Home-health monitoring has given me back some freedom. A few weeks ago my breathlessness and blood oxygen went up and my community matron was round my house in no time to check on me. It gives me and my loved ones peace of mind.”

The Care Innovations™ Guide The Care Innovations™ Guide allows carers to gather information to help manage their patients’ conditions more effectively at home while proactively engaging patients in their own care.

The Guide makes biometric data collection, interactive patient health sessions, video conferencing capabilities, and multimedia educational content available on hundreds of consumer devices – which gives healthcare organisations choice in how to help their patients.

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Innovations in sexual health provision: technology’s role in tackling inefficiency and supporting service development

The state of the UK’s sexual health is a major issue for the NHS. Although 2010’s report from the Health Protection Agency recently highlighted a marginal decrease in reported cases of STIs (dropping by 1% compared with 2009 figures), there was still a staggering 418,598 new STI diagnoses made in England alone. The report also identified that the peak age for contracting an STI is between 19 and 20 for women and 20-23 for men, and that around 10% of 15-24 year olds treated for an STI will be re-infected within a year.

This, accompanied with the much publicised teen pregnancy rate, which is currently the highest in Western Europe, creates an incredible demand for effective sexual health provision.

However, there are barriers to creating effective services and perhaps the most prominent, in light of public sector austerity measures, is the current financial climate. Yet by embracing technology to tackle inefficiencies in existing services or to help develop appropriately tailored new services, costs can be cut and provision improved.

The Inform Sexual Health application has been developed in partnership with senior sexual health consultants in order to deliver fast and tangible results relating to: opening up access to services, supporting service delivery, speeding up service analysis and facilitating service development.

Opening up access for improved health outcomes

Targeting the hard to reach social groups associated with sexual health means making services available at times and locations convenient to the patient; thereby making

attendance for often embarrassing conditions as quick and easy as possible. And it was this ethos that has recently prompted a major shake-up of the sexual health services in Stoke on Trent, as Sue Scott, principal health improvement specialist of NHS Stoke on Trent’s Directorate of Public Health, explains: “Historically, Stoke on Trent’s sexual health service has been spread over several locations, with different services offered at different clinics. This not only caused confusion for patients, who were unsure of which clinic to attend for their specific need, but also caused problems for the numerous patients who present with multiple conditions, as clinicians had no choice but to refer them on to other services. This meant that accessing the care required was prolonged, which obviously had a massive impact upon both patient experience and the cost of provision.”

To improve access to services, NHS Stoke on Trent made the bold decision to integrate all of its sexual health services into one central community setting, and by doing so create a one stop shop where all sexual health needs can be met, backed up by ongoing prevention advice. But the bringing together of services from a range of existing providers, including private organisations, meant tackling the problem of multiple stand-alone legacy and paperbased systems. Sue comments: “To function as a fully integrated service it was clear that the technology supporting our service delivery also had to be integrated. In the past, prior to IT integration, too much of our resource had been spent completing paperwork and collecting data – resource that

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would have been better spent treating patients.

“We are attempting to develop and deliver a truly integrated one stop sexual health service to meet the current and future needs of the local population. To futureproof service delivery it is imperative to invest in technology which is capable of improving patient experience, drive in efficiencies and release staff time to focus upon patients. I believe that this is the way forward to achieving an overall improvement in the sexual health of the local population and that we will quickly see a return on our investment in the Inform technology.”

The overall project, which is being delivered by public sector transformation experts Tribal Group PLC, utilises the Inform framework to enable the sexual health service to triage the patient level of need to the right medical personnel in the required medical environment, manage patient records and patient flows and provide data reporting. The onsite kiosks will interface directly with patients to provide information, low level issuing, check in and appointment booking. Access will be improved further with a patient portal on Stoke on Trent’s website, which will also offer an appointment booking functionality.

As technology becomes an ever present part of our everyday lives and people from all backgrounds and age brackets utilise it regularly for weekly food shops, booking holidays and checking in at airports, it seems only natural that health provision embraces the new way patients wish to access information and manage their health. A primary way sexual health services can open up access and reach notoriously hard-to-reach groups is through

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The Inform Sexual Health application delivers a better patient experience and cuts down on admin

the internet. Having a strong online presence and a user-friendly patient portal can make booking appointments, communication with the clinic and checking results far more appealing to the patient and cost effective to the clinic.

The typical demographic utilising sexual health services, including HIV clinics, have grown up surrounded by technology – and the anonymity it offers matters to patients.

Delivering a more effective service

A key theme highlighted in the recent next stage review plans for the NHS is that of promoting patient experience. And the first step in the process of improved patient experience is ensuring the patient is directed to, and then receives, the most appropriate level of care, and is neither waiting for excessive time periods nor passed from pillar to post in the process.

Increasing the number of clinic locations, and opening hours alike, is pointless if services available or the competencies of staff on duty fail to match patient requirements. The universal goal of improving patient experience fails, and the investment of increasing physical access is wasted, if inefficiency in planning and a drastic lack of visibility prevail. The Inform technology offers a solution to this problem and a cost effective means of mitigating the risk of sexual health services failing to deliver.

A one size fits all approach to health services of any kind is unrealistic and delivering sexual health provision is no different. One way technology can promote improved service delivery is by ensuring the required service is available at the required location. This can be achieved simply by matching clinician competencies with treatments required during the appointment booking stage.

Sexual health professionals are qualified in different areas: some are able to offer HIV counselling but unable to prescribe medication, others can test for STIs but are unable to provide pregnancy advice. Therefore the type of care that can be delivered by a health outlet is entirely dependent upon the clinical staff present on any given day. Having the ability to match appointment bookings with locations, and the staff competencies available, not only removes the cost associated with inappropriate

bookings but facilitates a better experience for the patient.

The Inform Sexual Health application facilitates better service delivery by providing users with a holistic view of the services that are available in each clinic. This is achieved by storing individual clinicians competencies, which in turn allows the patient to select the most appropriate appointment level that they require. This level of control allows patients, via triage, to automatically book the most appropriate level of care available through the use of automated technologies. This creates a more reliable means of matching patients with services and frees up resources for service staff.

The Self-service technology is another innovation that can improve the overall patient experience by reducing waiting times and assisting with way-finding. Self-service technology, which patients of all walks of life are familiar with, thanks to its uptake in supermarkets and airports, offers a confidential method of checking into a clinic for the patient, and helps reduce the burden of administration for the clinic.

Accurate data capture and

the unique problems associated with any given area are correctly identified and scrutinised. Without accurate data collation and analysis, service managers and commissioners risk stabbing in the dark when it comes to attempting to create effective services. The traditional method of analysing data stored within paper-based patient records is time and labour intensive and the results are often untrustworthy. Thus, taking into consideration that clinics are paid by results, each inaccurate record of activity incurs a financial penalty in addition to the associated cost of the inefficiency.

Technology has the ability to remove this barrier to effective service improvement by automatically storing accurate patient information each time the patient is seen by a clinician. Meaningful data can then be analysed at the click of a mouse and services tailored to a specific area’s requirements. For instance, if a high volume of patients from a particular geographical area were requesting the morning after pill, the technology would quickly help commissioners identify the trend, enabling them to implement educational and delivery outreach services designed to promote the use of contraception.

analysis

Before existing services can be developed or new ones implemented, it is imperative that

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To enhance the sophisticated level of data scrutiny, the Inform system incorporates

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mapping capabilities from leading software analytics consultancy, Beacon Dodsworth. A visual illustration of services provided over a set period of time, is more compelling than a simple graph or spreadsheet and provides a far better understanding of the health needs of local communities and populations, by identifying trends and patterns in order to target health improvement more effectively.

By incorporating Beacon Dodsworth’s mapping and analysis functionality, the Inform system can create detailed maps highlighting each sexual health hotspot and allow users to drill down into an individual patient’s record.

This technology is not new to healthcare and is being used in other areas to overcome similar challenges. Beacon Dodsworth’s geographical information system is used by Derbyshire NHS Mental Health Services Trust

to achieve their aim of providing an effective, accessible and modern Mental Health Service.

The ability to develop services to meet client need and maximise service efficiency is essential in achieving this goal.

Through the use of this product, Derbyshire Mental Health is able to plot and analyse service locations and facilities against patient attendance data, their referral location and their specific needs to establish and evaluate patterns and densities. These patterns help plot mental health inequalities in terms of geography where no services, facilities or resources are available to a particular ward or postcode and in terms of individuals, where access to services may be restricted for certain groups of people. This not only allows the Trust to target resources better by providing relevant help and education to areas identified

as most at risk, but is used to influence the Trust’s plans for future build locations, service provisions and resource allocation. This in turn leads to improvements in administration efficiency and staff usage improves the routing of referrals in line with the NHS operating framework whilst improving patient experience and outcomes.

Another instance where accurate data collation is crucial is within a HIV clinic.

Automation, through the use of Inform’s functionality, will enable users to check results, identify trends based on these results and provide a holistic view of the whole situation.

This in turn will allow the operation of the clinic to become more efficient and proactive and ultimately help reduce the spread of the disease through promptly identifying disease clusters and emerging trends.

Allowing technology to lend a helping hand in relation to collecting meaningful data not only plays an important role in assisting service development but facilitates more efficient research by enabling quick access to specific patient information. For example, patients who satisfy the inclusion criteria for a particular study can be identified by simply clicking a few options and pressing the return key, rather than having to manually read through endless sets of notes or clinic letters.

Facilitating service development Today, NHS budgets are perhaps at their most stringently guarded since the organisation’s inception. So when it comes to meeting the national improvement objectives through service development, financial investment of any level must be able to demonstrate a tangible return on investment, through the creation of a realistic and well researched business case.

On first consideration, investing in technology to improve, expand or develop services can appear an unnecessary expense. However, upon closer inspection, the benefits of moving from a paper-based or static appointment booking system, to a sophisticated yet userfriendly electronic model become obvious.

Technology has the power to facilitate service development. A HIV clinic, for example, deals with a large percentage of follow up patients:

Population density for adults aged 16+ in a given geographical boundary

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Location of patients attending Clinic 1, anonymised to ward level

these are patients who will need to visit the clinic regularly to be monitored and prescribed medication – varying from twice a year to twice per month depending upon the stage and severity. Cumbersome legacy systems in place in a majority of HIV clinics only provide appointment booking functionality and leave clinicians reliant upon paper-based patient records for the medical history and a variety of software packages for the rest of the clinical information. This not only contributes to the general administration and staffing costs of the clinic but also runs the risk of reducing the actual clinic capacity, due to delays associated with locating paper based records, missing or misfiled results or even patients being booked into the wrong appointment slot. In turn, this can have financial implications not just for the clinic, but for the Trust as a whole.

Gabriel Schembri, a consultant in GU medicine at Manchester Royal Infirmary, has been working alongside a team of developers at Inform to create an application specifically designed to enhance efficiency and improve patient care in a HIV clinic setting. Drawing upon his clinical experience within the HIV field, Gabriel has been able to provide an insight into the problems experienced by physicians and patients during an HIV clinic, and work with Inform to create solutions to these problems.

A significant difficulty highlighted by Gabriel is that of quick and reliable access to all the bits of information required during the consultation, including recent and past test results, vaccination history, sexual history, letters from other clinicians and the patient’s drug history. This is solved easily with Inform’s secure platform, which enables authorised users to immediately navigate to the specific data group required, similar to navigating through a well designed web page. There are however a number of other areas that the Inform platform will help HIV clinics improve so that the expected efficiency savings can be delivered.

Investigations can be requested directly through the Inform interface, eliminating the need to fill in multiple forms and the possibility of labelling errors. Test results can be updated automatically within a specific patient’s record, which in turn eliminates filing errors.

Abnormal results can be highlighted for further action by a clinician, based on a number of predefined parameters. Resistance mutations, both recent and historical, can be analysed automatically by tapping into the Stanford database directly to ensure the most up to date interpretation. The Framingham cardiovascular risk calculation can be done automatically using the patient’s demographic data and the latest laboratory results. Alerts can be set up for vaccinations and cervical smears. Reminders can be sent automatically to patients who have appointments the following week, or to those who have failed to attend. The system is also highly customisable and can be tailored according to the needs of the service.

Gabriel comments: “It’s essential that clinics function as efficiently as possible to ensure that the maximum number of patients are seen and that they all receive the highest

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possible standard of care. Unfortunately, outof-date systems can often make this goal harder to realise and in many cases prevent it from happening altogether. The Inform HIV application understands the barriers to streamlined services and provides the solution to the problems of disjointed data capture, a lack of quick access to patient records, lengthy manual analysis and a lack of patient interactivity. I’m confident that HIV clinics using Inform’s technology will benefit from improved working practices and a reduction in administration costs.”

To find out more about Inform Sexual Health and how it can help improve the effectiveness of sexual health services, or to request a demonstration, please contact: Susan Bunn Tel: 01285 657516 or visit the Inform website at www.informsexualhealth.co.uk

INNOVATION IN HEALTHCARE

Innovative microbiology services for the 21st Century Philip E Luton, business development and marketing manager of the Health Protection Agency explains the support and services the agency can offer

The Health Protection Agency (HPA) was formed in 2003 with the remit of providing an integrated approach to protecting UK public health through the provision of support and advice to the NHS, local authorities, emergency services, other arms length bodies, the Department of Health and the devolved administrations. The HPA has a large network of approximately 3,500 staff based at four major centres (Colindale, Porton, Chilton and South Mimms) with laboratories and units regionally and locally throughout England. There is a small central office based in London.

Since its inception the HPA has dealt with numerous emerging and re-emerging infectious diseases and other emergencies. These have included amongst others: »» SARS, a severe respiratory disease caused by the SARS coronavirus (SARS CoV), which spread worldwide before being contained by July 2003 »» The UK public health implications of the Polonium 210 incident in 2006 »» The H1N1 (2009) ‘swine flu’ pandemic virus, which emerged in Mexico in 2009 causing mild/asymptomatic disease in the majority of cases but severe illness and

death in a small proportion of cases, particularly in more vulnerable groups »» Numerous outbreaks of more “common” infectious diseases including those caused

by E.coli, MRSA (Methicillin-resistant Staphylococcus aureus), salmonella and TB. This includes identifying novel and antibiotic resistant strains of such microorganisms.

Throughout the last nine years HPA scientists have been at the forefront of protecting public health by investigating outbreaks, as well as undertaking cutting edge research into developing new tests, methods and protocols to identify, detect and diagnose rapidly the causative agents.

Looking forward, we are committed to providing a modern, cost effective and integrated public health microbiology service that is fit for purpose for the next decade and aligned with the new Public Health England (PHE) governmental body that is due to come into existence in April 2013 Our aim is to enhance health protection outcomes both nationally and internationally for a global population. A key priority to enable us to help the new commissioning consortia set out in the government’s Health and Social Care Bill is to engage with commissioners so New tests, methods and protocols are in development to assist rapid diagnosis

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The HPA is unique in that it has a network of laboratories across the country

that they procure best value for the public health system as a whole and not just immediate local priorities Our expertise lies in : »» Reference microbiology »» Specialist diagnostic microbiology »» Food, water and environmental microbiology »» Research and development to underpin the knowledge base.

We are committed to providing a modern cost-effective and integrated public health microbiology service Specialist diagnostic microbiology is a collective term that denotes microbiology tests that are not performed routinely in local or hospital based laboratories, including various molecular diagnostic tests, strain typing and fingerprinting, in addition tests for rare and unusual infections and environmental microbiology.

»» Development of accurate and reliable diagnostics »» Ensure tests are validated and verifiable, for example EQA schemes The HPA is unique in having a network of laboratories strategically placed across the country, that together with our national centres, deliver a total microbiological service, providing end to end diagnostic services with specialist consultant clinical advice In addition, the HPA undertakes contract services including fundamental research and development, plus developmental production and manufacture of bio-pharmaceutical products. This contract work not only broad-

ens the funding base of the agency, therefore offsetting the cost to the tax payer, but also allows any income generated to be reinvested back into the system to develop the capacity and capabilities. This type of funding mechanism is uncommon in the public sector but has been acknowledged as central to the new role of PHE As we develop our services we need to provide clear information to our stakeholders (NHS trusts, local authorities, GP consortia and others) as part of an integrated system of pathology services so that patient outcomes can be managed with seamless coordination.

We seek to provide clear information on our

Our reference laboratories are national centres of excellence in particular fields of microbiology and laboratory medicine.

They establish and use methods that are the most accurate and precise in the hierarchy of diagnostic testing and are capable of validating and verifying testing results of other laboratories for public health or epidemiological purposes.

Across our centres of excellence and network of laboratories we are able to conduct work such as: »» Specialist testing »» Microbial strain typing and fingerprinting »» Rare and unusual illnesses/infections »» Environmental microbiology Contractual services are undertaken, which offsets cost to the tax payer

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Expert support can be given to labs to confirm diagnosis of unusual microorganisms

expertise, capabilities, ease of access and assurance on delivery so that those commissioning services select us as their first choice We believe that one of our major advantages is the ability to support the more routine laboratory work by providing clinical and expert advice to confirm diagnoses, especially with regards to unusual illnesses, or novel and dangerous pathogenic strains of microorganisms.

Looking forward we aim to be in the forefront of adopting new technologies and ways of working, whilst keeping the focus on the patient as a key aim. This will include the adoption of new ways of working in conjunction with our partners, including for example, point-of-care or near-patient testing. The introduction of such new cutting edge technologies to give faster, more accurate and clinically relevant results is critical if we are continue to keep up with ever evolving microorganisms and the demands of a modern health service.

With a proven track record of both responding to evolving health threats, aligned with the development of new and innovative scientific methods that bring real benefits to peoples lives, the HPA is definitely at the centre of innovation in healthcare for the 21st century.

Health Protection Agency, Porton Down, Salisbury SP4 0JG Tel: 01980 612725 Fax: 01980 612241 E-mail business@hpa.org.uk Web: www.hpa.org.uk The HPA aims to be at the forefront in developing new technology

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“Providing Excellence in Healthcare”

Commissioning mental health pathways A project overview by Carole Green, Project Director, Care Pathways and Packages Project (CPPP); Ian Smyth, Chair, Pharmaceutical Mental Health Initiative (PMHI); Miranda Stead, Director, Mednet Consult

Mental Health services were identified as the main priority area for currency development following the Department of Health (DH) consultation of the ‘Options for the Future of Payment by Results (PbR) 2008/9–2010/11’.

A currency model initially developed by the Care Pathways & Packages Project (CPPP) was subsequently endorsed as the model for further development. The project is a formal Consortium comprising of the North East and Yorkshire and Humber SHAs, all of the secondary care MH Trusts and all of the PCTs in those areas. It is also supported by local authorities via membership of the Consortiums Board and has continued on this basis with its aim being to develop a currency for use in mental health services Payment by Results in support of the national project for MH PbR. The DH encouraged a development site approach to MH PbR Development and this has seen sites in London and the West Midlands, along with CPPP, demonstrating how the service can effectively develop national policy.

Unlike acute hospital PbR, the intention has been to focus on a care pathway that promotes evidence-based care and encourages the correct incentives rather than a payment for procedures that focuses on activity. Use of the correct incentives will support the drive for efficiency and effectiveness, major changes that are required in the current environment.

The DH timescales require »» The use of the Mental Health Clustering Tool (MHCT) for working age and older people from 01.04.11 »» Complete collection of MHCT and allocation to one of the 21 clusters by 31.12.11 »» Reference cost collection on the basis of the 21 clusters by 30.09.11 »» The establishment of currency and local tariff for use for 2012/13 »» 2013/14 being the earliest point at which a national tariff for MH services will be considered.

In mental health it has long been recognised that diagnosis is not a good proxy for the costs associated with the person’s care and treatment received and thus a traditional PbR arrangement of a price related to a diagnosticled procedure would not work, as there would

Care Pathways and Packages Project – developing currencies for Mental Health payment by results

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be a great variance in care package and cost for the service users with the same diagnosis.

This was the prime factor that lead to a currency model being developed that is based on the classification of needs of the treatment. The currency that has been developed for working aged adults and older people has 21 care clusters across psychosis, non-psychosis and organic diagnoses.

In order to place individuals within a care cluster, clinicians score individuals using the recently mandated Mental Health Clustering Tool (MHCT) against 13 descriptions of problems that they may have experienced in the last two weeks and five descriptions of more historical or episodic problems. Thus the nature and the severity of the impact of the problems on the individual are recognised and rated so that they are then allocated to one of the 21 care clusters.

Newly referred service users are allocated to a cluster following their assessment and application of the MHCT. This is repeated at their routine reviews (CPA) and at any point where a significant change in their presenting needs occurs. The mental health trusts using this approach are currently achieving over 90% allocation of service users, and work is now progressing to validate the accuracy of this and is supported by the development of a national algorithm that will provide a degree of validation and assurance. It is a fundamental requirement to ensure service users are in the correct cluster at all times.

The content of the care package provided

INNOVATION IN HEALTHCARE

to service users in each of the clusters is currently determined on a local basis. Work at a local and national level is progressing to provide guidance that incorporates current evidence and best practice on the content of care packages for the clusters, which whilst not intended to be prescriptive will enable stronger benchmarking across services.

The next step is to describe the care pathway related to each care cluster so that commissioners and service users can see what service is being proposed to treat and support the individual issues identified. The care pathway will be evidence-based wherever possible and be related to recognised positive practice for the individual. The benefits to service users and practitioners are potentially enormous.

Costing is also underway, with reference cost collection on the basis of the 21 clusters being undertaken by all providers in September 2011.

The CPPP sites have developed a costing methodology that is based upon producing a ‘cost per day per cluster’ in the first instance, with the intention of developing a cost per cluster episode that can be used in contracts in the future whilst also undertaking further testing and learning during 2012/13.

To complete the currency model, the linking of quality indicators and outcome measures to the clusters is also being developed. The national Product Review Group (PRG) sub group for Quality and Outcomes has a threephase approach that includes; »» 2011/12 analyse a number of national indicators currently mandated, link these to clusters, and recommend further use and development »» 2012/13 test, refine and recommend a number of service users presenting for additional measures including individual items within the MHCT on a cluster basis and identify »» 2013/14 test, refine and recommend a comprehensive range of quality indicators and outcome measure that reflect the whole system’s needs collectively the clusters, their care package, cost and

IMHSeC – Industry and Mental Health Services Collaborative Project – developing a web-based tool to provide guidance on the content of care packages associated with the 21 clusters quality indicators form the overall currency model and their on-going development testing and refinement continues.

Other currency models are being developed for CAMHS, forensic, learning disability, talking therapies and drug and alcohol services.

The IMHSeC group consists of members from the Department of Health, the Pharmaceutical Mental Health Initiative (PMHI) and the NHS Confederation. The development of this aspect of the MH PbR Q&O PRG sub group has been supported by this collaborative approach, and resourcing for the project has been provided by the PMHI group.

The project is responsible for developing a tool that provides guidance on the content of the care packages whilst supporting the implementation of Outputs linked to National Guidelines (eg NICE) for each of the 21 Payment by Results clusters, working across the various interested agencies and parties, collating work already carried out and focusing on producing a core set of

Contact: Mednet Consult Ltd, Leeds Innovation Centre, 103 Clarendon Road, Leeds, LS2 9DF Tel: +44 (0) 113 827 2039 E-mail: info@mednetconsult.co.uk Web: www.mednetconsult.co.uk INNOVATION IN HEALTHCARE

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Outputs that will also help to make the linkages between inputs and Outcomes by cluster and condition. The output of the project will be a web-based platform that can be accessed by professionals in the commissioning and provision of services covered by the 21 clusters.

A third-party organisation, Mednet Consult Ltd, has been tasked with providing expertise on the steering group and also building and designing an appropriate web-based platform for the project.

The website initially aimed at commissioners and providers will: »» show for each PbR cluster what the evidence says should be provided as the content of a care package for an individual »» outline interventions, outputs and signpost information, if available, on skills »» link to outcome. It will link into the national quality standards (where possible) and the developing work on indicators and outcome measures as an integral part of the PbR process.

This web-based resource for NHS providers and commissioners will provide guidance and signposting to commissioners and practitioners on the content of care packages and will need to be regularly updated to remain fit for purpose. The effectiveness of the project will be measured by the level of use and feedback on the quality of the resource. The website will be launched in March 2012.

Mednet is a healthcare consultancy and solutions provider of patient-focused and cost effective solutions to any healthcare requirement.

Mednet works with all healthcare organisations and specialises in using new technology, such as web-based platforms and mobile applications, to empower patients and support policy.

For any queries, please contact: Carole Green: carole.green@humber.nhs.uk Ian Smyth: ismyth@its.jnj.com Miranda Stead: mstead@mednetconsult.co.uk

“Providing Excellence in Healthcare”

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“Providing Excellence in Healthcare” Mednet Consult is a UK healthcare consultancy and service provider commi ed to providing unique and innova ve solu ons. Our exper se and dedica on in providing pa ent-focused and cost effec ve solu ons to any healthcare requirements is evident from our wide range of services listed below:

Mednet Adherence Support Service (MASS)

Empowering pa ents, improving outcomes, reducing costs

We have developed a proven working model for our clients to increase pa ent outcomes and reduce the cost of par al or non-adherence. Through combining ever improving informa on technology and telecommunica ons, we are able to offer a customised state-of-the-art treatment reminder service which is an effec ve way to increase pa ent involvement, loyalty and a endance to medica on appointments which significantly improves efficiency of treatment whilst simultaneously reducing cost.

Reminders can be delivered in the form of text messages, phone calls or mobile alerts using a mobile app.

Integrated Resource Pla orm (IRP)

Dissemina ng the latest informa on to Healthcare Professionals (HCP's) through user-friendly digital solu ons

It is an integrated resource with a two-way communica on pla orm informing HCP’s with the up-to-date informa on through various modes of communica on such as local/remote computers, mobile devices (also using Mobile Apps on smartphones such as iPhone, Blackberry, and Android) and support centre, effec vely and efficiently using the media they prefer. It also includes an interac ve environment feature (discussion groups, blogging, live chat, secure file sharing and links to social media) allowing knowledge sharing between users. We also develop e-Learning modules for HCP's to enhance their knowledge and exper se.

Mobile Applica ons

Knowledge and educa on @ your finger ps

Our mobile technologies educate Health Care Professionals, encourage pa ents' ac ve involvement in their treatment, and enhance the provider's access to pa ent data and sta s cs, all with the goal of improving healthcare outcomes. We have created and deployed Standard Opera ng Procedure (SOP) apps compa ble with Android, Blackberry and iPhone opera ng systems. The apps contain interac ve videos and anima ons, a user feedback mechanism and GPS data, which tracks usage and short-term and long-term trends. They also provide live links to the support team via telephone, email and web-links.

Suppor ng NHS

Providing assistance to drive NHS policy, using state-of-the-art technologies

We work with key na onal organisa ons to support the development of new policies, including several projects with the Department of Health. Currently, we are working on the Payments by Results (PbR) programme to help support the achievement of the PbR Project Group’s objec ves in delivering a comprehensive range of indicators and outcome measures. It includes development of an integrated web based pla orm that will advise providers and commissioners on the evidence based pathways linked to the 21 Clusters and will support the achievement of outcomes for people through the implementa on of these interven ons.

For more informa on, please contact us at T: +44 (0) 113 827 2039 E: info@mednetconsult.co.uk W: www.mednetconsult.co.uk h p://twi er.com/mednetconsult

Director: Miranda Stead T: +44 (0) 113 827 2039 E: mstead@mednetconsult.co.uk

The power of touch: using touchscreen technology to engage patients The challenge of patient engagement

Healthcare providers are expected to engage, listen to and involve patients. The Care Quality Commission (CQC) demands that healthcare services “provide service users with appropriate information and support”, enable patients to “express their views” and “involve service users in decisions”. The CQC also requires that patient experience is monitored. Meanwhile the Quality and Outcomes Framework (QOF) and Directed Enhanced Services (DES) reward GP practices for having a patient participation programme and measuring patient experience.

Beyond the formal requirements, patient engagement goes much further. In a world of greater patient choice, it’s vital that healthcare services put patients at the centre of everything they do, encouraging service design that gives patients what they need and want. This means providing patients with the right information at the right time, asking them questions and listening to what they have to say.

However, patient engagement is not easy. It takes time, effort and money. Patients can be isolated, disadvantaged and disengaged. They come from different backgrounds, face different challenges and have different needs.

The great challenge is to have an effective patient engagement programme that’s inclusive and accessible for patients, whilst being cost-effective and easy to manage for healthcare providers.

Interactive technology – driving an engagement revolution

Interactive technology is driving an engagement revolution. From touchscreen kiosks and handheld tablets to touch-sensitive windows and tables, this intuitive technology is being used to increase patients’ access to information and enable them to leave feedback on services.

With a combination of accessible hardware, bespoke software and related engagement services, Elephant Kiosks are at the forefront of this revolution; enabling patients to leave feedback in new ways and helping the NHS extend the reach of information to patients who may otherwise not have the opportunity or know-how to access it.

Measuring patient experience Touchscreen kiosks and handheld tablets enable service providers to run electronic patient surveys. Patients simply complete the survey by touching the screen, giving service providers instant access to real-time reports.

Pennine Healthcare University NHS Trust recently launched 35 touchscreen static kiosks across the boroughs of Bury, Rochdale, Oldham, Stockport, and Tameside and Glossop, delivering one of the most accessible surveys developed in the NHS. The survey is available in 10 languages, with automated audio, large text and pictorial symbols.

Stoke-on-Trent Community Health Services utilise the technology in a different way, with 50 handheld devices running a selection of surveys, used out in the community by health workers. It ensures patients being treated in the community get the same opportunity to have their say on services as those in health centres and hospitals. Unlike paper surveys, results are submitted securely and privately by the patient, with no manual data entry or analysis required. Service managers are able to view real-time, online reports at any time, keeping a daily or weekly track of patient experience across seven service teams. “The size of our project,” says Liam Norcup, project lead at NHS Stoke-on-Trent, “demonstrates the power of touchscreen technology to improve patient engagement on a large scale, whilst also saving money and staff time.”

Touchscreen surveys also facilitate instant e-mail alerts to a designated member of staff.

So if a patient leaves feedback about an unclean waiting room, for example, an e-mail Interactive kiosks and tablets allow patients to leave instant feedback or complete surveys about their experience of NHS services

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A real-time system allows NHS managers to act quickly on patients’ opinions and implement changes quickly and effectively

is instantly sent to the relevant senior sister.

As explained by Barking, Havering and Redbridge University Hospital NHS Trust, this real-time system means managers “can access results regularly, so can act on patients’ opinions to implement changes quickly and effectively”.

Accessible patient information Interactive technology provides a unique opportunity to ensure patients access vital information at the right time, whether it’s a kiosk based in a pharmacy like at Cambridge and Peterborough NHS Foundation Trust, or out in the community and at GP surgeries as with NHS North Staffordshire. The technology means information can be delivered at the point of service, in multiple languages, audio and video. It can act as a staff resource, and patients can also print information or e-mail it to a personal e-mail address. “We use touchscreen kiosks to deliver health information, news and leaflets, and to provide service directories,” says Hayley Darlington at South Staffordshire PCT. “It means more people can access the information they need, and it also makes our information provision easier to manage and more cost-effective.”

Making engagement inclusive Interactive technology will continue to develop and become more popular. In addition to kiosks and tablets, Elephant Kiosks already provide touchscreen windows, floors and tables, and interactive holographic displays. With the endless opportunities this presents for service innovation, the biggest opportunity intuitive touch technology brings to the NHS is to make engagement inclusive; to involve patients young and old, technically savvy or not, no matter what their language, literacy level or disability.

You don’t need to be technically savvy to use touchscreen kiosks and information can be provided in many different languages

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Case study

Bradford District Care Trust

by Shahid Islam, service user & carer involvement project manager, Bradford District Care Trust Around 18 months ago we installed touchscreen and handheld technologies across our organisation to collect feedback about specific teams and individuals, relating to performance from the service users’ viewpoint. Data is collected in real-time and centrally collated by Elephant Kiosks who, amongst other things, ensure the technical elements run smoothly. The anonymised data is made available to individual clinicians, teams and wards. Graphical illustrations show how service users scored a number of topics, ranging from quality of food to how well treatments were explained. Labour intensive tasks such as analysing data are automatically taken care of, which saves a great deal of time and mental energy.

Results show most respondents rate care in a very positive way. Where there are trends which deviate from the high standards we can investigate further through inspection, audit or evaluation exercises, or rectify the issue immediately if it’s more straightforward.

For example, we noted 28% of inpatients were not provided with information about the ward routine. A flyer was produced in a participatory way, with information about the ward, including meal times and activities. This is now provided to all patients on admission. There are many further examples of small changes that have had a ‘drip-drip’ effect leading to service improvements, which are not always easy to quantify. This is exemplified by one doctor who stated; “By virtue of creating a system where people can score performance, one can’t help but ensure that standards are always high”.

We have found e-feedback to be a powerful tool and a useful ally in our quest to increase the amount and quality of data. In an age where a great deal of activity is turning towards technology to improve convenience and outcomes, it’s only logical for feedback to follow.

What is interactive technology? »» Touchscreen kiosks »» Handheld tablets »» Touchscreen tables »» Interactive window displays »» Touch-sensitive floors »» Motion sensitive displays »» Holographic displays

“I started Elephant Kiosks 5 years ago after seeing the opportunity for accessible touchscreen kiosks to deliver vital information out in the community. We designed the UK’s first manually height-adjustable kiosk, accessible to wheelchair users and people with other disabilities. Since then interactive technology has developed rapidly and so have we, but I never forget our founding principles; that technology should empower people to access information and directly engage with public services.”

Annette Walker MBE, managing director, Elephant Kiosks

Mark Worger, Business Development Manager Elephant Kiosks Downing Park, Swaffham Bulbeck, Station Road, Cambridge CB25 0NW Tel: 01223 812737 E-mail: mark@elephantkiosks.co.uk INNOVATION IN HEALTHCARE

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Principia, Nottinghamshire

When Kenneth Clarke speaks enthusiastically about the coalition government’s NHS reforms, his views are informed by knowledge of a trailblazing initiative in his own parliamentary constituency. Clarke, the Justice Secretary, is Conservative MP for Rushcliffe, a leafy borough on the southern outskirts of Nottingham. It happens to be the location for one of the most advanced experiments in GP commissioning anywhere in England.

There are 16 practices in the borough, which has one of the lowest deprivation scores in England, but more than its fair share of pressures on the NHS budget from a growing population of older residents. Five years ago, the GPs were concerned that what they regarded as an enlightened approach to patient care might be disrupted by a round of NHS mergers. Their local Rushcliffe Primary Care Trust was due to become part of NHS Nottinghamshire County. The headquarters of the merged PCT was to be in Mansfield – only 45 minutes to the north, but a world away in the perception of the doctors.

That was in 2006 when the government was encouraging GPs to take part in an initiative known as Practice-Based Commissioning. Dr Stephen Shortt, one of the leading local GPs, recalls: “We squinted our eyes at the horizon and took a view on what the future might hold. We thought about how we could deal with increasing demand for healthcare services once NHS budgets stopped increasing.”

The Rushcliffe GPs considered how they could reorganise services to reduce inefficiency, delay and duplication. They were particularly concerned about the unnecessarily high levels of spending on patients going to hospital for tests and treatments that could be provided

closer to home. Switching services into the community would be more convenient for the patients and less costly for the NHS. It could be achieved without any reduction in quality or safety. This was a common problem across England, but the Rushcliffe GPs devised a distinctively different solution.

They began to explore a “mutual” model of healthcare in which the local population of about 120,000 patients could have a direct say in the planning and delivery of services.

After much discussion with other healthcare professionals, NHS managers and patients, the GPs formed a company to design and deliver health services across the borough. It was set up to provide care for the benefit of the community and not for the profit of its members. They called the company Principia and pledged themselves to uphold public sector values. Dr Shortt says: “It was only later someone told us that what we had set up was a social enterprise. At the time we hadn’t even heard of the phrase.”

The main Principia board has a lay chairman, six patient directors, three clinical directors who are all local GPs and three directors from other health professions such as community nurses, therapists and health visitors, all working in the area. That puts patients in the driving seat. GPs and their professional colleagues may come up with innovative ideas for changing services, but they can get nowhere without listening to what patients want. The system works thanks to a network of relationships – between professions, between primary care and the Nottingham University Hospitals NHS Trust, and between all these people drawing income from the NHS and the patients they serve.

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Since 2006, NHS Nottinghamshire County (the PCT that has statutory control over the commissioning budget) has delegated effective control over NHS spending in Rushcliffe to the Principia social enterprise. PCT employees sign the cheques, but the Principia board is allowed to influence the reorganisation of spending on medicines, hospital care and community services worth about £200 million a year. Under current law, the PCT could have pulled the plug on this arrangement at any time, but it has never chosen to do so.

That was probably due to the success of the social enterprise’s innovations. For example, Dr Jeremy Griffiths, a local GP who is Principia’s clinical lead, says it has developed three “virtual” wards in the community. GPs, practice nurses and community matrons identify vulnerable patients who are most at risk of needing an emergency hospital admission.

Instead of waiting for a medical crisis they work together to keep these patients well. The patients stay in their own homes, but they are placed on the register of what Principia calls a “community ward.” This offers the same breadth of care that a patient would receive in hospital, but in a community setting. Healthcare staff from different professional disciplines use common documentation and there is regular formalised communication across professional boundaries. Once a month every GP practice has a community ward planning meeting at which GPs, nurses and other staff discuss which patients are at a high enough risk to become candidates for entry to the virtual ward.

Dr Griffiths says: “The community wards that we have developed in Rushcliffe were triggered by something that we read was happening in Croydon, south London. We could not have

INNOVATION IN HEALTHCARE

adapted those ideas without the flexibility and impetus we were given by Practice-Based Commissioning. It gave us permission to go out and organise these pieces of work.”

The idea spread to practices in four other commissioning groups across Nottinghamshire and the PCT and Nottingham University Hospitals have now agreed to appoint the first jointly funded community geriatricians – 2 consultants who will work in the community to keep older people well enough to carry on living at home. The working groups are now evolving to develop more “hospital at home” services and to work with social care to look at helping vulnerable people out of hospital beds as soon as they are fit to discharge.

Other initiatives include the appointment of additional community nurses for patients with chronic airways disease and those at risk of heart failure. GP practices have been offered incentives to improve services for Type 2 diabetes patients who would otherwise have needed treatment in hospital. Principia has arranged for a specialist nurse from Nottingham University Hospitals to attend diabetes patients in the community – helping people to spend less time in hospital as inpatients and making cost savings of about 20%.

And Principia got money from an East Midlands regional innovation fund to trial an urgent community support service. The social enterprise, in partnership with Nottinghamshire county council, will provide dual-purpose support staff who can help people with both health and social care needs. Under the normal rules, a patient with a chest infection might need a nursing auxiliary to administer drugs and a home help to assist with daily routines. The new team of health and social care support workers will swing into action within four hours of referral by a GP. They will provide an alternative to admission to hospital when it is not clinically required. The new service will cost £126,000 a year, but it is set to save £728,000 in unnecessary emergency admissions to hospital. The scheme requires close cooperation between Principia and the county council – a relationship that will increase in importance under the government’s proposals for NHS reform.

Principia is an unusual organisation in that it has no employees. Under current law, staff transferring to Principia from other parts of the NHS would have lost pension rights. So the social enterprise’s tiny band of four man-

agers is seconded from NHS Nottinghamshire County. They work in offices on an upstairs corridor of the PCT’s outpost in Rushcliffe.

The GPs remain independent contractors with their own staff.

for other healthcare professionals. Representation for patients? No problem: Principia has even put them in a position where they could outvote the professionals, although they have never chosen to do so.

Pricipia ran into difficulty when it asked to use the NHS logo as part of its branding on letterheads and on the door of each practice.

In spite of the social enterprise’s strong public sector ethos, the Department of Health said the name Principia could not appear too close

Dr Shortt’s only real anxiety is that GP consortia in future may need a helping hand to achieve the truly integrated care that is his ultimate goal. He says: “What we have done in Rushcliffe is not revolutionary. We have developed a culture that gives us some chance of success. As GPs, we have built up relationships with our patients, with our clinical colleagues in secondary care and with colleagues working for other community services.” In all this work Principia has been supported by its PCT. But what will happen in future when there is no PCT to hold the ring in areas where relationships come under strain? What will happen if a GP consortium and a hospital cannot agree about the reconfiguration of a service? And will it be acceptable under EU competition law for GP commissioners to form close relationships with hospitals or other providers to provide a seamless service for patients? Dr Shortt and his colleagues are excited by the government’s NHS reforms, but offer a word of caution about a continuing need for people of knowledge and authority to manage the system as a whole.

A nurse on the board of every GP commissioning consortium? No problem: Principia already has a nurse on the board and places for other healthcare professionals to the famous NHS lozenge. So the model for GP commissioners in the future has been somewhat hamstrung by rules from the past.

Dr Shortt is optimistic that petty problems of this nature will be sorted out when the Health and Social Care Bill becomes law. Dr Shortt is chair of the Professional Executive Committee of NHS Nottinghamshire County and he is about to become Principia’s clinical chair and accounting officer. He says he welcomes some of the ideas that ministers are understood to be considering during a pause for reflection on the content of the Bill.

A nurse on the board of every GP commissioning consortium? No problem: Principia already has a nurse on the board and places

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Andy Warren, who leads Principia’s patient reference group, is concerned about possible changes to the Health and Social Care Bill.

He says ministers should not think patients can be adequately represented by appointing someone from local government to sit on a GP consortium board. Warren uses a network of more than 700 patients to collect ideas and consult on proposals for redesigning services in Rushcliffe. He says: “The views of patients are given the same standing as the views of the clinicians. For example, when they looked at diabetes services it mattered that we told them how people were expected to turn up at the hospital and waste half a day waiting for a blood test. The patient lives with diabetes 24/7, whereas the clinician may spend only a few minutes in a fortnight with each one.

“We give the patients better representation than local government could ever give us.

Local politicians represent political parties, but our people are the patients of our local GPs. We have better insight. It would be a negative step to replace us with local government and I would fight it with every breath.”

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PRINCIPIA A TALE OF TWO PENSIONERS Albert – 77 years old

Robert – 77 years old

Lives with his wife in Cotgrave, Notts.

Has severe Chronic Obstructive Pulmonary Disease

Lives with his wife in Cotgrave, Notts.

Has severe Chronic Obstructive Pulmonary Disease

Becomes unwell with a productive cough and increased shortness of breath.

Becomes unwell with a productive cough and increased shortness of breath.

Too unwell to go to the surgery – GP does a domiciliary visit. £200

Robert’s GP has referred him to the COPD team to optimise his medication and management. Robert rings his specialist nurse for advice.

Antibiotics and steroids are prescribed for an infective exacerbation. £10

Robert starts his home supply of antibiotics and steroids straightaway £10, following discussion with his nurse £23 and guidance from his self management plan and COPD booklet £10.

Following day, Albert’s shortness of breath worsens. His wife becomes very concerned and rings an ambulance. £100

Robert’s nurse visits him £100 within 24 hours to review his condition and offer any further advice.

Albert is admitted but there isn’t a bed available on a respiratory ward so Albert is what is called an outlier (this means he is given a bed on a general ward awaiting a bed on a specific respiratory ward).

Robert’s wife says that she is confused about Robert’s new medication so an Urgent Community Support Worker visits for 5 days £500 to help Robert with his medication.

Whilst in hospital, Albert’s wife says she is finding it difficult to cope with Albert at home so a care package is discussed.

Robert’s nurse remains in phone contact with him £56 and visits again a week later £100. She reviews his medication and adds inhaled steroids £10, checking his inhaler technique also.

Delays in putting the care package in place mean that Albert stays in hospital for 21 days. 21 day stay = £2,779

Robert feels his breathlessness is limiting his activity. After discussion he agrees to be referred for pulmonary rehabilitation £100 and an OT assessment £100.

Albert is discharged home without any outpatient follow up or changes in his medication.

2 months later, Albert has another exacerbation. He is admitted to hospital again and whilst there he contracts hospital acquired pneumonia.

Robert’s nurse also books him an appointment at the Community Clinic to see a consultant £200 to rule out any other problems.

Albert becomes very poorly and stays in hospital for 18 days. He is eventually discharged home on oxygen therapy.

18 day stay = £2,779

As winter is approaching, Robert’s nurse signs him up for the Met Office Forecast Alert £23 so that Robert knows what to do when very cold weather comes.

Albert and his wife are anxious about the oxygen therapy £100 and as they are not sure when to use it, they call out the GP. £200

Robert’s nurse visits him again a month later £100. He continues to get better and she books a phone call with him in 3 months time £23. Robert knows he can ring her at any time in between for more support £56.

Robert remains at home and well for a further 9 months.

The bottom line:

The bottom line:

Total Cost £6,168

Total Cost £1,411 Saving £4,757

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KMHIS – a commitment to Green IT at the heart of healthcare Kent and Medway Health Informatics Service is an NHS organisation providing IT services to health, social and third sector organisations Kent and Medway Health Informatics Service (KMHIS) takes green IT seriously.

We understand that the world’s resources are finite and that as an organisation we must try to minimise our impact on the environment – and not only ours, we want to help our clients achieve this too.

In response to the plethora of government (and other organisations’) initiatives – carbon emissions to be cut by 20%; saving carbon, improving health; the EU’s code of conduct on data centre energy efficiency; the Climate Change Act – we have created a Sustainability Strategy.

David Ovenden, KMHIS director, comments: “We want to shout about our commitment to reducing costs and improving efficiency, conserving natural resources, meeting legislation, being an exemplar of best practice, as well as sharing environmentally beneficial solutions and best practice with clients.”

David adds: “We have developed key services to ensure that these commitments are met.”

Asset and applications management

Over-provision of IT systems is an obvious waste of resources, whereas under-provision may lead to inefficiencies elsewhere in an

David Ovenden, KMHIS director

organisation – for example staff queuing to use a PC or terminal will impact on productivity.

KMHIS uses a Configuration Management System and the Asset Management application to monitor the allocation and configuration of PCs and terminals in the client’s workforce.

These systems are also used to provide service support and general infrastructure management. KMHIS is working towards providing this data directly to clients to allow them to rationalise their infrastructure according to need.

In addition, David says: “Consolidation and reduction in the overall number of applications will have a resultant effect on the computing resources required to run the consolidated application set. KMHIS works with clients to ensure they have conducted an audit of applications by January 2012 and to implement reduction and consolidation of applications throughout 2012.”

Virtual servers Many user applications are run on dedicated servers that are often under-utilised as standalone servers. Understanding the load profile and resource requirements of servers, services and applications is essential in order to optimise infrastructure architecture and drive up the utilisation of the underlying computing resources.

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David says: “Virtualisation is used by many of our clients to pool the underlying physical server resources and run several virtual servers per physical server. Three years ago, we implemented this for one of our customers saving over £200,000 in the first year based on the reduction in number of physical servers required. The Trust went from 48 down to one standalone server. Not only did it minimise energy usage, which should save in excess of £6,000 per year and reduce the impact on the environment, but it is a huge space saving for the Trust too.”

Whole life impact of IT systems Whole life impact includes manufacture, assembly, distribution, implementation, operation and disposal. David says: “We work with our clients to ensure appropriate procurement and that the various rules and regulations that are in place to reduce environment impact are met. We cannot stress enough the importance to set requirements and ask questions during the procurement process about the production and transportation methods used. This information can then be used to influence the purchasing decision in favour of those systems and services that have less impact on the environment.”

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Data centres and hosting environments

Computing resources should be, where possible, located in facilities that have been designed for that specific purpose and where the power and cooling are optimised. Industryleading data centre facilities now operate using filtered fresh air to cool the facility with mechanical cooling only required when the outside temperature rises above 25oC. This leads to very high power usage efficiency.

David says: “KMHIS has commissioned work to look at options to determine the best way forward for data centres across Kent. We want to minimise energy usage in terms of the server and network communications equipment located in these centres and also reduce air conditioning and lighting needs.”

During 2011, KMHIS worked with the Medway NHS Foundation Trust to build a new data centre that met all the necessary requirements. Energy efficiency, high resilience and exceptional value for money were the drivers for the new state of the art data centre at Medway NHS Foundation Trust.

The data centre is now the primary hub for the Trust. It works in conjunction with the existing IT centre to provide a high level of IT resilience for the Trust’s storage, servers and network cores. In normal use, the new and old data centres work together, but they also act as back-up for each other.

Mark Bishop, Infrastructure Manager for KMHIS at Medway FT, comments: “This data centre is by far the best we have built in Kent. Energy efficiency was an important

factor in this build because as a rule, data centres are a major source of power consumption. By having lots of specific measures in place, including energy-efficient air cooling and UPS units, a hot aisle and a higher than normal operating temperature for the room, the Trust is able to reduce its energy consumption.”

Benchmarking and the Green ICT Workbook KMHIS recommends the use of the Green ICT Workbook as a standardised action recording and reporting tool. David explains: “The workbook brings together a set of agreed best practice recommendations and techniques to reduce the environmental impact of ICT. It contains actions that can be implemented immediately that reduce the environmental impact of IT systems. The workbook also acts as a tool to benchmark progress against implementing the actions. It has been designed to be used as a single source of advice and best practice relating to green IT.”

The future’s green It’s a busy time for KMHIS – we are hoping to do so much more with our clients. David says: “We are exploring a number of concepts and technologies with our clients that can further improve our green status. It’s very exciting – there are endless possibilities for green IT in healthcare and elsewhere.”

About Kent and Medway Health Informatics Service Kent and Medway Health Informatics Service is an NHS organisation providing a portfolio of IT services to health, social care, third sector and private organisations.

Employing over 250 people based at sites across Kent, we have a user base in excess of 30,000.

We provide complete solutions, seeing them through from initial planning, to development and day to day running.

To find out more contact David Ovenden.

E-mail: david.ovenden@nhs.net Visit: www.kmhis.nhs.uk

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How GE is rethinking the role of technology to address the UK’s healthcare challenges Michael Smeeth, Director of Healthcare Infrastructure for GE, explains how GE’s technology can help the NHS create efficiencies, new services and meet carbon emissions goals.

The NHS is the source of much national pride in the UK, but it is currently facing many challenges on different fronts. It is coming under increasing pressure as the cost of healthcare rises and the Government is forced to make cuts across all areas of public services. At the same time people have ever-growing expectations of the quality, range and type of care that they want and expect from the NHS, adding to the pressure that it already faces.

efficient sources of energy, the reduction of emissions, and the supply of abundant sources of clean water. Since then, we’ve been using our unique energy, technology, manufacturing and infrastructure capabilities, honed over

In addition to this, GE launched healthymagination in 2009, which is our six-year, £4 billion strategy for taking on one of the toughest challenges: global health. Our mission is to help provide better health for more people at a lower cost.

With 1.3 million people working for the NHS, cutting the budgets of the largest national employer is politically difficult and can affect the services and hospital staff that we all rely on. Meanwhile, the health service is increasingly having to tackle other issues. For instance, hospitals consume on average three times the energy of an ordinary commercial building, in fact the NHS in England is one of the largest consumers of energy in the country, with a spend of nearly £600 million annually.

It is, therefore, not surprising that in January 2009, the health service pledged to reduce its carbon emissions by 80% by 2050. With this drive to cut both costs and carbon footprint, hospitals and other health organisations are having to look at new ways to save money, by identifying where reductions can be made without cutting key staff or frontline services.

We are investing and innovating in ways that break through cost, quality and access barriers to health, for individuals and entire health systems. We believe that more effective technology and cost-efficient delivery mean that more lives can be touched.

Over the next few pages we will show you some of our innovative solutions and technologies that we believe could help you achieve your goal of providing more and better healthcare for less cost.

In 2005, GE launched ecomagination to address critical challenges such as those that the NHS faces; the need for cleaner and more

INNOVATION IN HEALTHCARE

more than a century of experience, to develop solutions that deliver impactful results across a wide range of industries. It is our belief that we have been presented with a false choice: great economics or great environmental performance. We believe that through innovative thinking we can design, deliver and therefore achieve both.

Michael Smeeth believes that GE’s technology can help the NHS to achieve more with less

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The cross GE Landscape in Healthcare Care Innovations »» Telemedicine & remote care »» Enables independent living & early discharge

Solar »» Self generation to take advantage of renewable subsidies

Combined Heat & Power »» Distributed co-generation of heat & power »» Significant ROI

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Lighting »» A complete range of cutting edge energy saving lighting solutions, both indoor and outdoor

Intelligent Platforms »» Prophicy & Habiteq solutions »» Provides energy usage data & automated controls

Healthcare IT »» Patient information available quickly at the point of need

Performance Solutions »» Using technology and consulting expertise to take organisational performance to the next level

Diagnostics & Imaging »» Traditional diagnostic products including MRI, CT, ultrasound & Xray Electric Vehicles »» Energy efficient fleet management solutions »» Award winning charging stations

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Combined Heat and power (CHP) GE in the UK is helping the NHS in its effort to provide more with less, not just with healthcare solutions, but in other innovative ways.

One recent example of GE making a positive contribution to UK healthcare infrastructure beyond its healthcare expertise is an awardwinning project involving GE Energy.

GE Energy UK has been working with Clarke Energy, a power generation and green energy specialist, to reduce energy costs and improve carbon savings at London’s Guy’s and St Thomas’ hospitals. Two of GE’s 3MW Jenbacher combined heat and power (CHP) engines for natural gas have been installed – one at each hospital site – cutting the hospitals’ annual energy bills by £1.5 million and reducing their carbon footprint by 11,000 tonnes of CO2 per year. The project is expected to pay for itself in a matter of years.

The Jenbacher units were installed in the summer of 2009 and officially launched by Ed Miliband (the then Secretary of State for Energy and Climate Change). They provide the hospital sites with all of the heat and hot water needed in summer and half the required heat in winter, as well as providing half of the hospital’s electricity needs. The waste heat generated by the plant, in the form of steam and hot water, is collected and used to supply the heating and hot water for the hospital.

Also, as the CHP units are located within the hospital grounds, this means that virtually no electricity is lost during transmission, so they are also highly efficient.

The CHP units have helped the hospitals exceed their 20% emissions savings target in the first year. As Alexandra Hammond, sustainability manager for Guy’s and St Thomas’ NHS Foundation Trust explained: “We did look at alternatives but it quickly became clear that in terms of both financial and carbon savings, CHP was the most effective choice.”

In January 2010, Guy’s and St. Thomas’ also became the first NHS foundation trust to win the Mayor of London’s Green500 Platinum Award, as well as the Green500 Trailblazer Award for its outstanding achievements in carbon reduction.

is ideal for those who have trouble being still or feel claustrophobic in larger MR scanners – a more comfortable patient is less prone to accidental movement during the examination, which means that images are likely to be even clearer and more consistent.

Innovation in diagnostics

As one patient, a footballer, put it: “I think the key word is ‘mobility.’ For you to be able to move around the machine, and the machine actually working to adapt to your injury, I think is the greatest experience for any athlete, or anybody. This is definitely for me!”

Through the Healthymagination strategy, GE Healthcare is also developing technology to create more efficient hospitals and improve the efficiency of busy radiology departments.

This innovative project was the UK’s only successful nomination for the 2011 Sustainable Energy Europe Awards One of the many Healthymagination products already launched is the Optima MR430, an extremity MR (magnetic resonance) scanner that resembles a very large doughnut, with a separate chair. A huge leap forward in MR technology, it delivers precise imaging of the arm, including elbow, wrist and hand; or the leg, including knee, ankle and foot, while allowing a patient to recline on a comfortable padded and adjustable chair. It

In keeping with Healthymagination’s goal to create more access to healthcare, an advantage of the scanner is that it can alleviate the demand on a full-body scanner. As an addition to a busy radiology department, the system can relieve patient backlogs and boost efficiency. Its small footprint allows for easy siting and low installation costs, while the lightweight magnet fits through standard-sized doors.

A further example of innovation in diagnostics is the Vscan, a pocket-sized visualization tool providing black and white anatomic and colour -coded blood flow images in real-time.

It can easily be integrated into physical examinations allowing physicians to add a visual inspection into the body. The images are generated based on ultrasound technology.

Vscan is handheld and helps to enable personalized use at the point of care. It can be used by physicians who are interested in enhancing the way patient examinations are done today.

Vscan is optimized for clinicians who want a quick inspection of the heart, abdominal organs and urinary bladder and will provide

This project was also the UK’s only successful nomination for the 2011 Sustainable Energy Europe Awards Competition for excellence in energy production, reaching a shortlist of 27 energy projects across Europe from a pool of 300 entrants.

Installing Jenbacher units at Guy’s and St Thomas’ hospitals has slashed energy bills

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Top, the Optima MR430 scanner delivers precise imaging; left, the pocket-sized Vscan produces colour-coded bloodflow images

Lighting One area in hospitals that falls under scrutiny when energy savings and costs are being considered is lighting. Good lighting plays an important role in the healthcare process and in the past there have been urban myths perpetuated about the quality or lack of light delivered by energy efficient lighting.

GE has long been a key player in the lighting industry, as it was founded by Thomas Edison, inventor of the commercially producible light bulb. GE debuted its fluorescent lighting fixtures at the 1939 New York World’s Fair and the technology swept into widespread use during World War II as people sought ways to conserve energy. GE is a world leader in energy efficient lighting, with a series of products ranging from highly efficient lamps designed for retro fitting to the cutting edge, such as LED edge lighting.

insights into areas of OB/GYN, pleural fluid and motion detection and paediatrics.

For primary care clinicians, Vscan has the potential to help redefine the physical examination, providing an immediate look inside the body to help speed detection and diagnosis. Vscan allows critical care clinicians to look beyond patient vital signs, offering the potential to identify critical issues, such as fluid around the heart, a possible sign of congestive heart failure. For cardiologists, Vscan provides a dependable visual evaluation at a glance of how well the heart is pumping, allowing more efficient patient treatment.

Performance Solutions GE Healthcare’s Performance Solutions team is also helping health service providers to deliver higher levels of efficiency, and ultimately a better quality of care, to more patients as Joe Rafferty CEO of Central Lancashire PCT explains: “At NHS Central Lancashire, our investments in developing a culture of leadership and accountability over the [past 18 months] are starting to bear visible fruit. We’ve been working with GE Healthcare Performance Solutions as a change partner because

we saw the need to get this right sooner rather than later. We see the resilience and accountability within their organisation that we have been unwilling or unable to develop on our own. The money we’ve invested with them has been more than returned, not only in our documented cost savings but perhaps more importantly in the reduced timeline by which we are delivering on our strategy and making the needed changes to systems, tools and culture in our organisation to meet the looming financial challenges,” Andrew Reed, CEO, Ipswich Hospital NHS Trust said of Performance Solutions: “The future is uncertain but change is inevitable. By developing a partnership with GE Healthcare Performance Solutions, we are tackling our challenges head-on. Selective use of consultancy is very important because it can offer the speedy development of new skills and quicker implementation of complex programmes of work. GE has become our trusted advisor and the support that we can depend on when we’re facing such large and complex challenges. This prudent investment in external support is providing substantial returns in terms of quality of care, financial productivity and cultural change,”

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An example where a different approach to lighting has had a big impact is at the Queen’s Medical Center (QMC), Honolulu, Hawaii. Its energy costs were averaging $375,000 a month and increasing every year, plus oil price increases were regularly passed on to QMC by utilities in the form of “energy cost adjustments.”

“Our base kilowatt consumption wasn’t increasing substantially,” said Michael Kim Seu, manager of general maintenance for the hospital, “but our energy costs were just climbing ever upward.”

To contain costs, the facility implemented an enterprise-wide energy initiative, which included a comprehensive lighting retrofit.

“We would be doing a disservice to our community, our patients, our staff and all QMC stakeholders if we didn’t aggressively seek out ways to improve our facilities and our bottom line,” said Dennis J Burns, manager of facilities and biomedical engineering.

The hospital’s administrative council wanted proof that a large investment in new lighting technologies would provide a substantial and immediate payback. So GE worked with QMC to show how a new mix of GE Consumer & Industrial lighting products could lower QMC’s overall cost of light.

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Energy-efficient bulbs can provide better light than traditional ones and deliver savings

The team demonstrated new GE technologies and products alongside existing solutions in use at QMC so they could see firsthand how newer, more energy-efficient lighting solutions could lower energy and maintenance costs with less of an impact on the environment.

The process involved removing over 22,300 linear fluorescent lamps and over 15,000 standard electronic ballasts. These were replaced with highly efficient GE linear fluorescent lamps and UltraMax® ballasts.

“Our patients, staff and security team have all had high praise for the new lighting, which provides equal or better light output and better colour rendering than the previous system,” said Seu. After the forecasted 18-month payback period for the full project QMC has realized savings of $375,000 per year and as a bonus, the retrofit netted QMC over $100,000 worth of rebates from Hawaiian Electric Company.

“This major lighting retrofit project utilizing exclusively GE lamps and ballasts is one of several energy-reduction programs that are ongoing at our hospital and it has had the greatest impact on the reduction of energy,” says Kim Seu. “The large monetary rebates and the reduction of power from this retrofit had a direct impact on our utilities bottom line, which equates to more cash flow for patientcare personnel and equipment.”

Electric Vehicles Electric vehicles (EVs) may not immediately spring to mind when considering innovative and new ways of saving money and delivering better healthcare services, but when you consider how many miles NHS staff drive each year during the course of their jobs then the numbers are staggering.

Community staff, such as health visitors, district nurses and out of hours GPs drive many miles during their working day and this

The award winning GE WattStation charges electric vehicles as part of the smart grid

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number is set to rise as more people have their care delivered in a community setting.

The potential savings for a Trust of having a fleet of electric vehicles can be significant when compared against the cost of paying for staff to drive their own cars. On top of this there are other benefits. EVs are less polluting, particularly when recharged using sustainably generated electricity, they also ensure that the Trust is able to provide a consistent and high quality vehicle, which maximises staff availability and, if desired, they can also be liveried to promote the Trust. Providing cars for staff also means that those without their own cars are not precluded from these roles.

One of the issues around EVs is that without a well-developed charging infrastructure people are unlikely to buy an EV, and without more people buying them then no one is likely to invest heavily in creating that infrastructure.

At GE we take the view that both need to happen together, so we have developed the award-winning GE WattStation EV charging station and also pledged to purchase 25,000 electric vehicles. GE also runs one of the largest car fleet leasing operations via GE Capital. This allows us to offer a complete solution to Trusts by combining infrastructure, vehicles and financing. GE is also developing cutting-edge technology for EVs themselves. In fact, more than 70% of hybrid electric vehicles on the road today rely on GE innovations.

By 2010, our research activities were in full swing. While scientists and engineers in GE’s Global Research headquarters in Upstate New York slept, their colleagues in China and India were performing in-depth research to find the right material configuration. As the Asian workday came to a close, GE scientists and engineers in Munich, Germany, the heart of the solar industry, were just getting started.

Using state-of-the-art solar testing facilities, they assessed the overall system performance of our panels to see if what we had was scalable into a best-in-class product.

As the sun reached its peak in Munich, researchers at GE’s Global Research headquarters in Upstate New York made their way to work. In the lab, they developed cell sample after cell sample. They tested thousands of different configurations, with each one telling them how to push efficiency and performance ever higher. Throughout the process, the Upstate New York team worked seamlessly

with Primestar’s team as cell designs were replicated in modules on their 30MW pilot manufacturing facility in Colorado.

GE’s record-setting solar panel was a fitting close to the chapter of research in 2010, but the work goes on. With ambitious commercialization plans and the solar industry more competitive than ever, GE researchers already have second, third, even fourth generations of solar panels in their sights.

In addition to developing class-leading technology, GE via GE capital has created a bespoke funding model for the NHS. This allows Trusts to access the benefits of solar technology with a shared risk reward approach that brings greater potential financial benefits to the Trust whilst allowing them to retain ownership and control of their roof space.

In the words of GE’s founder Thomas Edison: “I’d put my money on the sun and solar

We believe that an EV solution can provide significant financial savings, as well as environmental benefits for Trusts.

Solar GE is a leader in solar technology and has worked hard to develop a highly efficient product. In December 2010, GE researchers set a world record of 12.8% for thin film solar panel efficiency. This achievement was made possible in a short time by our global team of technologists, working around the clock across three continents.

We were fortunate to start from a great foundation. In 2007, GE Energy invested in a small thin film solar start-up, Primestar Solar Inc, as Primestar’s cadmium telluride (CdTe) technology matched up well with GE’s diverse research capabilities.

GE’s record-beating thin film solar panel technology is incredibly energy efficient

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energy. What a source of power! I hope we don’t have to wait till oil and coal run out before we tackle that.”

Operating the intelligent Hospital and healthcare building

The first concern of any hospital trust is to heal and to maintain patients in a safe environment. So, in a modern hospital that functions with many technologies, including fluid and energy, it is vital to keep technologies running at their highest performance 24 hours a day.

To fully understand, manage and derive the greatest financial return from its building operations, the Trust must be able to visualize, analyze and optimize every aspect of its processes, equipment and resources.

GE Intelligent Platforms (IP) provides the tools, equipment and processes needed for a Trust to achieve the most from its buildings.

It is not just a building management system, but a complete energy management system.

GE IP is successfully in use in hospitals in 17 countries including the UK. A recent installation was undertaken at a major hospital in France with a capacity of 2,900 beds and 10,000 employees, spread across several buildings.

The scope of the French project included: »» Deployment across multiple sites »» Heating and air conditioning »» All critical equipment: including elevators, incubators, scanners »» Electrical distribution »» Temperature, hygrometry, pressure data acquisition and monitoring »» On-line alarming integration The system provides continuous monitoring and data collection, high performance reporting and data integrity as well as solution redundancy to ensure continuous operation.

This has enabled maintenance personnel to prevent the failure of all devices and maintain a safe environment, as well as making a significant contribution towards reducing energy, carbon and, importantly, costs.

Innovative financing solutions for a financially constrained

NHS

New innovative technology and solutions are often not implemented in the NHS, not

because of a lack of willing or understanding of the potential benefits, but because the Trust is unable to access capital to invest.

This has meant that in the past many Trusts who could have benefited greatly from the huge savings in cost and carbon delivered from technologies such as combined heat and power (CHP) generation, as provided by our class leading GE Jenbacher engines, have been unable to do so.

As well as developing innovative technology GE also has a proud history of developing innovative financing solutions designed to specifically meet the need of customers. Healthcare Financial Services is part of GE Capital and has wide-ranging experience of developing funding solutions for the NHS, particularly for diagnostic and imaging products. GE Capital has also developed a range of new financing solutions tailored specifically for the healthcare sector and the NHS in particular. These solutions enable NHS organisations to access the benefits of many of the technologies that you have been reading about on previous pages while also offering excellent value.

Looking ahead, GE will continue to help the NHS take a fresh and creative approach to tackling the challenges of the day, enabling it to focus resources on providing access to the highest standards of healthcare provision.

For more information or to discuss how we could help your organisation please contact:

Michael Smeeth, Director of Healthcare Infrastructure, GE E-mail: michael.smeeth@ge.com Tel: 020 7302 6475

One particular example of this is our new managed equipment service approach to funding CHP technology for the NHS, which enables Trusts to access our GE Jenbacher engines with no upfront capital requirement. The savings means that the Trust is usually able to save more in energy bills than it pays for the CHP from day one, while retaining control of its hard FM and estate if desired.

Whether you are growing a new, leaner hospital from the ground up, or targeting specific areas of your existing facilities for greater returns, GE can help bring new efficiencies and savings to every area of your facilities.

Our broad portfolio of products and services can help reduce energy demand, conserve water, generate renewable energy onsite, maintain air quality, reduce waste, improve staff productivity, patient satisfaction and clinical efficiency.

As all these examples illustrate, GE is enabling many parts of the NHS to achieve important process efficiencies and financial savings while at the same time protecting the vital frontline services we have all come to rely on.

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Why the NHS needs to get up close and personal Chief Executive Ian Gillespie, from Vanguard Healthcare Solutions Ltd, discusses the implications of the Health and Social Care Bill with regard to clinical commissioning groups and mobile solutions, and suggests it is not a question of ‘them and us’ but a collaborative approach between the private sector and the NHS required to find cost efficient answers.

The Health and Social Care Bill 2011 represents probably the most significant and farreaching shake-up of the NHS since it was set up in 1948, and will be implemented at a time when the UK is facing one of the biggest financial challenges in its history. The reforms to legislation are contentious by any standards, and there is growing professional opposition to some of the aspects which could undermine the reforms that the government is trying to make.

Two of the main aims of the reforms are to improve quality of service provision for patients, and to make health services more patient-focused. Unsurprisingly, these com-

mon goals attract widespread support from both public and private sector providers, and one of the mechanisms for achieving those ideals is to create a service that is more localised for the general public. This means creating a National Health Service that is successfully managed and controlled within the communities it serves, and is necessarily responsive to the needs and concerns of patients. The ideal situation that the government hopes to achieve is to create an NHS where clinical professionals work collectively across previous organisational divides, and collaborate together in order to provide high quality healthcare services that are consistent, effective and efficient. The system would be

one where the clinicians take charge of creating care pathways and have full responsibility for the use of resources available.

One reason why this legislation is so contentious is due to the concerns surrounding the development of competition in the delivery of healthcare, the requirements to perhaps increase the role of the private sector providers, and the increased use of new procurement methods, such as Any Qualified Provider (AQP).

However, rather than discussing the pros and cons of the politics, or even suggesting further changes to the Bill that would perhaps attract greater support, I intend to focus instead on practical implementation and how the use of the private sector, in particular mobile solutions, can help the UK public healthcare system thrive under this new regime where patients may more appropriately be deemed as customers, rather than solely statistics to be juggled around according to a ready-made formula cooked up by civil servants.

State-of-the-art facilities inside a Vanguard endoscopy procedure room

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Delivering a localised service, closer to home – Vanguard’s mobile Day Surgery Unit

Bringing healthcare closer to home

Under the proposed reforms, commissioning consortia will continue to be made up of groups of GP practices across the country in regional locations, but the government is now making a number of changes to try and provide greater assurance that commissioning of services and provision will involve patients, carers, the public and a wide range of healthcare professionals. These local NHS organisations are no longer being called GP Consortia, but have been renamed as Clinical Commissioning Groups (CCGs).

This all sounds positive, but as a company we are continuing to see that most CCGs are unclear on practical implementation and responsibilities thus far. As we find friendly Installed on-site with an expert team and minimal disruption, within just 2-3 hours

Typically there are a number of treatments and procedures that would normally be carried out in local community locations, such as wheelchair provision, back care, podiatry and pressure ulcer treatment, amongst others.

These and other suitable services will now be open to provision from an increased selection and choice of healthcare provider. faces to sit down with, we start to learn more about how the reforms will affect our own service provision, enabling us to engage further with others in a similar situation.

The Any Qualified Provider (AQP) scheme supersedes the previously named Any Willing Provider, and is quite simply a mechanism put in place to help extend choice for patients and help to increase community based services.

industry. Primary Care Trusts have been able to invite other private sector providers into their services for the last couple of years, with varying levels of success. The basic principle is that we should be moving a large amount of patient care from acute hospitals back into the community, where clinically appropriate.

Whilst it was Roosevelt who said we have nothing to fear but fear itself (or words to that effect), it is true that the NHS must reinvent itself and place innovation at the heart of what it does. To accept anything less than efficiencies and an improved system when there is so much at stake is not an option.

This was thought to be one of the biggest policy initiatives; however, this is not a new practice but simply one that is being underscored with more force. Though it is simply an extended version of something that has already been tentatively tabled, it still is the cause for much debate in the healthcare Making its way to the next location – a mobile healthcare unit takes to the road

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Providing additional capacity – a Day Surgery Unit recovery ward area make any mistakes easier to rectify and much less of a problem.

Conclusion I would like to encourage Primary Care Trusts, clinical commissioning groups and other healthcare professionals, to start thinking collaboratively and on an innovative level, committing to cost efficient and longer term contracts and partnerships with organisations outside of the NHS ‘family’. It is not a question of them and us, but more properly of ‘all together’ providing solutions. Custom and practice from years ago needs to be readdressed and new models adopted. Providers should be invited to come up with proposals as to how they can help supply services within communities, free-up space in larger acute

hospitals, and increase treatment and investigative procedures in a less expensive clinical environment that is also closer to home. Community hospitals need to be able to deliver services, and mobile facilities can help bolster capacity and levels of treatment available.

The advantage of a mobile solution is just that: it is not fixed. An attractive option in opposition to investing in the building of new permanent facilties long term, which cannot be altered if unsuccessful, is to try a mobile unit in one location; if requirements need to change over time then try it in another. The model exists to offer flexible solutions, and

One thing is clear, clinical commissioning groups will try many things in the light of the latest reforms, and some will work whilst others will fail. Vanguard Healthcare is able to draw on its experience across the country to talk through regionally specific issues and problem solving innovations. We have worked with the NHS successfully for over 12 years and boast directors and staff who have a proud and respected track record for many more years in public and private sector health provision.

The key to reforms surely is to accept that change is needed, to retain all of the founding principles which have made universal access to free healthcare a watchword globally, and to adopt some long held principles of business.

In this way, we can look forward to a healthy system of patient care in the UK, which embraces efficiencies and delivers against the mandate of access and provision of worldleading healthcare at a local level.

The power of mobile healthcare: artist’s impression of a flexible ‘healthport’

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A lifetime of good oral health Trisha Rawsthorne, professional education manager for Philips explains why preventing periodontal disease is vital to patients’ health We are living longer and healthier lives and are more likely than ever to keep our teeth for a lifetime than we were even a decade ago.

However, the oral health status of older people is still a cause of concern as they have the highest rates of periodontal disease and need to do more to maintain good oral health.

At least half of non-institutionalised people in westernised countries over 55 have periodontitis and almost one in four people aged 65 and older have lost their teeth. Receding gum tissue affects the majority of older people and periodontal disease and tooth decay are the leading causes of tooth loss in older adults.1

It is also concerning to note that a major cause of joint replacement failure is infection, which can travel to the site of the replacement from the mouth in people with periodontal disease. Recent research has also advanced the idea that periodontal disease is linked to a number of major health issues, such as heart disease, stroke, respiratory disease and diabetes. Older people with loose and missing teeth often have restricted diets since biting into fresh fruits and vegetables is often not only difficult, but painful, making it more likely that the elderly will not achieve a proper level of nutrition. Other risk factors that may make older people more susceptible include their

weakend health condition, menopausal status, lowered immune system, side effects from medications, depression, worsening memory, diminished salivary flow and functional and dexterity impairments.1 New research has also confirmed that people with mental disabilities, including depression, anxiety or dementia, have significantly lower levels of oral health. New concepts on how to approach and treat those patients will have to be developed, according to Dr Kuan-Yu Chu from the Department of Dentistry, Tao-Yuan General Hospital, in Taiwan, who carried out the research.

Even if they have successfully navigated this minefield of risks and avoided periodontal disease, it is especially important for such patients to practice a meticulous oral care routine, since receding gum tissue affects a large percentage of older people and this condition exposes the roots of teeth and makes them more vulnerable to decay and periodontal infection as they age.

Power toothbrushes like the Sonicare FlexCare+ are ideal for patients with limited dexterity or disability

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Evidence suggests that patients with poor oral health are more at risk of developing lung infections

However it is not only elderly or mentally ill people who are vulnerable to impaired oral health. Considerable evidence exists to suggest that patients in hospital are at risk. A study published by the American Dental Association described the relationship between poor oral health and the oral microflora and bacterial pneumonia, especially ventilator-associated pneumonia in institutionalised patients. Teeth or dentures have non-shedding surfaces on which oral biofilms (that is, dental plaque) form, which are then susceptible to colonisation by respiratory pathogens. Subsequent aspiration of respiratory pathogens shed from oral biofilms into the lower airway and increase the risk of a lung infection developing. In addition, patients may aspirate inflammatory products from inflamed periodontal tissues into the lower airway, contributing to lung insult.2 Oral healthcare is also an essential component of daily hygiene for long-stay hospitalised patients, and nurses and auxiliaries have an important role in helping patients maintain an acceptable level of oral health. However, it has been suggested that nursing students are graduating with an insufficient knowledge of oral healthcare for hospitalised patients.

In a recent study, four groups of senior nursing students revealed gaps in their knowledge of, and rationale for, oral health care procedures for hospitalised patients. However, the subjects also indicated a high level of interest in improving their ability to offer appropriate oral care services.3 Meanwhile, a study in the International Journal of Dental Hygiene published in 2009 concluded that “a majority of [hospitalised] patients need oral health care; poor oral hygiene and accumulation of dental plaque are the most evident problems and may lead to gingival inflammation. The majority of patients presented with infections in the mouth and some of them are described as risk factors to worsening systemic health status. Ageing and health conditions seemed to be associated with periodontal health. Ageing is related to tooth loss and the latter is a factor associated with eating difficulty. A future action of a dentistry professional in hospital facilities may contribute to ameliorate oral health problems, and to some extent, the systemic condition and feeding of hospitalised patients.” 4

Brushing up on oral health care For patients with poor oral hygiene, exacerbated by dexterity problems or a physical disability, dental professionals often recommend the use of a power toothbrush and the Philips range of sonic toothbrushes, and in particular the Sonicare FlexCare+, are especially suitable for patients with periodontal disease who require advanced care to improve and manage their conditions. By encouraging patients to use it, dental and healthcare professionals can reassure themselves that they are providing the next best thing to being there to brush their patients’ teeth with them.

Sonicare FlexCare+ in particular makes it easier for patients to get to grips with effective cleaning, since it does the lion’s share of the brush work for them and it features a ergonimally designed handle that is both easy to manoeuvre and grip. It also makes it easier for a carer to tend gently and effectively to the mouths of their elderly or sick charges.

In addition, FlexCare+ has a number of advanced functions, the most pioneering of which is a Gum Care Mode. This mode encourages patients to brush for longer and allows them to target specific areas of concern. On this three-minute cycle, patients can target places that need more attention in order to improve their oral health; particularly the gingiva, both interproximally and along the margins. The Gum Care cycle starts with two minutes of whole mouth cleaning and is

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followed by another minute of gentle, site specific cleaning for the most problematic areas.

In clinical studies1, it has been shown that patients brushing with FlexCare+ in its Gum Care Mode brushed for significantly longer, and as a result reported back with fewer bleeding sites than those using a manual toothbrush. Notably, returning patients who took part in the trial, showed significant improvements in their gum health in just two weeks. When patients can witness such measurable results in as little as a fortnight, they are encouraged to keep up the good work and maintain the return on their investment.

It is also important that the brush head is properly cleaned after use. The FlexCare+ head can be placed in the brush charger’s built-in UV sanitiser after brushing, which kills 99% of microorganisms5 and so ensures that it remains germ free. For any older or hospitalised patient who is at greater risk or immunologically compromised this provides an additional level of reassurance.

No strings attached After tooth brushing, flossing is considered by many to be the second most important preventative measure patients should take against tooth decay and gum disease. Yet research carried out by Philips revealed that 82% of respondents cited flossing was “too difficult”, “too time consuming” or “difficult to remember”.6 Its answer was to develop Sonicare

INNOVATION IN HEALTHCARE

Philips’ research shows that many of us find traditional methods hard to achieve

AirFloss, a hand-held powered device which uses forceful bursts of water droplets and air propelled at 45 miles per hour to remove plaque and food particles from between the teeth in less than a minute. The device is easy to grasp and manipulate, and features a long nozzle to extend to the spaces between the teeth at back of the mouth, so that the user no longer has to reach inside their mouth to clean effectively.

The reservoir in the handle can be filled either with a teaspoon of water or mouthwash so that dental and healthcare professionals can ensure that those in their care can be effectively dosed with the medicated rinses they prescribe to treat periodontal disease.

The implications of this new innovation have impressed Professor Edward Lynch, Head of Dental Education at Warwick Dental School, Warwick University and regularly voted one of the most influential voices in Dentistry.

Professor Lynch, who has a special interest in Gerodontolgy, recently presented at the International Conference for Anti-Ageing Medicine in Westminster, during which he extolled the virtues of Sonicare AirFloss particularly for ageing patients “‘Many patients have difficulty using string floss so AirFloss is a great innovation as it is easy, quick and effective to use”. This is because it requires none of the manual dexterity needed to manipulate string floss or interdental brushes.

As we have seen on the previous pages, healthcare professionals have an important role to play in rehabilitating patients in long term hospital care or when treating elderly or vulnerable people in residential care by ensuring their oral health is also attended to. In this way the spread of infection from the oral cavity to the rest of the body can be limited, so lessening the risk of exacerbating a range of systemic conditions. Conversely, good oral health has real health gains that can improve overall health as well as patient’s social acceptability, self-esteem and quality of life.

To find out more about how Sonicare products can help, please visit www.sonicare.co.uk/dp or call 0800 0567 222.

For further information, please contact:

About Royal Philips Electronics

Please visit www.sonicare.co.uk/dp or telephone 0800 0567 222.

Royal Philips Electronics of the Netherlands (NYSE: PHG, AEX: PHI) is a diversified health and well-being company, focused on improving people’s lives through timely innovations. As a world leader in healthcare, lifestyle and lighting, Philips integrates technologies and design into peoplecentric solutions, based on fundamental customer insights and the brand promise of “sense and simplicity”. With headquarters in the Netherlands, Philips employs 119,000 people in more than 60 countries worldwide. With sales of EUR 25.4 billion in 2010, it is a market leader in: cardiac care, acute care and home healthcare, energy-efficient lighting solutions and new lighting applications, lifestyle products for personal wellbeing, plus it has strong leadership positions in flat TV, male shaving and grooming, portable entertainment and oral healthcare.

For more information and news about Philips visit the website, www.philips.com/newscenter.

References 1

American Academy of Periodontology

2

Am Dent Assoc, Vol 137, No suppl_2, 21S-25S.

3

Miller R, Rubinstein L. J Nurse Educ, 1987, Nov;26(9):362-6.

4

International Journal of Dental Hygiene Volume 9, Issue 1, Article first published online: 10 Nov 2009

5

E coli, Strep mutans, Herpes Simplex

6

Milleman J, Putt M, Jinling W, Strate J. Data on file. 2009

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Innovation in other health economies Mainstream telehealth support is a new approach that is positively helping significant numbers of patients with chronic diseases around the world says Giles Tomsett, managing director, of Healthways Europe Clinical commissioners across the UK are experimenting widely with new solutions to support patients to better self-manage their chronic diseases and address modifiable health risks.

pressures. It is currently estimated that people living with long-term conditions account for: »» 50% of all GP appointments »» 64% of outpatient attendances »» 77% of all hospital bed days.

(Source: Dept of Health Aug 2011)

Throughout the developed world there is a real focus on seeking to better manage the growing burden of chronic disease. These diseases have a major impact on quality of life, are a leading cause of premature death, and are responsible for a rapidly increasing share of health spending in all major economies.

Here in the UK, the NHS is continually seeking ways to improve the care of the over 15 million people living with long-term conditions and reduce the number of unnecessary trips to hospital. People with long-term conditions are some of the most frequent users of the NHS. In 2009-10, an estimated £70 billion of total health and social care expenditure was spent on patients with long-term conditions.

The number of people with a long-term condition is set to rise to around 18 million within 20 years – combine this with our ageing population and the NHS faces even greater

personalise services to suit their needs, not fit them around how the NHS is organised.

It is innovative changes like this that will help us create a modern NHS that can respond to 21st century needs.”

Building innovative new

Healthways is a leading innovator in supporting patients and helping health economies find new ways to deliver support services to those patients with chronic diseases. The company demonstrates real examples for mainstreaming these innovative services effectively. In providing well-being services to address key health risk factors, such as smoking, poor nutrition, and lack of exercise in addition to full disease support services for all patients with chronic disease (including their co-morbidities), Healthways continues to learn new approaches to help commissioners and patients meet their goals.

Health Secretary Andrew Lansley recently stated: “We have a vital opportunity now to modernise the NHS. People with long-term conditions have some of the most complex health needs in the country and we need to

approaches

In the late 1990s, the conceptual chronic care model developed by Ed Wagner, emphasised the importance of reordering the care delivery system for people with chronic diseases. It stressed the co-ordination of community, the health system, self-management support, delivery system design, decision support and clinical information systems, with later emphasis put on safety, care co-ordination and case management. The model was taken up across many health systems as a beacon for realignment, but gaps in patient care and the phenomenal growth in modifiable risk factors such as tobacco use, poor nutrition and lack of exercise have continued to challenge all major health economies, and have further reinforced the need to place the patient at the centre of any solution.

The prevailing challenge is to offer patientcentred support that provides: »» Consistent alignment to the doctor’s treatment plan for all patients »» The management of scale with comprehensive, clinically sound advice and guidance for all users based on their personal circumstances and risk needs »» Seamless support upon hospital discharge and within primary care with appropriate signposting support to local health and social service providers.

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During the last decade, many European health systems investigated how best to move forward, leading to recent developments in France to deliver a national diabetes patient support service for all diabetic patients covered by the national insurer, Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés (CNAMTS). The French decision to mainstream their patient support service, called ‘Sophia’, builds from amendments to French law, an authoritative French government report (IGAS), that concluded that such services could benefit the management of diabetes, and the recent completion of a three-year pilot to prove the concept working initially in only a few regions of France.

Helping patients eliminate lifestyle risk factors now will reduce future health spend

About Healthways Healthways has 30 years of experience delivering health programmes across client populations. Healthways’ solutions are designed to keep healthy people healthy, mitigate or eliminate lifestyle risk factors that can lead to disease, and optimise care for those with chronic illness. Our proven, evidencebased programmes provide highly specific and personalised interventions for each individual in a population.

Ten Principles for effective implementation

Key facts:

The development of innovative services always presents various challenges. As Healthways has built new deployments of our services into Europe, Brazil and Australia, the following 10 principles to achieve success have been common to all deployments: 1 Client centred business model 2 Tailored and personalised engagement and ongoing patient support 3 Appropriate segmentation and intensity of support 4 Whole patient approach that will address co-morbidities 5 Focus on behaviour change 6 Interventions built upon local Evidence Based Medicine 7 Self-care education and support 8 Doctor integration and links to local community services 9 Reporting and outcomes 10 Implementation tailored to the unique requirements of each health economy

»» Founded in 1981;

Building on innovation here in the UK and moving forward to address the needs of large chronic disease populations requires UK commissioners to articulate their service objectives fully and win the confidence of local stakeholders. Bringing telehealth services to the mainstream of care delivery necessitates reflection of the needs of the local delivery teams in both primary and secondary care and their current work practices. Healthways has been developing large-scale programmes that offer support solutions to help patients remotely for over 30 years. Healthways’ 10 principles for supporting patients have provided all parties in our deployments with clarity and confidence in adopting the innovation, and in mainstreaming it across the system.

»» Active on four continents; »» Over 38 million lives enrolled worldwide; »» Mission: Creating a healthier world, one person at time; »» Client base: governments, health plans and over 1,000 companies.

Client centred business model Clients throughout the world want either the option of relying on a fully outsourced approach using an expert partner or may choose to buy in the tools and expertise to facilitate running telehealth programmes for themselves. The latter enables the client to build competencies, resources and operating platforms that can be leveraged for wider strategic purposes. Local commissioners need to choose which option supports their local plans most appropriately. In Australia, the state of New South Wales has opted to outsource to Healthways’ nurses, whereas in France, the national health client has opted to licence the Healthways’ specialist platform and experience, enabling their own teams to deliver effective care. In both cases, a fully local service is provided around the objectives of the client commissioner.

Tailored engagement and support

Healthways’ telehealth support programmes are tailored to individual patient levels of complexity and risks, however large the population under management. These services are built to outreach and support thousands of patients utilising a bespoke technology

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platform able to seamlessly manage interactions with many millions of patients across a range of different chronic conditions. Modes of communication can be via post, SMS or email, in addition to telephonic exchanges.

The action plans built by the expert health coach are totally personal to each individual participant and are designed around their

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Telephone support addresses the patient’s holistic needs and breaks down barriers

Whole patient support To ensure effective support for each individual, Healthways’ experience has focused on the needs for the whole patient and their individual circumstances and not a focus on their disease issues only. The disease of a patient ensures their participation in the programme, but does not define the support which they receive. Telephonic support is valuable in addressing the patient’s holistic needs, as often the barriers to a patient’s progress are not tied to their medical status alone. personal goals and aspirations and, crucially, their own attitude to changing their risk behaviours. Invitations and engagement are designed to reflect the most appropriate methodology within each health system and the client’s own preferences. The most effective routes are the processes that are built around GPs, specialist community nurses and on diagnosis. Service objectives then inform the choices that define the patient engagement and ongoing support.

Segmentation Segmentation into tiers is a dynamic process that assigns the patient effectively to the correct level of intervention, providing the

appropriate resources at the appropriate time and frequency. If data is available under data protection/privacy regulations, there is then an opportunity to create a baseline. If not, the recruitment process that seeks to achieve the participant’s informed consent can be utilised to address the segmentation analysis.

Once identified for the telehealth programme, the patient is initially assigned to one of the agreed acuity levels. The higher a participating patient’s level of acuity, the greater the intensity of intervention. As data is collected from each of the various interventions with the patient, their segmentation can be ‘dynamically’ re-evaluated as new data comes on stream.

Behaviour change The Healthways principles of behaviour modification are based on the research of Dr James Prochaska and the Transtheoretical Model (TTM) of behaviour change. Putting pressure on patients who are not prepared to change does not result in effective long-term changes in behaviour. Consequently, Healthways has successfully applied interventions previously demonstrated to be effective in the treatment of depression, weight loss, stress management and drug addiction. The TTM assumes that for every conscious change in behaviour, a person goes through five specific cognitive stages. An intervention to support change can succeed

Experiences in Germany

Experiences in France*

Programme size: 40,000 called ‘besser leben’ drawn from two regions of Germany

Programme size: In March 2011 over 100,000 patients enrolled via their GPs from 19

Client: Statutory health insurer Deutsche Angestellen Krankenkasse Duration: Three years to December 2010

regions. National coverage by end 2012 Client: Statutory health insurer Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés Duration: Into its 4th year and moving from pilot to national ‘generalisation’

Qualifying diseases: Diabetes, COPD, CAD, CHF

Qualifying Diseases: Diabetes (and co-morbidities) extending to cardiovascular and

Average age of participants: 71

Average age of participants: 64

Staffing: around 100 specialist nurse ‘health coaches’ based in Berlin and regional liaison teams

Staffing: Currently two nurse-led call centres located in Nice and Albi (approximately

Results*: participants had 21.1% fewer hospital admissions than the comparison group (*Published in the journal Population Health Management, Volume 13, Number 6, 2010)

respiratory disease in 2013

80 nurse health ‘councillors’) and set to expand to several more centres over time (likely an additional four) Results: Initial clinical and financial results are positive and satisfaction survey results published by CNAMTS indicate that 80% of the patients in the program are satisfied by the services provided. The same survey suggests that 70% of the participating GPs think that the investment of the CNAMTS in patient education is a positive thing. (* Sophia Point d’information 10 March 2011)

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only if it is tailored to match an individual’s current stage of change.

For Healthways, that means interacting with patients at the appropriate level. It would be impossible to convince a heavy smoker who does not yet have any physical complaints that he should stop smoking if he has no desire to quit. At this stage, explaining serious health consequences can provoke resistance. Only when the patient has moved to the stage where he is considering quitting can the first steps toward changing behaviour be made.

behaviours with symptoms, clinician-patient interactions enable patients to have true ownership of their day-to-day self-care.

The TTM model emphasises the patients’ own responsibility and offers the advantage that behavioural changes can be initiated in a carefully targeted and effective manner by the supporting telehealth clinicians, according to the patient’s assessed readiness level.

Educational materials are a cornerstone of all patient support programmes. Local literacy and health literacy are taken into account when designing and planning interventions and patient education materials. Proven techniques are used to maximise understanding for all reading abilities (text boxes, pictures and diagrams, bulleted points, short sentences) to ensure that readers of all levels can take away key points and basic understanding. It is crucial to work with the commissioner to analyse what materials are already in use, the target population profile (including key demographic and culture information), and the characteristics of its principle communities.

Evidence-based care

Doctor integration and local

All Healthways’ programmes are based on internationally recognised standards of care and evidence-based guidelines. Every assessment and intervention can be traced back to an evidence-based protocol or recommendation that is cited in our software solution. Healthways has built the patient assessments, engagement practices, and goalsetting around the total healthcare needs of the patient, resulting in comprehensive, integrated, and personalised health coaching initiatives. Clinical literature, information, and guidelines (specific to each territory) are continuously reviewed and updated. For every patient record in the system, the commissioner or their GP can access all data and validate the full list of evidence-based references that are in play – all of which align to their own local clinical standards and practice.

links

Self-care Healthways’ programmes are firmly rooted in supporting and promoting independence in self-care. All patients enrolled in these programmes receive ongoing self-care instruction and training specific to their personal diagnoses, as well as information about the corresponding lifestyle and risk issues that are most closely associated with those conditions. In addition, the foundation of the clinician-patient telephonic conversation is rooted in teaching and encouraging self-care strategies and solutions. Whether it is helping a patient understand their key disease metrics, think through medication reminder strategies or teaching a patient to associate

Healthways believes that the fundamental relationship within healthcare is between the patient and doctor. Telehealth services delivered by expert health coaches extend the reach of the doctor’s care and enable clients to effectively introduce this complementary service, supporting both patient and physician.

For self-care to work effectively, a high degree of localisation is needed. This is driven by the subtleties of each healthcare economy in which the service is deployed and is a large part of the implementation methodology. All relevant written communications must emphasise local best practice, initiatives, help groups, and other resources. This is an important component in helping patients best manage and navigate their ongoing care.

The Healthways delivery platform has been designed to support the relationship that the patient has with his or her physician and associated health and social care providers by anticipating and understanding individual needs, working within established evidencedbased protocols, communicating effectively about the status, needs and progress of the patient, and supporting everyday clinical practice. Next appointment dates with these services are captured and patient phone calls are scheduled accordingly. Our interventions specifically support the physician’s treatment plan for the patient, increase the patient’s understanding of and compliance with that treatment plan, and improve the patient’s overall self-management skills.

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Reporting and outcomes Healthways is committed to improving the quality and effectiveness of healthcare. Each client commissioner requires a service that fits their unique needs for a high-quality of service that is compatible with their requirements for clinical effectiveness and patient satisfaction.

Since 2002, Healthways has been accredited and/or certified by the American organisations of certification for DM quality. To guide rollout and direction, our systems are configured to offer commissioners real time reporting and analysis, augmented by local leaders who project manage each local deployment. The outcome measurement for services are aligned to service objectives and methodology for measurement agreed before implementation as part of the overall service design.

Tailored implementation Having deployed services into private and public health systems in Australia, Brazil, France and Germany, it is our experience that the unique profile of each health economy needs to be fully taken account of to achieve successful implementation and the ongoing progress of these services. Working at scale requires the inclusion of many stakeholders and their alignment to the objectives of the service. Whether outsourcing or licensing Healthways’ telehealth platform and capabilities, close collaboration with the client commissioner, regular dialogue and effective team working is critical to success.

Healthways continues its journey to support patients living with chronic illness to improve their health status and quality of life.

To find out more about Healthways contact: Giles Tomsett, Managing Director, Healthways UK giles.tomsett@healthways.com www.healthways.com

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Our research.Your business.

The perfect MATCH What MATCH does

About MATCH The Multidisciplinary Assessment of Technology Centre for Healthcare (MATCH) is a well-established research collaboration between four leading UK universities (Birmingham, Brunel, Nottingham & Ulster) and is funded since 2003 by the Engineering and Physical Sciences Research Council and partner subscriptions.

MATCH helps improve decision-making for technology

Assesses value …

suppliers and procurement agencies. It enables

…by developing methods and models to assess the value of

companies to identify better products earlier in the

products at each stage of development, from identification of

design process and bring them to market sooner, with

need through to mature offerings in the market.

greater confidence that the value to patients and others

Optimises product development and manufacture…

will be consistently defined and readily recognised.

…by researching processes for improving information and

To this end, MATCH delivers: standardised methods for

decision-making, leading to more effective development and

establishing clinical value; new approaches to capturing

production processes, better clinical integration and improved

user needs for early design and in-use upgrades; best of

provision for users.

breed research into production and decision-making

Engages end users…

processes; and a forum for engaging regulators and

…by employing empirically based valuations of health and

finding better ways forward for all concerned.

related benefits to inform value models and develop methods for engaging with users at the conception and design stages.

Focuses on Industry… …by maintaining a strong industrial perspective, and using real industrial problems to drive and ground its research activities.

MATCH Membership MATCH membership will provide you with access to experts to work alongside your staff, helping them transform your company's competitive performance by embedding flagship techniques, derived from best-practice in healthcare technology assessment and user needs analysis.

For further information please contact Elizabeth Deadman match@brunel.ac.uk 01895 266050 or check the MATCH website: www.match.ac.uk

®

A complete system for producing autologous cells for use in regenerative medicine Exploiting the results of remedi, the EPSRC Innovative Manufacturing Grand Challenge in Regenerative Medicine, this project is creating an automated production system for the regulated manufacturing of cellular therapies Amit Chandra, Centre for Biological Engineering, Loughborough University Regenerative Medicine (RM) is widely seen as the next major innovation in healthcare.

The ability to repair and replace damaged cells and tissues using emerging technologies such as stem cells, offers the potential of lifetime cures for unmet medical needs, including conditions such as Alzheimer’s, heart failure, blindness and joint degeneration. The UK has a unique opportunity to build on its strong science lead to create and retain an industrial base in RM that will deliver long term health, wealth and employment.

Partnership (now TAP Biosystems) in collaboration with Loughborough University with EPSRC funding under the remedi project. Use of this platform to transfer manual human cell culture processes to automation was first demonstrated at Loughborough. This subsequently led to the development of the CellBase CT platform, which is designed to meet the regulatory requirements for GMP. GMP stands for Good Manufacturing Practice, which is the standard required by the regulator for manufacturing of therapeutics.

One of the major challenges in developing therapies using cells is to translate cell culture from a laboratory scale into clinically effective, reproducible and economically acceptable manufacturing processes. The determination of cost effective repeatable and efficient process parameters is at the core of the design of any production process.

The Loughborough team is continuing to develop techniques for cell culture and cell differentiation that were first established during the remedi project.

Centre for Innovative CompacT SelecT Manufacturing is an automated cell culRegenerative tureinplatform developed Medicine

by The Automation

Loughborough University with the support of the EPSRC, the East Midlands Development Agency (emda) and the Technology Strategy Board (TSB) has funded the design, construction and commissioning of the Cell Therapy Manufacturing Facility (CTMF) located in the

EPSRC

Centre for Biological Engineering at Holywell Park, Loughborough University.

The facility will provide both the physical requirements and technical expertise to aseptically culture, expand, differentiate and harvest human adherent cells. With the establishment of a viable business model, the ultimate aim is to deliver contract research services (including process design (including QbD), development, transfer and improvement) and manufacturing services for the preparation of GMP compliant batches of cell-based therapeutics for clinical trials.

Business in the field of Regenerative Medicine begins with a primary focus on successfully reaching ‘first in man’ clinical targets; this is followed by the ‘one-to-many’ translation process – the rapid expansion of delivery capability including GMP manufacturing of clinical trials and production batches. Both require increasing attention to regulatory pathways and product reim-

Centre for Innovative Manufacturing in Regenerative Medicine

Doctoral Training Centre Regenerative Medicine

EPSRC

Regenerative medicine research, research training and services

Doctoral Training Centre Regenerative Medicine

www.epsrc-regen-med.org www.dtcregen-med.com

INNOVATION IN HEALTHCARE

Keele University

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Development of the validation procedure for GMP

Lifecycle approach to Qualification and Validation

O P E R A T I O N A L

The CTMF Team »» »» »» »» »» »» »»

Q U A L I T Y

Project Sponsor: D. J. Williams Project Manager: P. Hourd Quality Manager: D. Alvey Engineering Team Leader: A. Chandra Regulatory Consultant: P. Ginty Business Consultant: M. McCall Industry interface/cell expert: R. Thomas

R I S K M A N A A G E M E N T

S T A T U S

Microbiology/cell experts: E. Ratcliffe K. Glen V. Workman K. Brosnan K. Sikand

bursement in order to refine the business model for the product.

The CTMF has been constructed to include separate areas for both manual and automated cell culture. There is a suite of cleanrooms (Grade B, EU classification) containing the essential equipment required for manual cell processing (performed within a Grade A environment) as well as containing the automated GMP-specified cell culture platform CellBase CT incorporating a processing environment to Grade A. As a part of its development as a contract research unit, the CTMF will be initially developed to transfer collaborators’ protocols to Loughborough, develop automation of protocols and manufacture cells for Phase I, II and III clinical trials of therapeutics. The automated platform will help for through the ‘one-to-many’ in Centre the transition Innovative Manufacturing stage as it demonstrates the ability to manuin Regenerative facture at high volumes inMedicine a scaleable way.

Storage of Incoming

Process Validation

PQ

QMS Construction

Towards a GMP Specified Facility

Analytical Method Validation

People Validation

Cleaning Validation

FMS Qualification

H&S Assessment

Facility Qualification DQ/IQ/OQ Equipment & Utility Qualification

DQ/IQ/OQ Cellbase Qualification

C H A N G E C O N T R O L

IQ/OQ

IQ/OQ

Transfer to Critical Area

GMP requirements for the facility require a four stage validation process (development of the procedure is shown above) as follows: »» Design Qualification (DQ) »» Installation Qualification (IQ) »» Operational Qualification (OQ) »» Performance Qualification (PQ) TSB funding was used for completing DQ, IQ and partial OQ by June 2011. KTA (EPSRC leveraged Knowledge Transfer Account) funding for the completion of OQ and PQ for the CTMF manufacturing facility and the equipment it contains, including the GMP CellBase CT is available until September 2012.

The current focus of the project is to establish the cell manufacturing facility and validate protocols in preparation for MHRA (Medicines and Healthcare products Regulatory Agency) inspection and licensing, ultimately enabling the manufacture of cell-based therapeutics for clinical use.

One of the next key tasks is the completion

EPSRC

Programme Governance

Preprocessing

Processing on Cellbase

PostProcessing

Storage of Product

of a sterile fill run to show the effectiveness of the facility and the platform in preventing contamination and cross contamination. The KTA funding will be used to complete the OQ for the entire facility including the equipment it contains. Commercially important protocols will be developed to facilitate progress through the final phase gate and the performance of the facility will be tested by PQ. Contacting the regulator is a major component of the work. A number of discussions have taken place with MHRA concerning this novel manufacturing system. A regulatory submission will be made using the KTA funding.

In December 2008, Biolatris Life Science Consulting Service was commissioned by Loughborough University to define the initial business case for the Contract Research and Manufacturing Facility. Its report charted a plan for the sources of funding for the facility, starting from grant funding and moving towards fee based services. The business case and business model will be revisited and amended as appropriate during the validation process.

Centre for Innovative Manufacturing in Regenerative Medicine

Doctoral Training Centre Regenerative Medicine

EPSRC

Regenerative medicine research, research training and services

Doctoral Training Centre Regenerative Medicine

www.epsrc-regen-med.org www.dtcregen-med.com

Online pageturner www.innovationinhealthcare.org

Keele University

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INNOVATION IN HEALTHCARE

When the CTMF is fully qualified as a GMP research and manufacturing unit at Loughborough University, it is intended that the facility will be able to offer a contract research service and manufacturing services to clinicians and business for the following processes: »» Process transfer of the protocols of different collaborating companies to Loughborough thus demonstrating portability of processes »» Developing methods for culture process improvement and optimisation »» Performing laboratory based experiments for culture process improvement and optimisation as required by collaborators and customers »» Achieving effective production processes where a reduction in the input materials can lead to improved cost of goods supplied »» Culture of human cells for allogenic therapeutic use »» Culture of human cells for autologous therapeutic use »» Culture and differentiation of Mesenchymal stem cells for individual patients

CentreThe formanual cell culture area Innovative Manufacturing in Regenerative Medicine

»» Culture and differentiation of embryonic stem cell lines »» Preparing cell banks for cells relevant for therapeutic use

Acknowledgements The significant funding and support of EPSRC for these initiatives must be acknowledged.

Initial funding was secured from its Innovative Manufacturing and the Life Sciences Interface Programmes both for the remedi Grand Challenge and its successor, the EPSRC Centre for Innovative Manufacturing in Regenerative Medicine. The construction of the Centre for Biological Engineering has been funded by Loughborough University and the East Midlands Development Agency (emda). Funding for the validation of the CTMF has come from the Technology Strategy Board (TSB) and the Knowledge Transfer Account (KTA) of Loughborough University funded by EPSRC.

Contact: David J. Williams Wolfson School of Mechanical and Manufacturing Engineering Loughborough University Loughborough, LE11 3TU Tel: 01509 227668 E-mail: D.J.Williams@lboro.ac.uk

Centre for Biological Engineering, Loughborough University, www.lboro.ac.uk/lcbe

The automated cell culture laboratory

EPSRC

The Cell Therapy Manufacturing Facility, Loughborough University

Centre for Innovative Manufacturing in Regenerative Medicine

Doctoral Training Centre Regenerative Medicine

EPSRC

Regenerative medicine research, research training and services

Doctoral Training Centre Regenerative Medicine

www.epsrc-regen-med.org www.dtcregen-med.com

INNOVATION IN HEALTHCARE

Keele University

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NHS Alliance The NHS Alliance invited GP consortia to submit brief statements about what they are achieving at local level, including innovations they have made to deliver a better service to NHS patients. This section includes a selection of what they said.

Central London Healthcare (CLH)

The Community Alcohol Detoxification service

The County Durham and Darlington Pathfinder

Central London Healthcare is a consortium of 24 GP practices in London, recognised recently by the Department of Health as one of the new “pathfinder” GP consortia. Dr Ruth O’Hare, the chair, and Peter Crutchfield, the managing director, point to two innovative projects that they would like to highlight.

CLH has also established a new Community Alcohol Detoxification service in a fresh attempt to deal with the growing problem of alcohol abuse. Alcohol abuse accounts for 12% of A&E attendances and there are at least 6,500 physically dependent alcoholics in Westminster, over half of whom are within the CLH area.

A pathfinder consortium that will deliver GPled commissioning in County Durham and Darlington is set to take forward the pioneering work of seven local groups of Practice Based Commissioning GPs. They will work as a federation of consortia to share financial risk. Here five of the groups report highlights of their commissioning work.

The service accepts referrals from all CLH practices and is being financed by the consortium’s Innovation Fund, which provides money for pilot projects to improve patient care. Bids were received from six GP practices within CLH and a panel of clinicians, patients and practice managers decided on which programme to invest for 2011. CLH now covers the cost of an experienced specialist nurse to run the service, room improvements and Hepatitis C test kits.

Durham and Chester-le-Street

Medically Unexplained Systems Central London Healthcare has set up a new community based clinic to support patients who often seek multiple medical opinions and diagnostic tests whilst their underlying health condition, that of health anxiety, remains untreated.

The clinic operates during the week and also on Saturdays so that people don’t have to take time off work and can cope more easily with childcare responsibilities. It offers an innovative 6 to 10 week programme of psychological therapies and provides practical guidelines to help patients deal with their anxiety.

This community-based service reduces: the number of primary care consultations and attendances; the number of referrals or investigative/diagnostic procedures to secondary care and A&E/Urgent Care Centre attendances; and the amount of prescribed medication for physical symptoms, anxiety and depression. The pilot is being monitored and evaluated by independent university researchers and the results of the initial 12 months will be available at the end of the year.

The Community Alcohol Detox service provides a GP-supervised detoxification programme at home as an alternative to a two-week inpatient programme. Two-week inpatient detoxification costs over £5,000 with uncertain results, whereas communitybased detoxification can be provided for a fraction of this cost and offers an equal chance of long-term recovery. The service is already demonstrating some success and CLH is now publicising it more widely to member practices in order to increase the volume of referrals.

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shadow consortium

Dr Richard Lilly, chair of the Durham & Chester le Street PBC group, said: “One of the main thrusts of our shadow consortium is to pilot a scheme whereby GPs can admit elderly people to a sub-acute bed in a local nursing home. We can look after them there in the community without needing to admit them to hospital. This is designed as an alternative for mainly elderly people, who are in need of 24-hour nursing intervention, but not specialist medical attention. They can be looked after by their GP in a location close to their home and family. We are designing this to have quick access to diagnostic facilities, rehabilitation opportunities and secondary care medical services, if required. In addition we will be putting in place pathways to ensure that their care needs will be tied in with the intermediate care pathways. The service is planned to go live in June.

Derwentside shadow consortium Dr Kate Bidwell, chair of the Derwentside PBC group, said: “Our part of the County Durham and Darlington pathfinder is looking at re-designing our paediatric services to avoid

INNOVATION IN HEALTHCARE

children having as many short stay emergency admissions to hospital. We are planning to review the “poorly child” pathway to ensure a high quality service for every child and family that, wherever possible, avoids the need to attend hospital. We are working together with our local foundation trust as well as our community services, our local authority and the ambulance service.”

Durham Dales shadow consortium Sue Jennings, programme manager of the Durham Dales PBC group, based in Bishop Auckland, said: “Over the last two years, we have been running one of 16 pilots across England looking at how to integrate health and social care services better. In Durham Dales, our pilot was led by eight GPs across eight different work streams – rural mental health, older peoples’ mental health, transport, vascular screening, urgent care, care closer to home, fuel poverty and a GP beds project.

Examples of innovations that we achieved included: Fuel poverty; We implemented an “Energy on Prescription” project that paid 10 patients’ fuel bills over the winter months and educated them on how to keep their homes warm and energy efficient. We know we have reduced GP attendances and prescriptions. We hope to prove that we have also reduced hospital admissions.

Weather warnings; We have introduced a Met Office weather warning for 500 patients across the Dales. This system phones every patient up when there is going to be some bad weather and advises them to make sure they have enough medication in, urges them to attend their GP practice if they are not feeling very well and has been extremely well received by patients.

also be welcomed by any family/carers who will be able to log on to the internet at any time and be re-assured as to where their relative is.

sioning partnership. Working closely with our local authority partner will allow us to try out greater integration of services.

GP beds; We were able to set up a pilot GP ward within County Durham and Darlington Foundation Trust, our local acute hospital.

This was a collaboration between the trust and local GPs. This enabled patients to stay much closer to home. From those patients who were admitted to the beds, the feedback was excellent.

Joseph Chandy, chair of the Easington shadow consortium and practice manager at Shinwell Medical Group, said: “The consortium covers the majority of the practices in East Durham, a former coalfield area with persistent public health problems, and among the highest prevalence in England of long term conditions, obesity and smoking. Local practices have identified a huge potential for improving patient outcomes through better management of long-term conditions and their exacerbations.”

Darlington shadow consortium The Darlington shadow consortium is working to manage the budget for unplanned care.

Joanne Evans, the clinical commissioning project lead, said: “This initiative will ensure that the most appropriate clinical care is delivered to the population of Darlington, ensuring the right services are accessible at the right time.” The initiative includes four strands: »» integrating urgent care services to help reduce the number of unnecessary A&E attendances. This may include locating a walk in centre next to A&E and providing improved intermediate care bed access; »» changing paediatric pathways procedures to reduce the number of children admitted to a ward for observation; »» integrating health and social care teams to ensure patients with respiratory conditions have access to support services to prevent admissions into hospital; »» working with our local authority to increase access to intermediate care beds and develop a re-ablement service. The aim is to help reduce the number of emergency admissions, reduce length of stay for patients admitted and help patients who need extra medical support, but do not require acute medical interventions.

Older Peoples’ Mental Health We have devised a six-question dementia screening tool, working closely with Tees, Esk and Wear Valleys, our local mental health NHS foundation trust. This tool has been rolled out across all of our practices. As a result, diagnosis of dementia in Durham Dales has increased quite significantly, meaning that we have been able to diagnose people earlier in the disease pathway.

GPS tracking; We are also in the process of setting up a small project that will track patients with dementia through a GPS system.

This will enable these patients to stay in their own homes longer, keeping them safe and will

Darlington locality is also leading on the development and commissioning of musculoskeletal pathways for County Durham and Darlington as well as the commissioning of an integrated physiotherapy and musculoskeletal assessment and treatment service to help coordinate referrals for musculoskeletal conditions. The aim is for the GP consortium to take responsibility in shadow form of the contract negotiation and subsequent performance management of the service.

Darlington GP Consortium has the same boundaries as Darlington unitary authority, providing us with the basis for a joint commis-

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Easington shadow consortium

Key elements of the consortium work plan include: »» Building on the award-winning pathway designed to prevent hospital admissions though provision of intensive support at home for patients with exacerbations of Chronic Obstructive Pulmonary Disease (COPD), improving the pulmonary rehabilitation services and home oxygen services that local leadership has already obtained, reducing variations in care and learning from regular evaluation of all COPD emergency admissions. »» Improving access to mental health care and psychological therapies, including developing services to ensure the specific psychological needs of patients with chronic physical health conditions are met. »» Providing treatment for long term conditions, and support to patients to manage their condition, closer to home. Easington does not have an acute hospital within its boundaries so patients and carers have to travel to access services, reducing patient engagement with those services and making the condition more disruptive to quality of life. The shadow consortium aims to build on previous work on diabetes and musculoskeletal conditions to ensure an integrated pathway of care provides patients with the support and care they need at the right place and at the right time. »» Working with other interested consortia within County Durham, parents, acute and community healthcare providers and schools to continue developing and rolling-out an integrated approach to childhood respiratory illness including asthma and wheezing with the aim of

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improving condition management, providing intensive support in case of exacerbation and increasing the confidence of parents and teachers. »» Building on our established patient and stakeholder group and close relationships with groups such as East Durham Breathe Easy to ensure patient, carer and stakeholder experience shapes service development and identifies good practice or failings in patient access or service quality.

Mr Chandy added: “The consortium will be able to demonstrate the value of involving practice staff from all professional groups in commissioning. Easington has a long record of leadership across professions, demonstrated in the GP, practice nurse and practice manager involvement in leading the consortium.”

Coventry: Godiva GPCC and InSpires GPCC Coventry has two GP commissioning consortia, called Godiva GPCC and InSpires GPCC. Both have pathfinder status and both are rooted in the experience of Practice Based Commissioning. Dr Ken Holton, a director of the InSpires board who is responsible for data and information across both consortia, said: “We undertook a number of PBC initiatives as federated projects, shared by the two consortia and led by one or other: »» “We identified patterns of unscheduled care for two groups of patients: people wanting to die at home and with dignity, and people in residential care with complex needs. It is only by operating jointly that any solution to the urgent care needs of these individuals can be achieved. We have made available medical time throughout the city (equivalent to three whole-time GPs) to deal with urgent care needs for these people and avoid the need for transport to hospital. If they do finish up at hospital, we have entered a joint information sharing agreement so that the primary care data becomes available outside of the originating practice.

This avoids duplicated investigation and decision making. No single practice could achieve either of these advances as even the largest is only 4% of the city population. »» “We agreed principles of good clinical care that extend well beyond the national standard requirements. In order to be a member of a consortium, the aspirant practice must agree, for example, to

publish lists of prescribing habits and conformity to local prescribing preferences. The aspiring practice must also agree to allow its referrals to hospital to be scrutinised by external GP moderators to determine: (1) that the referral is justified at all; and (2) that the case has been appropriately managed and data supplied as part of the referral to ensure that nothing happens in acute care that could have been provided in primary care. »» “We appointed visiting teams of peer GPs to meet with practices and discuss detailed audit material relating to the clinical performance of the practices. »» “We created an audit facility that assembles and interprets performance information drawing directly from several sources including the practices’ own clinical data. This ensures that the information is directly relevant to the practices. We made it a requirement of membership that these audits were run and externally moderated by local peers.

“We have plans too, mainly on the delivery of diagnostic facilities outside of the acute sector, the delivery of care closer to the patient, and the integration of community nursing teams within practice based nursing. This latter is in progress in Coventry, but is only just being rolled out within pilot groups of consortia practices.”

Hundreds Health, Salford Fiona Moore, head of clinical commissioning for Hundreds Health in Salford, says: “Our consortium has been involved in, if not led, all service improvements and commissioning decisions that have been made across Salford Primary Care Trust in the past two years. Each practice has a clinician identified as the lead for Practice Based Commissioning (PBC).

They attend monthly meetings on behalf of their practice and feed back information and requirements.

Unscheduled care “One example of service improvement/redesign came when the consortium was able to pilot a scheme using GPs to assess the medical needs of patients arriving in the A&E at Salford Royal Foundation Trust. This showed that not all patients attending A&E required hospital attention and so more of them were referred into primary care services. The assessment of patients arriving in A&E is known as “triage”. Before the pilot scheme, our A&E department was using the Manchester Triage

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protocol, but this triaged patients into the right part of A&E rather than directing inappropriate attendees to alternative services.

The pilot has since developed into the Salford Integrated Care Programme, which is looking to make savings of £7.2 million by 2013. This will be achieved through redesign of unscheduled care services across the area’s health economy, including processes to educate/redirect patients from A&E to self-care or primary care.

Referral management “All consortium practices keep a close watch on the number of patients sent by GPs for appointments and follow-ups in the hospital outpatients department. Between 2008/09 and 2009/10 the mean average spend per 1000 population reduced by £40 for outpatient first appointments and £70 for followups.

Our PBC group worked with the local foundation trust to agree a consultant-to-consultant referral protocol. The aim was to reduce the number of inappropriate internal hospital referrals for conditions that were already (or could be) cared for in primary care or alternative services. There was initially concern that this would increase GP workload, but this has not been the case.

Prescribing PBC incentive schemes are undertaken by all practices. They contain a number of prescribing components based on improving both quality and efficiency. In addition to this each PBC cluster signs up to a cluster prescribing plan focusing on the delivery of the national prescribing indicators. The cost of prescribing between 2008/09 and 2009/10 reduced by £10,000 per 1,000 population.

Best Value savings attributed to prescribing have been: »» 2007/2008 - £1 million »» 2008/2009 - £1.6 million »» 2009/2010 - £800,000 »» 2010/2011 – projected £2 million

Redesign of patient pathways The PCT has altered procedures to ensure that all commissioning strategy groups report through the operational board of Hundreds Health – Salford. Pathways that have been changed included: diabetes, dermatology, musculoskeletal, anticoagulation, heart failure, atrial fibrillation, diagnostics, ophthalmology, community services, unscheduled

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care, neurology, respiratory and many others.

All of these service redesigns have involved an appropriate form of patient engagement to inform the recommendations made and decisions taken.

Invicta, West Kent Dr Sanjay Singh, was chairman of Invicta, a Practice Based Commissioning group in West Kent with 112,000 patients. In April 2011 it merged with two other PBC groups to form Salveo commissioning consortium, a pathfinder consortium serving a population of 366,000. Dr Singh has been elected to the board of the new organisation and nominated as its GP chief commissioner. Here he outlines two Invicta schemes in which he took particular pride.

Tele-dermatology Dr Singh said: “We contracted with a Dutch telemedicine company to run an innovative dermatology project. Our GPs were given training and equipped with cameras to take photographs of dermatological disorders at the surgery. The photos, together with a brief history of the presenting problem and other relevant details, were uploaded from the GPs’ computers to a secure server. From there they

were relayed online to the dermatologists at our local hospital for diagnosis and therapeutic opinion. The average response time was less than a day, compared with an average of 60 days that our people used to have to wait for an outpatient appointment. The service was delivered at less than half the cost of a normal outpatient department tariff. There was a significant decline in new outpatient referrals to dermatology. The scheme was subsequently extended to other parts of the West Kent Primary Care Trust.

community. However, if onward referral was required, the initial assessment would have been completed in the community, thus shortening the interval before therapy. The valuation showed it to be highly cost effective, with reduced waiting times for assessment and treatment, reduced attendances at local A&E and high patient/parent satisfaction rates.

This scheme is due to be rolled out across other parts of West Kent.

Ivel Valley Commissioning Group, Bedfordshire

Children’s mental health “A second scheme addressed the problem of under-provision of Child and Adolescent Mental Health Services (CAMHS) in our area.

Waiting times for assessment ran into several months. In collaboration with CAMHS, we appointed a senior Community Psychiatric Nurse (CPN) to work with children, 75% in the community and 25% in the secondary sector.

She held clinics at GP practices and GPs were able refer some mental health cases directly to her under an agreed referral protocol. She spent a quarter of her time in the secondary sector where she could liaise with consultants directly and agree on joint management protocols. Most of the cases were resolved in the

Tele-health technology Sonia Jordan, chief operating officer of the Ivel Valley Practice Based Commissioning group in Bedfordshire, said it is using tele-health technology to monitor patients with long-term conditions. The Doc@home tele-health box takes key health readings of patients at home and sends the information electronically to a monitoring station. If any readings give cause for concern, local health services are alerted to provide rapid support in the patient’s home.

This helps patients stay at home and reduces costs by preventing avoidable admissions to hospital.

Ms Jordan said the implementation of Telehealth has been achieved by good teamwork involving GPs, community matrons and specialist nurses. Early anecdotal patient feedback is positive, with patients feeling reassured that their condition is being monitored and providing early intervention.

Melvina Smith, 73, calls the health monitor she’s been trying out in her home “my electronic friend.” She has had emphysema for the last seven years and can’t walk more than a few paces without getting breathless. “The condition does curtail my life,” says Melvina, who lives on her own. She worries about having a sudden deterioration in her health when alone. That’s where tele-health or remote health monitoring comes in. The Doc@home tele-health box takes key health readings including pulse, weight, ECG and blood pressure. The information is transferred wirelessly from scales, blood pressure cuff and other equipment in the patient’s home. For Melvina, regular transmission of this data can make the vital difference between managing her health

Reduced waiting time for assesment and treatment

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at home and being rushed into hospital as an emergency.

Ms Jordan said: “Patients have really embraced tele-health, it provides reassurance for the patients, and supports individual care closer to home. Tele-health empowers clinician and patients, as well as helping us to make efficiency savings.” Ivel Valley Commissioning Group has developed a business case for rolling out the Tele-health scheme to other parts of Bedfordshire and over three years the number of units installed is expected to increase to more than 450.

Kernow Clinical Commissioning, Cornwall Kernow Clinical Commissioning represents more than 50 Cornish practices, which have joined together from a number of more local Practice Based Commissioning (PBC) groups across Cornwall. They all depend on single providers for secondary care, mental health, community services and social care Dr Colin Philip, a consortium member and GP in St Ives, Cornwall, says: “Much of what we have done as GP commissioners in Cornwall has been achieved across all our PBC groups.

That is because we all focus on one District General Hospital – the Royal Cornwall Hospital in Truro. There are a number of achievements at practice level, but I think the most significant have been across the wider community and across traditional borders.

“We have been very active in setting up GP input into medical admissions at the hospital. As a result we have managed to keep the number of admissions flat. We are about to have a similar presence into the Emergency department, where all the growth has come from, with emergency admissions increasing by 14% in the last year alone.

agreed protocols between primary and secondary care. The new service will have active primary and secondary care input and will progressively become the conduit for pathway development. It will act as a planning tool for the new Clinical Commissioning agenda, particularly to enable redevelopment of services closer to the patient, where it is safe to do so.

“None of these initiatives would have been possible without mutual cooperation between primary care, secondary care and the PCT. Sadly it has only been the PBC agenda - and latterly GP Commissioning - that has focussed attention on what can be done through clinically led collaboration. Before this secondary care and the PCT (mostly) went their own way. This could have been achieved in other ways I am sure, but it is interesting how legislative changes influence behaviour.”

London Hounslow, Great West Commissioning Consortium A redesign of dermatology services was led by GPs in the Great West Commissioning Consortium, a pathfinder consortium in the London borough of Hounslow. Nicola Burbidge, the consortium’s chair, said it is an example of collaborative work between different stakeholders, including local GPs, the PCT, North West London cancer network, national skin campaign groups, public and service user groups.

As a result, NHS Hounslow recently commissioned a consultant led community dermatology service. The key drivers for the changes are better integration between primary and secondary care providers, right care at right place and commissioning a value for money service.

Community dermatology service “We have progressively developed locally based musculoskeletal services, using GPs with Special Interest, Extended Scope Practitioners and Physios focussing on shoulders, knees and hips. This has reduced referral to secondary care considerably.

“We have just set up a referral management service to centralise all Choose and Book referrals to provide a better patient experience, better choice and fewer inappropriate referrals. We have done this through active triage, use of the Map of Medicine (a decision support tool tailored for local use) and

The important features of the service are: »» A Consultant led one stop service for adults and children in the community with support from a multidisciplinary team »» Triage of all referrals by consultant »» Patients to be seen within 4 weeks of receipt of referral »» The service offers a telephone and email advice line for primary care staff »» Manages all the skin conditions that don’t require a hospital facility »» Manages all skin cancer that doesn’t require a hospital facility »» Patient and carer education, including

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prevention of skin disease, is an integral part of the service »» Heavy focus on primary care staff education programme as core service

The service specification and business case was developed by lead GP commissioners and joint team from finance, information with in the PCT. The Northwest London cancer network was involved in designing the cancer pathways in the community.

The service was procured by single tender process. The evaluation panel was consisted of local GP representatives, PCT commissioners, finance, information, human resources, IT, estate representative, a member of public and a service user.

The service went live on 1st February 2011. It is delivered from 3 different sites and to facilitate the smooth running of the service a NHS Hounslow dermatology referral guideline and NHS Hounslow community skin cancer referral guidelines are produced.

The contract mechanism developed by the GPs with the finance and information team was perhaps unusual. It is a contract such that the Provider will benefit from raising the quality of GP dermatology care and will ensure the only the conditions requiring a hospital environment are seen there; with a mechanism for GP commissioners to audit these referrals via the referral facilitation service.

Newcastle Bridges Commissioning Consortium Newcastle Bridges Commissioning Consortium includes 16 practices serving the west and central area of Newcastle upon Tyne. Dy Guy Pilkington, its GP chair, says: “We are building upon long-established collaborative working across practices. Our approach is practical, team-based, collective and driven by the needs of our patients. The core features have been group working across the health economy, willingness to take responsibility for financial decisions, putting patients at the heart of service development and passionate commitment to addressing the socio-economic issues that contribute to ill health.

Dr Pilkington added: “We have a track record of enthusiastic and successful projects under

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Practice Based Commissioning. Whilst we have taken time to establish strong, open and accountable governance structures as a pathfinder consortium, we have not let this important task detract from the clinical improvements that are necessary for our patients. We have embraced joint working with Newcastle City Council and our provider organisations, to the benefit of our patients.”

The consortium is a phase one pathfinder. Its submission for pathfinder status outlined five objectives on which it would initially focus.

They were to: »» reduce non-elective hospital admissions for chronic airways disease; »» reduce orthopaedic referrals; »» ensure that pathology activity is in line with effective use; »» reduce diabetes admissions; and »» reduce non-elective admissions from care homes.

The approach can be illustrated by explaining this fifth objective. The Newcastle Care Homes Project aims to improve the health care of care home residents; reduce inappropriate unplanned admissions to hospital; and reduce the number of people admitted and then dying shortly afterwards. The project has increased clinical engagement with care homes by establishing link GPs. It has run a series of education events for GPs and care home staff. As a result of these sessions, 60% of link GPs and 92% of care home staff reported that practice within care homes had changed. Improvements included: end of life care plans being implemented, urinalysis and blood pressure measurements routinely carried out; and care home staff more likely to call the GP surgery for advice rather than 999.

The latest data to the end of 2010 showed a 1.5% decrease in emergency admissions, compared with a 12% rise nationally and a 9.8% rise for Newcastle PCT over the same period.

StHealth Consortium, Merseyside The StHealth Consortium is a group of 24 GP practices, serving a population of around 140,000 patients, and is located within the boundaries of the Halton and St Helens district of Merseyside.

Andrea Gupta, the consortium’s Chair, says: “We have led in the improvement of outcomes for patients with chronic obstructive pulmonary disease (COPD) by training health care

providers to manage patients in the community. So far we have diagnosed an additional 650 patients with COPD, mostly in the mild/moderate spectrum. The Draft National Strategy tells us that, without an early detection programme, most patients would be moderate/severe at diagnosis. Early detection improves patient outcomes and reduces costs, including secondary care and prescribing spend as well as socio-economic costs.

“We have had 22 out of 24 practices participating in this two-year initiative, which has put nurses, GPs and healthcare assistants through a bespoke educational programme.

We developed pathways and protocols, with the input and agreement of key stakeholders, including medicines management and secondary care. We also monitored patient experience with a robust IPSOS Mori patient satisfaction survey. The results were very positive. We worked jointly with GSK and together we won national awards. We are now doing a similar project relating to asthma and we are working on improving clinical pathways in several specialties.”

The Ridge Medical Practice, Bradford Nick Nurden is business manager at The Ridge Medical Practice, Bradford, which is part of Bradford South & West Practice Based Commissioning Alliance. He describes how it found innovative ways to reach out to needy communities.

A community health education centre “When we purchased the land for our new practice building, we inherited a derelict listed building, which we had to refurbish under the terms of our planning permission. The building was not particularly suitable for clinical use and so we converted it to create a “community health education centre.” We invested practice funds to pay for the outside work and used PBC freed up resource to do the internal fit out. The practice is paying for the ongoing operation of the facility, with no reimbursement. The facility has created four spaces: »» A community cafe selling healthy options sandwiches and snacks to staff, patients and the public. It is also used for cookand-eat courses and healthy eating education. »» A lounge room to accommodate 12 people. This is used for group therapy sessions (stop smoking etc) and for the patient participation group to meet with and get feedback from our patients.

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»» A classroom that can take up to 15 people. This is used for training people with specific conditions such as diabetes or living with cardiovascular disease. »» A space for teenagers, decorated and used by them as a drop-in place to hang out. The space is used for healthy living messages, particularly around sexual health and other YP issues. This is a good non-threatening environment, which encourages them to engage with healthcare. After taking this first step it is easier for them to come into the practice if they need professional help.

This approach is part of the practice philosophy. To make a significant impact on the challenges that we face, we must step up the amount of health education that we do and reach out to our most needy communities to change the way in which they manage their own health. We have created a facility that is available for use by the practice, by other local NHS organisations and also by voluntary and third sector organisations to jointly work on this challenge. Part of this work is also developing stronger links with social care, education and the local community.

United League Commissioning United League Commissioning (ULC) is a third wave pathfinder GP commissioning consortium in the North West. It spans two geographical areas to encompass 13 practices in Halton and St Helens PCT, and 12 in Ashton, Leigh and Wigan PCT, and has a registered population of 106,000 patients.

Acute Visiting Scheme Dr Shikha Pitalia, chair of the consortium, says: “The Acute Visiting Scheme (AVS) has been running in our St Helens practices since 2006 and has been pivotal in gaining clinical engagement and enthusiasm from GPs. It is an outstanding example of successful clinically led commissioning.

“We identified that many patients requiring urgent medical attention during surgery hours could be saved from an unnecessary visit to hospital if seen quickly at home by a GP. The scheme aims to provide patients with an in-hours GP home visit within 60 minutes of request. Patients are given a comprehensive clinical assessment and treatment options are discussed with them, which often include home and community based care rather than hospital admission, depending on their condition. In the ‘down time’ between home visits,

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the AVS GP is able to make unscheduled calls on nursing and residential homes where staff value the additional clinical input.

“Analysis shows that the award-winning scheme has reduced in-hours unscheduled hospital admissions by 30% for the patients covered by the scheme. It has generated net savings of more than £300,000 per year and 90% of patients are satisfied with the quality of the service.

Early Detection of Atrial Fibrillation “During 2009, ULC implemented a simple yet effective scheme for opportunistic screening during routine flu clinics to detect irregular pulses on patients aged over 65. The aim was to help diagnose Atrial Fibrillation (AF), an abnormal heart rhythm that is associated with a significantly increased risk of stroke. More than 3,500 patients were screened during the flu clinics, and more than 200 were found to have an irregular pulse. Of those, 32 new patients were diagnosed with AF and added to the AF registers.

Text-to-Cancel In 2009, ULC implemented a text-to-cancel scheme, using mobile phone technology to enable patients to text GP surgeries to say if they are unable to attend an appointment. The scheme was intended to reduce non-attendance, releasing more capacity for appointments with GPs and so reducing A&E attendances. The scheme has been extremely popular with patients, who say it is much simpler and cheaper for them to send a text to cancel an appointment, rather than trying to get through on busy landlines. The scheme was highly commended at the NHS Alliance awards and won the GP enterprise award, judged by the Royal College of General Practitioners and Medical Defence Union.

Community Ear Nose & Throat Service During early 2011/12, ULC will launch a community-based Ear Nose & Throat assessment and treatment service. It will provide patients with care closer to home as well as improving productivity and efficiency. The service will clinically assess referrals within 72 hours and see and treat patients within four weeks of referral. The service will be consultant led and supported by GPs with a Special Interest. It will be located in premises within 15 minutes of the majority of patients’ homes. The service will be delivered at a cost below the NHS national tariff and will require zero upfront costs from the Primary Care Trust.

Whitstable Medical Practice Whitstable Medical Practice (WMP) is a large single practice second-wave GP Commissioning Pathfinder. It has 19 GPs and more than 100 staff serving the health needs of more than 33,000 patients. WMP is also a national NHS Commissioning Exemplar site. Dr John M Ribchester, executive partner and shadow clinical accountable officer, said: “We are using our emerging GP Consortium position to further our aim of providing the best possible healthcare, whilst combining the best of traditional general practice with innovation and integration.

“Whitstable faces a growing health and social care challenge associated with its ageing population. What then has Whitstable Medical Practice been able to do so far? We have been able to redesign much of the provision of healthcare in Whitstable to provide a better patient experience, closer to home, with shorter waits and at less cost to the NHS. GP Commissioning will enable us to continue developing an economical model of community-integrated healthcare.

“WMP has commissioned the redesign of some clinical care pathways. We have also developed an innovative new medical centre, which provides general practice alongside healthcare services normally provided from hospitals. These include a range of GP and consultant-led outpatient clinics, a range of diagnostic tests and also day-surgery. In addition, WMP provides a 12 hours-a-day Minor Injury Unit with x-ray every day of the year.

“WMP has also developed the Whitstable Integrated Social and Healthcare (WISH) Network Integrated Care Pilot for better management of key long-term conditions. Our patient user group and Friends charity are fully involved in developments. Patient satisfaction has increased very significantly through access to these high quality services provided closer to home and with shorter waits. At the same time services are provided at less cost to the NHS and the taxpayer.

“GP Commissioning situates clinical responsibility alongside financial responsibility. This alignment seems a logical way of enabling clinicians, assisted by managers, to improve the design of the NHS. It allows for innovation and patient influence at a local level and is something we wish to work with in future.”

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Wyre Forest GP Consortium Dr Simon Gates is chairman of Wyre Forest GP Consortium, a second-wave pathfinder.

He says: “In our area all 13 practices are fully signed up to our consortium constitution and we have had a very good reception from all our GPs. We formed six months ago and, as leaders, we have since then spent time making sure that we meet every member of our consortium. To that end, we have had two half-day events with two representatives from each practice to help us set our strategy as an organisation. We have visited every practice to meet all the rank and file GPs in our patch to get their views on our consortium and to get our message to each GP face-toface. We have also set up a consortium advisory board, which is chaired by a local patient and has representatives from local authorities, patient groups, community housing and disability action groups. The chair of the advisory board sits in our board meetings in an advisory capacity.

GP/consultant pairings “The main contribution that the consortium has already made to improving commissioning in our area is that it has allowed us to start the process of integration between primary and secondary care. At our strategy-setting days, our practices have asked us to work towards a more integrated health economy.

To that end we have asked Worcestershire Acute Hospitals NHS Trust to nominate a consultant in each speciality. We are matching up each of these consultants with a named GP. (With one exception we have a GP volunteer from each practice.) The idea behind these GP/consultant pairings is that they start the process of commissioning by first of all learning more about each other’s work. Then they can get on with trying to improve care within that specialty. If possible, they will be able to agree changes on patient pathways without major recourse to the centre of the consortium. The consortium board will be there to help and support if needed. If the board decides to make a formal commissioning decision in a particular area of medicine, it will use the GP/consultant pairing to lead on this work and the board will make sure the pairing receives appropriate management support. We hope that this pairing arrangement will provide us with the first steps towards integration of care and help us design seamless, clinically led services. We hope this will deliver genuinely clinically led commissioning.

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How volunteers can help the professionals deliver better community healthcare Pathfinder Healthcare Developments CIC specialises in finding innovative ways to bring health services to hard-to-reach patients

Pathfinder Healthcare Developments CIC is a Community Interest Company, whose focus is to reinvest profits and assets for the public good.

The Healthy Communities Collaborative (HCC) team delivers innovative healthcare services across the Sandwell area in the West Midlands. This community engagement and service improvement approach goes hand-inhand, so that local people work jointly with statutory and voluntary sector staff to improve the health of their local communities and the responsiveness of local primary care services.

Local people know and understand better the barriers to healthcare that their neighbours and communities have to deal with than professionals and statutory bodies. By working with and training local volunteers and primary care staff, activities and interventions are being developed that are appropriate for the particular needs of Sandwell’s diverse communities.

We have run a number of programmes funded

by Sandwell PCT, to promote the earlier presentation of symptoms of cardiovascular disease and cancer in primary care, and so facilitate earlier diagnosis and treatment.

Aims: »» To identify people at risk of cardiovascular disease (CVD) and put them in contact with primary care services.

»» To promote the Fit for Work Programme, which is intended to help people who are employed and are off work with a sick note, or struggling to maintain their health while in work. We were tasked to highlight and market the service to Sandwell area GPs, companies and residents. »» To promote the earlier presentation of symptoms of bowel, breast and lung cancers in the community, GP practices and workplaces, to encourage earlier diagnosis and treatment »» To ensure people presenting with cardiovascular disease symptoms are referred according to best-practice guidelines.

While the interventions to promote earlier presentation are primarily practised in the community, the measurements to indicate whether or not there has been an improvement, need to be collected in a clinical setting.

Innovation in Healthcare: Role of The Healthy Communities Collaborative Team »» Communities are vital to improving health and can play a significant role in promoting an individual’s self-esteem and mental well-being by reducing exclusion »» With encouragement from HCC community volunteers, neighbours and colleagues, a significant difference can be make in ensuring that individuals feel supported in making positive lifestyle choices.

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»» Also,identifying a topic of importance to a community will prompt community action.

What difference does it make? »» It creates opportunities for collaboration and promotes the exchange of knowledge between the networks »» The programme has already expanded and is providing training to the volunteers – volunteer support is in place, which also links into employment opportunities. »» In community activities, it was found that using community volunteers made it easier to engage with local people, especially the hard-to-reach groups, such as young people manual/unskilled workers and the black and minority ethnic (BME) communities. Local volunteers can draw local people to health promotion stands.

They can also share their own experiences, which connects with members of the public in ways that healthcare professionals would not.

Main Achievements and Points of learning

»» The general consensus amongst the community teams was that events were often successful, because even by talking to one person, the messages being given could make a difference. However, volunteers did recognise that events that allowed them to engage directly or by using the Health Assessment paper tool

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»» »»

»»

»»

»»

(see below) to talk to people, rather than just hand out a leaflet, were much more likely to get the message across. Other materials distributed included information on healthy eating, physical activity, saturated fats and salt, stopping smoking and materials supplied by the British Heart Foundation It broke down barriers between local communities and healthcare professionals The benefit of local knowledge; volunteers know what is happening in the area and can target community events and community groups more effectively The value of personal experience; many volunteers could share their own story of CVD or cancer. Talking to somebody who has been through such illnesses can help Interpreting skills are vitally important in engaging with the community. This proved particularly successful when engaging with different ethnic minorities in raising awareness of CVD Using community volunteers makes it easier to engage with local people.

Innovation In Action: The Health Assessment Paper Tool Although we are only funded for one programme, which is to raise awareness of cancer, we have also put together a Health Assessment paper tool with our community volunteers, which incorporates local priorities such as: »» Increasing referrals to individuals’ own GPs for follow ups and for further checks »» By using volunteers to help individuals complete the Health Assessment paper tool, they can then, if necessary, be referred to the Health and Wellbeing Services, which covers healthy lifestyles, stopping smoking, physical activity, healthy eating, and Mental Health Services.

by Smethwick Medical Centre and other practices within Sandwell »» It may also identify those who fail to attend national screening programmes.

Creating Innovative Networks And Communication Has Been Successful In These Areas: »» Sandwell PCT/Healthy living centre/ Healthy hearts team/Brushstrokes/Lloyds pharmacy »» Boots pharmacy

Libraries across Sandwell »» Parkinson’s UK/Diabetes UK/Cancer Macmillan/Oldbury Council House »» 64 GP practices across Sandwell »» British Heart Foundation/Asda/Tesco Metro/Community wellbeing services »» Community Health Network Team – Target BME Communities »» Sandwell lifestyle choices /police/community centres/social clubs plus many more voluntary and statutory organisations and businesses.

Making Volunteers Successful

Volunteers know what is happening in the area and can target community events and community groups more effectively »» Schools in Sandwell/CAP centres/churches »» Taxi ranks/dentists/Sandwell Homes/ NPower »» Employment services/ Sandwell PCT cancer screening outreach nurse »» Oral health/health trainers/Agewell/ Ssaathi/Ideal for All – services for people with disabilities/Sure Start centres/

»» By providing ongoing training on health programmes and signposting services in the Sandwell area at community events.

Certificates are presented at monthly HCC meetings, this encourages more volunteers to come. We also ask volunteers what training would be beneficial to them »» Mentoring is important in building up volunteers’ confidence and empowers them to develop to their full potential »» By providing access to training specifically focused on back-to-work opportunities »» Identifying employment opportunities for volunteers within the employment and skills panel. Volunteers are contacted and supported on how to apply for jobs and access training to develop further. »» At monthly HCC meetings, volunteers are very good at identifying venues and how to target hard-to-reach communities. So they are given tasks to manage stalls independently. Positive feedback shows that this empowers them and improves their confident in engaging with people. »» By using the Community Engagement and Service Improvement approach – this

When approaching the public, community volunteers ask individuals to have a free MOT check, using the paper tool, which will signpost individuals to many services. These may include: »» Cancer awareness and three national screening programmes »» Alcohol services »» Health trainer services »» Employment services »» Stop smoking services, which are offered Community volunteers identify, set up and run ‘Health Day’ events aimed at local people

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Health day pictures -Community Volunteers and Project Manager

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enables local people to work jointly with statutory and voluntary sector staff to improve the health of their communities and primary care responsiveness

Healthy Communities Collaborative Team – Data »» We have engaged with 13,992 people since the programme began »» We have recruited a total of 72 volunteers »» The current number of volunteers on the programme is 46 »» We have empowered volunteers in giving them confidence to look for employment, with 24 volunteers finding employment or

going onto further education »» We have completed 2,978 health assessments in the community »» The HCC team has jointly worked with Health trainers and local pharmacies to offer health checks at supermarkets. This has proved successful, with 797 having blood pressure checks »» The HCC team has made over 1,500 referrals to the Sandwell Lifestyle Choices programme.

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the best healthcare, a healthy, long life and responsive service provision for themselves and their communities By educating individuals, giving out health information and signposting to health and wellbeing services, we have created a cost saving for health budgets as it increases upstream interventions and adds value to improving individual health, fitness and quality of life. This also results in helping individuals learn how to make better health choices Early intervention saves lives and longterm illness by raising health awareness and early presentation of CVD and cancer By delivering the Healthy Communities Collaborative programme on reducing health inequalities across Sandwell, we have improved access to healthcare for BME communities We have also reached diverse groups by developing effective partnerships to target specific groups Our interventions and ideas are now embedding within the PCT protocols. This is a working example of how real, live practice can impact on policy, planning and mainstream delivery.

Conclusion »» We have raised expectations by encouraging people to want and expect

Nadia Ahmed sustainability manager E-mail: nadia.ahmed@nhs.net Office: 0121 544 4324 Mobile: 07980 031194 Pathfinder Healthcare Developments CIC (Healthy Communities Collaborative Team) Smethwick Medical Centre, Regent Street, Smethwick, B66 3BQ

Asda - Community Volunteer carrying out a Health Assessment

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The Who’s Who of commissioning Over 2,000 healthcare professionals gathered in London’s Olympia in June for the launch of the definitive event in primary care commissioning

The Commissioning Show 2011 brought together some of the most senior figures in health policy with grass roots GPs, commissioning managers and care trusts, leading secretary of state for health, Andrew Lansley to describe the show as “A real opportunity to demonstrate how important commissioning is.”

Lansley’s key note speech at the conference drew attention from national media keen to capture GPs’ response to the Health and Social Care bill, generating coverage in the broadsheets and national news shows, including the Guardian and Sky News.

primary care in the exhibition zone. Many were actively seeking new expert partners to help them deliver the new ways of working and cost saving that the healthcare bill would bring about.

Also appearing at the speaker’s podium during the event were NHS chief executive Sir David Nicholson, NAPC chairman Dr Johnny Marshall and Dr Hamish Meldrum, chairman of the BMA, all sharing their vision of the pathway for primary care commissioning.

Programme highlights Four streams were packed with expert advice, practical tips and case studies: Consortia business: sharing best practice, targeting support and managing risk »» What are the potential consortia models? »» What to provide in-house and what to outsource »» Effective IT and data collection »» Understanding commissioning budgets.

But the real stars of the conference programme were all the GPs and commissioners who shared their real life experiences of meeting the challenges of new approaches to primary care commissioning. Partnership working, use of new technology and delivering best value were all hot topics for discussion on the conference floor and at the many informal networking points around the show floor.

Patient services »» Identifying local needs »» NICE and QIPP »» Assessing the impact of change.

Most delegates also used the opportunity to network with some of the leading suppliers to

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Speaking at the show, Andrew Lansley said it was a real opportunity to demonstrate the importance of commissioning

Partnership: forging successful commissioning relationships »» Involving patients in service planning »» Commissioning from the private and voluntary sector.

Leadership »» Engaging with other leaders »» Inspiring others »» Best practice from the private sector.

Key facts »» Total attendance 2,793 over two days »» GPs, practice managers, CCG managers and healthcare professionals from all over the UK »» Plenary sessions from leading policy makers including Andrew Lansley, secretary of state for health, Sir David Nicholson, chairman of the NHS and Dame Barbara Hakin. »» 60 practical workshop sessions »» 120 exhibitors »» Media coverage reaching over 10 million viewers.

What did delegates tell us?

GPs believe financial acumen will be their top priority to survive the NHS changes.

GPs and healthcare professionals who attended The Commissioning Show were asked to predict their top five priorities for 2012. The range of answers from respondents suggested that many healthcare professionals were uncertain as to what the future holds, but have already identified areas where they can improve their skills and become more efficient going forwards.

confidently manage the financial aspects of primary care commissioning.

GPs also expressed an interest in making savings through data and IT systems, with 14% of delegates focused on improving their working practices by increasing their use of new technology.

General management priorities anticipated a shift from standalone practices to larger groups and Consortia, with the HR, legal and staff engagement issues that this may bring.

Improving quality and specifically finding effective ways of measuring the quality of patient experience was considered a priority by 32% of delegates. Other responses included self-care, geriatric and end of life care, teenagers and the mentally ill.

What did our partners say?

“Commissioning 2011 was well-planned and created the opportunity to launch our new solutions to support joined-up healthcare and clinical commission groups. I will certainly be recommending the event and we will look forward to exhibiting at Commissioning 2012.” PCTI Commissioning brought together grass root GPs and managers with some of the most influential policy makers of the day to deliver an impressive array of delegates, speakers and supporting exhibitors.” AstraZeneca “The event was very well organised and well attended, it combined quality content for attendees with commercial opportunities for exhibitors in a highly professional manner.”

GPI

Top five priorities for 2012 »» Finance and budgeting »» Partnership working »» Strategic planning and alignment with changing landscape »» Quality of patient experience »» General management responsibilities.

Financial acumen was highest priority with 40% rating budgetary issues a priority and one in five delegates rating it as their top priority for the coming year. This reflects the concerns expressed by many GPs prior to the event that they do not yet have the skills required to

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Looking forward to 2012 A programme featuring key people from the commissioning world, plus debate and advice.

Commissioning 2012 aims to deliver a blend of practical advice, real solutions, facilitated learning and networking that clinicians and managers can take back to their day-to-day roles. Six streams will cover a range of key interests and responsibilities. Uniting all streams is the recurring theme of delivering better patient care. In response to delegate feedback, we have added two new streams for 2012, focusing on technology and the emerging role of Health and Wellbeing Boards.

Listen, learn, debate New for 2012, the facilitated learning area will allow you to join a facilitated workshop where you can work with colleagues and other groups on real life scenarios. Lead by a professional facilitator, each session will have a set task to complete as a group, with the objective of leaving with practical solutions that can be implemented in your locality.

Through our new dynamic registration system delegates can not only chose the session, but also the table they would like to join.

Commissioning’s hottest debates

Commissioning 2012 will cover the hottest topics of the day, although as yet we cannot be certain what they will be! Our round table programme will allow partners and experts to table hot topics and watch the debate unfold.

These lively, less structured discussions are an ideal way to gain insight into current practice and opinion.

The social network An innovative delegate booking platform opens up new opportunities for networking, both in the run up to the show and beyond.

Delegates can create a bespoke conference programme for themselves, by combining their selections from the formal sessions with facilitated networking and face-to-face peer meetings. You will also be able to book time directly with expert suppliers for in-depth discussions about the issues that you face.

This is a most valuable opportunity for you to spend uninterrupted quality time with prospective partners.

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Engage with content online

An integrated social media platform will allow delegates to share their experiences with others and discuss what they have learned. Combined with downloadable content, the value of Commissioning will extend well beyond the confines of a traditional two-day show.

Come face to face with your

More flexible programme

commissioning heroes

We listened to what delegates told us after the 2011 show: they rated the content highly, but sometimes found it difficult to fit in everything that they wanted to do. We have taken this onboard. While there is still a host of great content, we have opened out the schedule to allow more time to get between theatres, for networking and for talking to expert partners in the exhibition zone.

New for 2012, the facilitated networking area will allow delegates to build their own programme of meetings around the main conference programme.

Our innovative booking platform allows delegates to identify experts and peers with practical experience in key areas. You can even create your own sessions around the topics that matter most to you and invite like-minded colleagues to join you.

To book a place at Commissioning 2012 call Alice Andrews on 01926 485151 or e-mail a.andrews@closerstillmedia.com If you are interested in speaking or exhibiting at Commissioning 2012 please contact the show’s director Ralph Collett: ralph.collett@ closerstillmedia.com.

Be part of the agenda This platform also allows delegates to join facilitated learning sessions and round table discussions. They can even create their own sessions around the topics that matter most to them and invite like-minded colleagues to join them. In such a dynamic environment, where the hot topics of the day can change rapidly, this will ensure that every delegate has the opportunity to come away with the solutions they need.

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HEALTHYMAGINATION IS MORE HOSPITALS AND CLINICS HELPING MORE PEOPLE MORE EFFICIENTLY. healthymagination.com