Fit for the Future by Sarah Moll

CONTENTS

Introduction

Pathway Review Summary

Long Term Conditions

End of Life Care

p 23

Urgent Care

p 39

Planned Care

p 50

Staying Healthy

p 54

Health Improvement

p 61

Mental Health

p 66

Child Health

p 75

Maternity and Newborn Care

p 88

Acknowledgements

North West Community Provider Alliance Clinical Pathway Workshop 2009

North West Community NHS Services Clinical Pathway Workshop Introduction Across the North West, the NHS Providers of Community Services are working together as an Alliance to support collaboration in the promotion and development of high quality and innovative community services. Transforming Community Services has recognised the crucial role that community services have to play in the delivery of Quality, Innovation, Productivity and Prevention (QIPP) and that an essential element of the transformation process is the effective engagement of community clinicians and practitioners in shaping community services that are fit for the future delivery of high quality productive care. This report is the output of a half day workshop attended by over 100 community expert clinicians and practitioners from across the North West. They met to debate and agree a consensus view of the high impact changes that could be made by community services to enable service, pathway and partnership reform, and contribute to the wider system delivery of Healthier Horizons and QIPP. The event involved practitioners working in PCT provider services. However, it was recognised that it is vital for similar pathway discussions to be extended to include a range of stakeholders (including NHS, social care, third sector and independent sector providers, as well health and social care commissioners) if any of these proposals are to be taken forward and the anticipated QIPP benefits realised. We hope that this summary report provides the basis for these new conversations at service, health and social care economy, and regional levels.

Dr Barbara Green on behalf of the North West Provider Alliance October 2009

North West Community Provider Alliance Clinical Pathway Workshop 2009

Pathway Review Summary

Process The reviews brought together clinical experts, from all disciplines, to offer high level evidence based and clinically supported proposals of the key community service changes that could be commissioned to deliver the aspirations of the Darzi vision, Transforming Community Services and the implementation of Healthier Horizons. Eight expert multidisciplinary panels met, each focussing on a specific clinical pathway: Long term conditions, End of Life Care, Planned Care, Urgent Care, Health Improvement, Staying Healthy, Child Health and Maternity and New Born Care. Each panel was asked to: a) Provide a consensus of the top three to five high impact changes for community services, with reference to the evidence base and best practice examples where possible b) Identify the benefits of each, from the perspectives of the patient/client; the commissioner; and system reform agenda c) Consider the enablers and barriers to delivery The outputs from each panel are reproduced within this report including a summary of the relevant recommendations from Healthier Horizons and Transforming Community Services Best Practice Guides. As can be seen, there is considerable synergy between all three.

Summary of the themes across the pathways •

Community Services were seen as crucial levers for positive change in terms of improving the health and well being of the population of the North West and in enabling radical system reform.

•

There was unequivocal support for the ambitions contained within High Quality Care for All, Transforming Community Services and Healthier Horizons and a clear commitment that community staff – whether directly or indirectly providing care – would actively participate in the transformation process.

North West Community Provider Alliance Clinical Pathway Workshop 2009

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There was a realistic understanding of the scale of the challenge and that leadership at all levels was needed to successfully deliver the pace of change that is required.

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Practitioners were excited by the prospect of working collaboratively at service and system levels to improve quality and productivity. They also identified significant opportunities for the co-production and adoption of innovative practices for improvement.

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It was hoped that there would be wider recognition of the expertise that already exists within community services and that commissioners would actively support existing examples of excellent practice, delivered in some areas of the North West, being spread and adopted by all.

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The engagement of communities and patients and the whole community service workforce was seen to be fundamental to the success of the transformation process. Community services are very close to the needs of the communities they serve. They are part of the stories that families and individuals share and can offer a valuable insight into the real experiences of people of their lives, health and health care.

•

Community service practitioners have a strong ethos and commitment to empowerment and enablement. They have extensive experience of the coproduction of interventions with clients and communities to improve health outcomes and address health inequalities. The importance of building on existing community insights and relationships was highlighted and all panels emphasised the importance of strengthening universal services and prevention, health improvement and early intervention functions.

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There was consistent support for integrated clinical pathways to be jointly commissioned by health and social care with clearly defined outcomes and benefits. It was proposed that the design and delivery of the pathway should then be determined by providers working together to co-design and redesign effective integrated practice throughout the patient or client journey.

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There was strong support for the development of collaborative clinical networks and integrated care pathways, with a balance between a standardised approach and the flexibility to respond to individual choice and needs.

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Collaboration and competition were major themes with both being seen as providing the potential for improvement. It was suggested that commissioners might incentivise horizontal and vertical co-operation across a number of the pathways.

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Integration was offered as a philosophy to clinical practice enabling improved client experience and outcomes, as opposed to a focus on financial alignment or organisational form. Integrated practice and co-operation with a wide range of providers was seen as offering significant opportunities to improve access and quality.

North West Community Provider Alliance Clinical Pathway Workshop 2009

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Most community services are commissioned to operate during a typical 9am – 5pm weekday period. It was suggested that a simple and rapid improvement to patient experience, access and choice could be made if many community services were commissioned to deliver over more extended or flexible hours.

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Many of the panels identified workforce development and redesign to be essential for successful transformation. The general view was that this was recognised by the community services workforce who would welcome the opportunity for greater engagement in service and system reform.

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It was felt that there was a need for clinical leadership within community services to be specifically commissioned and the further development of generalist, specialist and expert practitioner roles.

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Knowledge management and the lack of reliable and comparable data were frequently seen as barriers to improved service delivery. Clinicians were keen to co-produce a range of meaningful metrics with commissioners so that energy and effort is focussed on measures that are valued and enable transformation.

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The panels identified significant variation in the scale and range of community service provision across the North West. There was no apparent rationale for this variation and very few standard service models.

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There were concerns expressed about the emerging tension of collaboration and competition between NHS community providers within the new market, and a worry that colleagues may become less willing and open to sharing their innovative practices.

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There has been an absence of a forum for community staff to meet and share best practice and therefore limited cross-fertilisation of knowledge and innovation between community services.

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The participants were very positive about the workshop and wish to develop the work further. They were keen for clinicians and practitioners to continue to work together in multidisciplinary pathway groups.

North West Community Provider Alliance Clinical Pathway Workshop 2009

LONG TERM CONDITIONS

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Continue with health and social care integration

Benefits for Patients Health and social care integration means less duplication/number of assessments and number of handoffs, which produces seamless care and links to care pathways. A single point of contact improves quality and the number of acute episodes. This means holistic needs are met. A single number to access services means increased satisfaction with a decreased ‘scatter gun’ effect. Right treatment first time for patients.

Benefits for Commissioners Able to efficiently manage economic markets, therefore, opens up markets. Brings increasing value for money and improves productivity by reducing duplication. Encourages integrated commissioning by Health & Social Care. Developing ‘care bundles’ reduces costs and increases quality control. Right treatment first time and so reduced waiting times. Encourages a community tariff.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Benefits for System Reform Integrated commissioning by Health & Social Care with improved market management. Patient involvement will give a more definite view of what patients want and need from a service. Breakdown of roles and boundaries. Encourages professionals to ensure that services are person led not service led. Lean. Streamlined. Empowers patients to use Choose and Book. Links to other pathways e.g. urgent care, end of life. Embedded Single Assessment Process.

Enablers To Delivery Integrated teams colocated with shared reporting systems and pooled budgets and IT systems.

Barriers to Delivery Inadequate IT systems.

Shared priorities/ protocols/information.

Terms and conditions of Service Level Agreements.

Commitment from organisations, staff and GPs.

Systems/policies.

Common understanding of ‘integration’ as practice rather than organisational form. Clear pathways linked to electronic Directory of Services. Staff training.

Financial barriers and freedom to act.

Different remits e.g. free at point of care/subject to eligibility. Respect for decision making.

Priorities in Transformational Guides • Develop personalised care plans using joint care planning, integrated assessments and joined up multidisciplinary working along the care pathway. Intermediate care and rehabilitation services should form part of the long term conditions pathway preventing inappropriate admissions to the acute trusts, facilitating early discharge and enabling people to achieve the optimum level of independence for their long term future. •

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Ensure that community teams and matrons make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients. Work closely with community mental health teams to develop referral pathways to improving services such as: improving access to psychological therapies (IAPT) or cognitive behavioural therapy (CBT) for patients who require specialist advice, support and treatment. Extend the hours of service according to patients needs. This may include telephone access for on-call and out-of-hours home visits. Offer services in local and convenient venues to reach patients who may not engage in traditional ways. This may include church halls, supermarkets, and train stations.

•

Use technology to implement shared care planning, so that all involved in the patient’s care including the emergency services, such as the ambulance trust or out-of-hours provider, have an understanding of the patients needs and treatment plan.

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Use technology as a form of documentation. This may include remote access devices such as palm tops and tablets which can be synchronised easily with IT systems, avoiding unnecessary travel or time wastage;

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • A new model of care should be commissioned that enables integration of health and social care, with the roles of professionals changing to meet patients' needs. There needs to be a clear description of what primary care should be like to incorporate social care, community care and specialists. •

A designated care co-ordinator will have responsibility for ensuring that a plan is developed and agreed.

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The role of primary care should be strengthened and developed with new skills and ways of working to deliver more personalised care around patients.

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The development of a virtual care campus to deliver health and social care provision within primary care for specialised problems.

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Greater use of technology to enable patients to be maintained /monitored in primary care.

2. Top 3-5 Improvements Integrated discharge planning, continuity across primary and secondary care

Benefits for Patients This approach will increase safety and provide seamless crossover care to community services. There will be fewer complaints, reduced readmissions, reduced length of stay as a result of positive care planning

Benefits for Commissioners There will be fewer complaints, reduced readmissions, therefore, reduction of cost of emergency admissions. Improved delivery of A & E 4 hour standard and 18 week pathways.

Benefits for System Reform

Enablers to Delivery

Increased health and well being outcomes.

Shared commissioned services with shared priorities for staff and patients.

Improved quality and efficiency subject to genuine investment in community services to deliver tangible benefits of care closer to home.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Shared IT systems means more efficient ways of working. Creation of new roles to enhance the service.

Barriers to Delivery PbR/block contracts – restriction of the development of local integrated care pathways. ‘Blame culture’ in the NHS. Organisational boundaries. Lack of shared knowledge

Priorities in Transformational Guides • Intermediate care and rehabilitation services should form part of the long term conditions pathway preventing inappropriate admissions to the acute trust, facilitating early discharge and enabling people to achieve the optimum level of independence for their long term future. •

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

A designated care co-ordinator will have responsibility for ensuring that a plan is developed and agreed.

•

The role of primary care should be strengthened and developed with new skills and ways of working to deliver more personalised care around patients. The development of a virtual care campus to deliver health and social care provision within primary care on specialised problems.

•

Greater use of technology to enable patients to be maintained /monitored in primary care.

Top 3-5 Improvements Self care management tele-health, personalisation, empowerment

Benefits for Patients

Benefits for Commissioners

Benefits for System Reform

Enablers to Delivery

Barriers to Delivery

Patients have greater autonomy, choice and improved access. This enables them to stay well, at home and gives them reassurance and increased confidence, which empowers them. Therefore, they are in control and independent. This would be a patient led pathway which enables choice and involvement, improvements in waiting times and is a timely intervention, i.e. choice of where and when for the patient.

This will reduce the need for professional interventions and need for services. Produces a healthier population who have choice. Self monitoring reduces exacerbations, hence, decreased GP visits/admissions. A good opportunity for looking at new developments/innovation through re-investment with a prevention and education agenda.

Re-investment opportunities across the pathways which supports a shift from illness to wellness.

Technology to be available with the possibility of using Expert Patients who can and wish to self care. This would reduce system costs.

Reliability of technology.

Condition specific programmes.

Programmes are condition specific.

Quality and Outcomes Framework for Pathways eg. COPD, so that quality/data can be collected for evidence.

Knowledge of how to access.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Patients in control of their own health which reduces the burden of Long Term Conditions. Financial benefit across economy - with a return to work. Enhances Choice and the self care agenda with a consistent message and approach to patients. Individualised budgets. Reduced burden of care.

Partnership working with Voluntary sector e.g. MIND.

Patients - culture. Financial investment. Trust /confidence.

Engagement. Safeguarding issues. Capacity for services to address real demand. Today's business - what about tomorrows double running. Priorities.

Priorities in Transformational Guides • Support and enable people to manage their own health. •

Priorities in Healthier Horizons for the North West • Place individuals with LTC and /or their carers in charge, enabling them to live well with their condition.

Invest in tele-health and tele-care to empower patients to take, maintain and maximise their own health potential.

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Greater use of current technology to enable patients to access their health records and test results remotely, for example, kidney care: MySpace.

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Address the skills gap of health 'educators' for LTC within a primary care setting.

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Develop personalised care planning using joint or integrated assessments.

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Use a ‘buddy system’ to support patients.

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Teach patients and carers to recognise the signs of deterioration/acute exacerbation and how to take action.

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Consider the person's social, cultural and family circumstances - not just clinical.

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Provide staff with appropriate training. This may include non-medical prescribing, advanced assessment, motivational interviewing or cognitive behavioural therapy skills.

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Develop and apply the social care model for personalised budgets and payments.

Replace where appropriate visits with a telephone contact. This may be useful to monitor a patient’s condition remotely.

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Increased support for patients, their families and carers in managing LTC, including from voluntary groups.

Offer choice through personalisation. Work with local authority to support patients wishing to make use of ‘self directed budgets’. Maximise the opportunity for patients to participate in the Expert Patient Programme.

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A named patient advocate and care co-ordinator for all patients with a LTC.

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Exploit the use of technology to maximum effect by providing support to dedicated staff on how to introduce new technology and how to measure its effectiveness.

North West Community Provider Alliance Clinical Pathway Workshop 2009

4. Top 3-5 Improvements Improve transitional care for children with long term conditions.

Benefits for Patients Improved quality of care and reduced anxiety of patients, carers and professionals, which in turn improves independence.

Benefits for Commissioners Long term cost benefits which address inequalities and increase reported mental health and wellbeing.

Increased mortality Reduction in long term rates and reduced complications with admissions. increased life expectancy/opportunities.

Benefits for System Reform Invest to move forward and improve health. Re-engineer pathways as patients have improved wellbeing and chronic illness.

Priorities in Transformational Guides • Practitioners closest to patients to lead change themselves and realise their own high ambitions for the care that they provide. •

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Provider Organisations to align high quality care to organisational vision and strategy. Commissioners to understand the constituents of high quality care and enable world class commissioning decisions to be made that are clinically led and focus on achievements. Strengthen partnership working across health and social care.

• Start discharge planning as soon as possible, make sure all practitioners are North West Community Provider Alliance Clinical Pathway Workshop 2009 14

Enablers to Delivery Open to new ideas/ways of working Technology/communications and transitional care can be caught electronically. Making the agenda personalised. Specialist commissioning with integrated care pathways. Commissioning across adult and children's services. Use of NSF for Long Term Conditions to move this forward.

Barriers to Delivery Different models of care for children/adults. Episodic nature of adult services /children's more preventative/ maintaining. Lack of knowledge in adult services. Paternalistic services. Lack of flows on neurological Long Term Conditions

Priorities in Healthier Horizons for the North West • Place individuals with Long Term Conditions and /or their carers in charge, enabling them to live well with their condition. •

Greater use of current technology to enable patients to access their health records and test results remotely, for example, kidney care: MySpace.

•

Address the skills gap of health 'educators' for Long Term Conditions within a primary care setting.

involved in this process, care is co-co-ordinated, and discharge summaries provided for all key services involved in the patients care. •

Addressing variability, working efficiently, demonstrating high levels of productivity and achievement of ambitions for quality.

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Support teams to develop creative approaches to service provision.

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Support and empower practitioners.

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Ensure that there are robust systems in place.

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Develop personalised care plans using joint care planning/integrated assessment and joined up multidisciplinary working along the care pathways.

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Intermediate care and rehabilitation services should form part of the Long Term Conditions

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Maximise the potential for modern targeted, community services to improve efficiency and effectiveness of the wider health and social care system. This may include joint health and social care team development. Extend the hours of service according to patients needs.

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Use case managers as key workers.

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Use technology as a virtual means of asking advice or a second opinion from a specialist, Allied Health Professional or GP.

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Use a 'buddy' system to support patients.

North West Community Provider Alliance Clinical Pathway Workshop 2009

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Consider the person's social, cultural and family circumstances - not just clinical.

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Develop and apply the social care model for personalised budgets and payments.

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Increased support for patients, their families and carers in managing Long Term Conditions, including from voluntary groups.

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A named patient advocate and care co-ordinator for all patients with an Long Term Conditions. Exploit the use of technology to maximum effect by providing support to dedicated staff on how to introduce new technology and how to measure its effectiveness.

5. Top 3-5 Improvements Improve Primary Care

Benefits for Patients Improved primary care will ultimately improve access for patients and reduce the need for Out Of Hours care. Ultimately this will improve quality of care and reduce complications. Enables care closer to home giving patients seamless care, continuity, good relationships with their carers and professionals.

Benefits for Commissioners Reduced acute admissions and interventions. Reduced need for services. Increased self care and quality of life.

Benefits for System Reform Opportunities for reinvestment illness/wellness with increased evidence for quality assurance. Improved community health and wellbeing.

Reduction in medication costs.

Improved and better coordinated working relationships between GPs/community services.

Barriers to Delivery GPs/QOF. Organisational boundaries.

Use of shared IT systems.

Relationships between GPs/Community Services.

Improved effectiveness and efficiency. i.e. Choose and Book.

Shared IT Systems. Lack of awareness/knowledge of services available. Referral criteria.

Medicine Management is more effective and efficient with a choice for patients.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Access to services.

Priorities in Transformational Guides • Know about local health needs and plan services accordingly. •

Work with Commissioners to agree outcome data that needs to be collected to demonstrate effective intervention.

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Develop systems and processes, which encourage constant patient, service user and carer feedback. Audit changes which have been made as a result of feedback on user experience

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Create effective health and care partnerships.

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Implement new services approach - addressing viability, working efficiently, demonstrating high levels of productivity and achievement of ambitions for quality.

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Provide local health information about your services, access, availability and choices for patients, the public and professionals.

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Provide clear information about OOH service provision to patients, public and practitioners.

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Provide the right resource, in the right place, at the appropriate time in accordance with need.

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For people with LTC or complex health care needs - provide a personalised care plan and, where appropriate, use joint care planning or integrated assessments such as the single assessment process or CAF.

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Use technology to implement shared care planning.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Further development of practice based registers to target screening - developing appropriate pathways for preventing further progression of disease.

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Commissioners (PCTs and Social Care) should jointly develop 'care passports'.

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PCTs should maximise the defined role of pharmacists in self care of long term conditions.

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The role of primary care should be strengthened and developed with new skills and ways of working to deliver more personalised care around patients.

6. Top 3-5 Improvements Joint working and integrated access to care pathway.

Benefits for Patients Joint working/single assessment process/planning means that patients only have to tell their story once which reduces duplication. Increased continuity and co-ordination of care. Joint working so there is always a professional knowledge base if unable to communicate with patients or other colleagues. Improved treatment and outcomes.

Benefits for Commissioners Improved efficiency of care packages. Improved quality and outcomes. Measurement of outcomes and benefits.

Benefits for System Reform Progressive way to make systems lean - spend to save. Funding is linear and therefore able to support timely and efficient pathway response to patients needs.

Improved safeguarding.

More patients cared for/maintained in the community.

Hits government targets.

Reduced demand for hospital services.

Agencies committed to use of Single Assessment Process.

Joint commissioning arrangement for efficiency and effectiveness and links to Mental Health and Physical Health agenda.

Timely and efficient service.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers To Barriers to Delivery Delivery Promote local specialist Location. networks/peer support. Co-location a benefit? Peer support with Healthcare increased knowledge professionals to charge base for sharing = for services? shared core skills. Sharper focus at interfaces between services and agencies through improved collaboration which breaks down 'silos'.

Differences in NHS and Social Care legislation. Culture. Protection of existing roles.

Priorities in Transformational Guides • Invest in telehealth and telecare to empower patients to take control of their health needs, under the guidance and support of the case manager.

Priorities in Healthier Horizons for the North West • Place individuals with LTC and /or their carers in charge, enabling them to live well with their condition. •

Greater use of current technology to enable patients to access their health records and test results remotely, for example, kidney care: MySpace.

• Engage service users and carers as a means of offering choice and personalisation. Include encouragement to participate in expert patient programmes with personalised budgets.

Address the skills gap of health 'educators' for LTC within a primary care setting.

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Commissioners (PCTs and Social Care) should jointly develop 'care passports'.

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Intermediate care and rehabilitation services should form part of the LTC.

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Develop and apply the social care model for personalised budgets and payments.

•

Work closely with the Mental Health teams to develop referral pathways.

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Increased support for patients, their families and carers in managing LTC, including from voluntary groups.

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Extend the hours of service according to patients needs. •

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Use case managers as key workers.

A named patient advocate and care co-ordinator for all patients with an LTC.

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Use technology to implement shared care planning.

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Use technology as a virtual means of asking advice or a second opinion from a specialist, AHP or GP.

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Use a 'buddy' system to support patients.

•

Develop personalised care plans using joint care planning/integrated assessment and joint up multidisciplinary working along the care pathway.

North West Community Provider Alliance Clinical Pathway Workshop 2009

7. Top 3-5 Improvements Intermediate Care as a philosophy rather than separate team plus priority for local systems to implement.

Benefits for Patients Care does not need to fit into a â&#x20AC;&#x2DC;boxâ&#x20AC;&#x2122;, there should be no criteria for exclusion. Services to be needs led, not criteria driven. Open access across a range of services.

Benefits for Benefits for System Reform Commissioners Underpinned by Links nicely to urgent care reform, NSF which is self-care, end of life care. measurable. Links with mental and physical Improves and health agenda. increases accessibility with Provides care closer to home. equality of Reduces hospital admissions. access. Patient pathways should include intermediate care as part of package of care rather than separate care.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Enables development of the rehabilitation agenda with increased clarity for the efficient use of resources. Less specialism and more joint working promoted. Links to clinical/medical support i.e. Geriatrician.

Barriers to Delivery Cultural change.

Priorities in Transformational Guides • Intermediate care and rehabilitation services should form part of the LTC pathway. •

Work closely with the Mental Health teams to develop referral pathways.

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Extend the hours of service according to patients needs.

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Use case managers as key workers.

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Use technology to implement shared care planning.

•

Use technology as a virtual means of asking advice or a second opinion from a specialist, AHP or GP.

•

Use a 'buddy' system to support patients.

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Create effective health and care partnerships.

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Provide the right resource, in the right place, at the appropriate time in accordance with need.

•

Invest in telehealth and telecare to empower patients to take control of their health needs, under the guidance and support of the case manager.

•

Develop personalised care plans using joint care planning/integrated assessments and join up multidisciplinary working along the care pathway.

North West Community Provider Alliance Clinical Pathway Workshop 2009

There needs to be a clear description of what primary care should be like to incorporate social care, community care and specialists.

•

A designated care co-ordinator will have responsibility for ensuring that a plan is developed and agreed.

•

The role of primary care should be strengthened and developed with new skills and ways of working to deliver more personalised care around patients.

8. Top 3-5 Improvements Improve staff skills in generalist and expert roles and develop advanced practitioners.

Benefits for Patients Right skills, in the right place, at the right time, which ensures minimum intervention, with maximum quality and effectiveness..

Benefits for Commissioners Less input but the same productivity with a flexible workforce. Uses a flexible approach with one person rather than numerous professionals. Commissioning pathways increases efficiency and effectiveness

Benefits for System Reform Extended career opportunities as professionals become multiskilled. Uses modernised training to gain skilled professionals.

Enablers to Delivery More modern training is required with defined roles to reflect this. Most of this can be work based learning/competency based on KSF

Barriers to Delivery Training not up-to-date. Job descriptions/roles not fit for purpose. Staff confidence. Professional bodies. Culture.

Trans-disciplinary.

Priorities in Transformational Guides • Provide staff with appropriate training. This may include non-medical prescribing, advanced assessment, motivational interviewing or cognitive behavioural therapy skills.

Priorities in Healthier Horizons for the North West • A review of the capacity and skills mix needed in primary care to support LTC. •

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Entrepreneurial practitioners maximising opportunities and demonstrating the ability to lead and develop effective and productive nurse and AHP services.

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Seeking out business opportunities to develop care closer to home initiatives.

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Display expert leadership skills ensuring that the attributes become embedded within work. Display influencing skills and ability to implement change. Work with commissioners, managers and others to redesign care pathways which will address all the elements of LTC management.

North West Community Provider Alliance Clinical Pathway Workshop 2009

A new model of care should be commissioned that enables integration of health and social care, with the roles of professionals changing to meet patients' needs. There needs to be a clear description of what primary care should be like to incorporate social care, community care and specialists.

END OF LIFE CARE

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Standardised care pathway for end of life care to enable equitable access, regardless of clinical diagnosis.

Benefits for Patients Standardisation of care pathways promotes equity, quality, experience, support, and advanced care planning. Clinical Pathways set out clearly defined expectations which promote consistency.

Benefits for Commissioners Clinical pathways are clearly commissioned as an integrated and complete service. They are cost effective and enable advanced planning which supports World Class Commissioning.

Benefits for System Reform Care delivered closer to home, which promotes patient choice. Develops Integrated Care Pathways for efficient service delivery.

Enablers To Delivery The North West End of life pathway is already in place with some evidence locally about using this to meet local needs/map service. The pathway is well evidenced. It promotes a high profile of end of life care nationally.

Benchmarking of quality and efficiency.

Some areas of the North West already have baseline measures of available resources.

Integrated Care Pathway is well evidenced.

Barriers to Delivery Ambiguity - where is the patient on the pathway? Personalisation of care. Change process for staff groups â&#x20AC;&#x201C; ie. move from established roles and functions, competencies. Getting partners to agree to work collaboratively. Unknown resource issues. Gaps in knowledge/ gaps in service provision.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Transformational Guides •

Ensure early identification of patients and have sensitive conversations about death, dying, choice and personalisation with patients, carers and families

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Ensure that care for those approaching end of life is accessible, responsive and available 24 hours a day. All patients should have a case manager and documentation (where appropriate) on advanced care wishes and preferences for care.

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Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway. Ensure GPs, ambulance trusts, out-of-hours providers, specialist palliative teams, district nursing teams, acute sector, hospices, care homes, social care and all other practitioners who have a contribution help devise care plans and agree roles, responsibilities and communication channels.

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Ensure that all providers who support end of life care within the home, and proactively work to prevent admissions into an acute trust, work together to understand their role in clinical care and prevention.

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Familiarise yourself with your SHA and PCT end of life care strategic plans which encompass patients with all diagnoses, care provided in any setting by a collective of organisations and providers, and covers each step of the end of life care pathway.

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Ensure that all end of life care teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients.

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Priorities in Healthier Horizons for the North West • The pathway should be underpinned by strategic partnerships with coordination across all organisations and at operational level between services delivered by hospitals, PCTs, social care, ambulance services and the voluntary sector to provide seamless service. •

It is vital to have a robust, integrated commissioning framework, based on the North West end of life care model across health, social care, voluntary, charitable and independent sectors, with strategic leadership. This will ensure consistency of approach, personalised care and choice, facilitating timely and appropriate access to services for patients and their families.

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A joint health and social care commissioning framework should be in place for the end of life care services.

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A financial investment programme should be identified to support the delivery of the health and social care commissioning strategy.

Identify all local agencies and third sector organisations who provide end of life care provision and support, including those offering emotional and bereavement support for children and adults. Develop collaborative relationships to complement and co-ordinate care. Integrated pathways are a widely accepted model to improving standardisation, continuity / collaboration among multi-disciplinary teams.

North West Community Provider Alliance Clinical Pathway Workshop 2009

2. Top 3-5 Improvements Ring fenced funding with robust tiered access to support people in their last days/weeks of life.

Benefits for Patients

Benefits for Commissioners Management of costs are more predictable.

Ring fencing means the money is available, therefore there will not be time delays to access this Allows speedier service for patients. safe discharges There will be speedier which are relevant discharge home which to helps patients make the economy/finance right choice. as care at home may be cheaper. Ring fencing means that organisation and forward Avoids planning is easier, hence, acute/emergency freeing up precious time admission as care for care of patients. is managed. Promotes fair access. An example is Stoke on Trent PCT - who ring fenced their equipment service.

Benefits for System Reform Enables patients and professionals to make choices. Rapid discharge through pathways. Admission avoidance.

Time is freed up through management of patients, therefore, it is better use of resources - more time to care and not chase up equipment etc.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Examples from other areas can be replicated. Predictable costs may be attractive. Preferred priorities for care (PPC) audit demonstrates where people have not had access to resources to enable their choice.

Barriers to Delivery By definition, limited resources. Access criteria, equity across other client groups. How much is enough? What are the right criteria for access: open to misuse?

Priorities in Transformational Guides • Know about local health needs and plan services accordingly. •

•

Priorities in Healthier Horizons for the North West • Advanced care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .

Work with commissioners to agree the outcome data that needs to be collected for a specific service area to demonstrate effective intervention.

•

A financial investment programme should be identified to support the delivery of the health and social care commissioning strategy.

•

Protocols for continuing healthcare funding are consistently and equitably applied and accessible in a timely manner (fast tracked).

Create effective and health and care partnerships.

•

Implement new service approaches.

•

Provide the right resources, in the right place, at the appropriate time in accordance with need Benefits realisation: demonstrate that the benefits envisaged are actually derived. Actions to create the change and the delivery of outcomes should be monitored through a plan to track the implementation and the service improvements.

North West Community Provider Alliance Clinical Pathway Workshop 2009

3. Top 3-5 Improvements Access to appropriate knowledgeable generalist care 24/7, supported by specialist practitioners (Multi Disciplinary Team) to include sitting service respite for carers.

Benefits for Patients Provides continuation of care and increases quality of life. Patients and carers have an improved experience of palliative care and support. This relieves burden and supports positive grieving with psychological support. Preferred Priorities for Care (PPC) gives patients and carers the confidence to stay at home. Crises are managed more effectively.

Benefits for Commissioners Decreased pressure on the system overall as it is managing more specialist care in the community. Decreased pressure on bereavement services as patients and carers are supported at home. Fewer emergency admissions. Enables speedier discharge. Promotes engagement with charitable agencies and other partners. Promotes reliable community service provision and increases staff morale.

Benefits for System Reform A change in working practices is needed in line with World Class Commissioning, NICE promotes a more positive end of life strategy. Patients able to exercise more choice. Skill mix, of integrated working and professionals supports patients and carers better at home. Admission avoidance relieves pressure on the whole system e.g. hospices.

NICE promotes a more positive end of life strategy.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery At the moment good practice is available, but in pockets - this can be replicated as the infrastructure is already commissioned. This just needs strengthening and building. This will provide a good evidence base.

Barriers to Delivery Reluctance of staff to change. Short term costs long term gains. How to measure success? Guidelines support development of specialist roles but these don't have capacity to deliver - or have the capacity to build.

Priorities in Transformational Guides • Use an established framework such as the gold standards framework or Liverpool care pathway to optimise care delivery. •

•

Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway. Make sure GPs, ambulance trusts, out-of-hours providers, specialist palliative teams, district nursing teams, acute sector, hospices, care homes, social care and all other practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels. Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients. Identify all local agencies and third sector organisations who can provide end of life care provision and support, including those offering emotional and bereavement support for children and adults. Develop collaborative relationships to complement ad co-ordinate care. Ensure that all providers who support end of life care within the home, and proactively work to prevent admissions into an acute trust, work together to understand their role in clinical care and prevention.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Advance care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) . •

Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61) .

•

All GP practices have a supportive register in place for patients who are known to be in their last year of life.

•

End of life services need to be comprehensive and available to all 24/7.

•

A single point of access for individuals and their carers also needs to be put in place and would include access for carers and family during the bereavement phase, ensuring the provision of appropriate support.

•

To ensure a comprehensive, co-ordinated and seamless approach, it is crucial that professionals and organisations work together so that when people need to use the service it is a 'one service' that is clear and easy to access.

4. Top 3-5 Improvements Commission clinical leadership in community services in End of Life care moving to drive, quality, access, innovation

Benefits for Patients Clinical leadership will drive the service, therefore, access/quality of care systematically improves. Innovations are delivered, profile is raised, infrastructure is developed, leading to a happier and more productive workforce so enabling increased service delivery.

Benefits for Commissioners There are long term gains plus quick wins for patients, with increased quality assurance.

Benefits for System Reform As this is service driven then access/quality of care systematically improves. Innovations are delivered, profile is raised as infrastructure is developed. A happier and more productive workforce will increase service delivery. Patients have long term gains plus quick wins. Quality assurance

Priorities in Transformational Guides •

Support teams to develop creative approaches to service provision, which will improve choice, personalisation, efficiency.

•

Support and empower practitioners to develop multidisciplinary teams using approaches such as transformational attributes

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Create effective health and care partnerships

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Use technology to support shared care, joint care planning.

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Joint working between specialist hospital care teams and community services can be particularly beneficial.

•

Commissioners and Providers work together to ensure that where good evidence exists this is implemented within local services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Using evidence of good practice gives existing practitioners a good base to deliver a robust and quality service.

Barriers to Delivery Expensive resource undervalued by commissioners. Avoid commissioners over-managing. Is it for the provider to deliver from whole pathways costs?

Priorities in Healthier Horizons for the North West •

NHS North West should work closely with all services to determine and meet workforce requirements and to ensure education and training programmes are available for all health and social care staff (NICE,2004:13).

•

The North West will work closely with all education providers including the hospices and third sector in particular to develop a more strategic approach to education and training for end of life care.

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Individual practitioners should ensure they have the knowledge and skills required for the roles they undertake within the spectrum of end of life care (NICE, 2004:14).

•

All provider organisations should identify the end of life training needs of staff and should facilitate their participation in training and ongoing development.

5. Top 3-5 Improvements Use of Primary Care Local Enhanced Service (LES) to improve GP case management in the community More people will die at home, well supported in the community.

Benefits for Patients Provide a working model of case management. This way of working enables patient and professional choice and coordination of care.

Benefits for Commissioners Outcomes are commissioned which decrease inpatient costs.

Benefits for System Reform This enables care closer to home giving patient choice. All services are integrated.

There will be a financial reward for GPs who are the most likely people to have awareness of client base. Local Enhanced Service (LES) is used positively elsewhere as an enabler of change.

Work towards the Gold standards framework where there is evidence of GP change of behaviour with QoF incentive.

Improving case management will release capacity in secondary care.

The use of Preferred Priorities for Care (PPC) allow patients wishes. Better communication in multidisciplinary team.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Barriers to Delivery GP competencies in end of life care. GP compliance with system and best practice (culture). Competing priorities for GPs.

Priorities in Transformational Guides • Create effective health and care partnerships - strengthen partnership working across health and social care.

Priorities in Healthier Horizons for the North West • All GP practices have a supportive register in place for patients who are known to be in their last year of life.

•

Implement new service approaches.

•

End of life services need to be comprehensive and available to all 24/7.

•

Provide the right resource, in the right place, at the appropriate time in accordance with need.

•

To ensure a comprehensive, co-ordinated and seamless approach, it is crucial that they work together across professions and organisations so that when people need to use the service it is a 'one service' that is clear and easy to access.

•

Advanced care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .

•

A financial investment programme should be identified to support the delivery of the health and social care commissioning strategy.

•

Ensure that all patients who are approaching end of life are identified early and sensitive conversations are had about death and dying, choice and personalisation with patients, carers and families.

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Ensure that a local practice register is kept and available for all health and social care practitioners involved in palliative and end of life care. The register should hold information regarding advance care plans and the do not attempt resuscitation (DNAR) status of the individual subject to their consent.

North West Community Provider Alliance Clinical Pathway Workshop 2009

6. Top 3-5 Improvements Advanced care planning - level 4 Gold Standards Framework (GSF) Integrated Care Planning (ICP) Preferred Priorities for Care (PPC)

Benefits for Patients Advance planning will help with medicine management by allowing anticipatory prescribing. Developing pro-active care planning across End of Life Care and into bereavement means that patients and carers receive a seamless service.

Benefits for Commissioners By using advance care planning there will be increased home deaths, therefore, a 10% reduction in hospital deaths saving money in the acute sector.

Benefits for System Reform Care management will help to streamlined services and by using integrated services duplication reduced.

GSF - level 4 â&#x20AC;&#x201C; in all care settings. Substantive End of Life Care facilitator.

Prescribing costs will be reduced as they are managed better = Value for Quality care = improved money. patient pathway, patient choice with better care Better, managed experience, which care will achieve reduces inappropriate quality markers admissions to hospital. increasing patient and carer Advance planning experience enables rapid because of discharge. reduced hospital stays.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery By using three tools, fully implemented in all care settings.

Extend principles of End of Life Care to all end of life threatening illnesses. Use peer review against quality markers.

Barriers to Delivery Optional not compulsory. Lack of awareness/confidence.

Cost/ funding.

Priorities in Transformational Guides • Implement new service approaches •

Priorities in Healthier Horizons for the North West • Advance care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .

Provide a personalised care plan and, where appropriate, use joint care planning or integrated assessments such as the single assessment process or common assessment process (CAF).

•

Provide patients and carers with a named key worker or case manager, with a care plan, to ensure high quality, safe and effective continuity of care.

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Use and develop evidence based practice and validated research to improve clinical practice. Ensure that care for those approaching the end of life is accessible, responsive and available twenty four hours a day.

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Offer all patients approaching the end of life the opportunity to express their preferences and wishes for care, death and dying.

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Patients should have access to 24hr emergency medicines

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Care should be avail 24hrs a day to enable people to live and die at the place of their choice.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61) .

•

All GP practices have a supportive register in place for patients who are known to be in their last year of life.

•

End of life services need to be comprehensive and available to all 24/7.

•

7. Top 3-5 Improvements Education, training including communication skills and non malignancy care.

Benefits for Patients Improved care for patients will be further enhanced by up-todate training for all staff.

Benefits for Commissioners There is likely to be a reduction in complaints/clinical incidents as there are the right skills in teams

This will increase patient, carer and staff It is cost effective confidence and help Improved quality of staff deliver choice for end of life care patients and carer, therefore, more likely to achieve Preferred Priorities for Care (PPC)

Benefits for System Reform Recruitment and retention will be improved as training is part of their job description, hence, better and more rewarding job satisfaction and productivity Enables succession planning where staff are aware of service development

Achieves better patient and carer experience

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery There needs to be an established, robust education and training strategy to develop the provider workforce and strategic development plans. Key worker scheme and development.

Barriers to Delivery Seen solely as a nursing responsibility. Education takes away from face to face contact. Costly/staff not released. Difficult to sustain in care homes (staff turn-over)

Priorities in Transformational Guides • Commissioner and provider management teams must be responsible for developing a competent workforce that will deliver sufficient current and future services safely, effectively and which have a positive impact on service user experience.

•

Individual practitioners should ensure they have the knowledge and skills required for the roles they undertake within the spectrum of end of life care (NICE, 2004:14).

Use and develop evidence based practice and validated research to improve clinical practice

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Ensure practitioners are trained in assessment and care planning, symptom management and advance care planning relating to end of life

All provider organisations should identify the end of life training needs of staff and should facilitate their participation in training and ongoing development.

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The development of competencies for end of life care, particularly communication skills, are identified and used to inform learning and practice.

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Practitioners and clinical teams need to review best practice and prioritise development plans for service delivery

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Provide access to robust training and education, clinical supervision and improved clinical leadership, managerial and business skills to improve health outcomes

•

Priorities in Healthier Horizons for the North West • NHS North West should work closely with all services to determine and meet workforce requirements and to ensure education and training programmes are available for all health and social care staff (NICE,2004:13).

North West Community Provider Alliance Clinical Pathway Workshop 2009

8. Top 3-5 Improvements Access to 24hr Specialist Palliative Care ( SPC) advice including 7 day face to face core hours contact 9-5

Benefits for Patients Improved access helps to keep patients at home with better pain and symptom control, therefore achieving Preferred Priorities for Care (PPC). Patients and carers have increased confidence in their end of life team.

Benefits for Commissioners Reduction in complaints/critical incidents. Reduction in prescribing costs. Improves patient and carers experience.

Benefits for System Reform Increased support for generalist staff.

Enablers to Delivery Review existing team and skill mix.

Opportunity for system reform and service redesign through collaboration between provider partners.

HR and staff side engagement. Commissioning intent. Robust partnerships. Single point of access.Information on services (in SPC Packs)

Reduction in length of stay

Priorities in Transformational Guides

Barriers to Delivery Funding, Fragmented approach. Patient and carers not accessing services. Reduced core service.

Priorities in Healthier Horizons for the North West

•

Use an established framework such as the Gold Standards Framework.

•

Advance care planning (ACP) and all three end of life tools are used in all care settings.

•

Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway.

•

Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61).

Make sure all practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels

•

All GP practices have a supportive register in place for patients known to be in their last year of .

•

End of life services need to be comprehensive and available to all 24/7.

•

A single point of access for individuals and their carers needs to be put in place.

•

Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients Develop collaborative relationship with all local agencies and third sector organisations who can provide end of life care provision and support.

North West Community Provider Alliance Clinical Pathway Workshop 2009

9. Top 3-5 Improvements

Benefits for Patients

Rapid Response Increases type services patient choice (24 hr) with reduced hospital admission at end of life. Rapid response also supports carers

Benefits for Benefits for Commissioners System Reform Rapid response Opportunity type service can for integrated service contribute to 10% reduction in delivery hospital death and also improves patient and carer experience.

Enablers to Delivery

Barriers to Delivery

Encourages partnership working across pathway with engagement from commissioners. Helps to develop robust contracts, equipment etc with other providers. Procurement is across partnerships.

Commissioner awareness of what provider services can deliver. No clarity around definition of rapid response for End of Life Care. Workforce resource issues Funding. Public expectations. Media message re: Macmillan Marie Curie

Define and develop robust service model and service spec to develop quicker response times. Supports the provider/commissioner relationship.

Priorities in Transformational Guides •

Provide local information about your services: the access, availability, choices, for patients, the public and professionals.

•

Check against the experience of those using your services to ensure understanding. Provide the right resources, in the right place, at the appropriate time in accordance with need. Ensure that all providers who support end of life care within the home, and proactively work to prevent admissions into an acute trust, work together to understand their role in clinical care and prevention.

•

Implement new services approaches and expand end of life care. This should include developing end of life services for patients with long term conditions and older people with co-morbidities. This should also include supporting the delivery of services in settings such as care homes, hostels and prisons.

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Care should be available 24hrs a day to enable people to live and die at the place of their choice, this may also include partnership working, joint systems planning with those who already provide a 24hr service e.g. ambulance services, Out of Hours.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West The pathway should be underpinned by strategic partnerships with co-ordination across all organisations and at operational level between services delivered by hospitals, PCTs, social care, ambulance services and the voluntary sector to provide seamless service (DH,2006.)

URGENT CARE

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Rapid Clinical Assessment and treatment in the community.

Benefits for Patients Patient Based/Centric Patients prioritised Reduced cross Infection Increased Rehabilitation Reduced Health Inequalities Improved Medicines Management

Benefits for Commissioners Value for money â&#x20AC;&#x201C; quality outcomes. Reduced Health inequalities. Reduced hospital admission.

Improved Medicines Management

Reduced hospital admission Care close/in the home

Population focused

Benefits for System Reform Integrated health and social care.

Enablers To Delivery Integrated health and social care

Barriers to Delivery Resistance to change

Improved quality and outcomes

Access to diagnostics

Clinical Ownership

Common IT System

Lack of care pathways

Innovative use of technology

IT not fit for purpose Transformed community function

Holistic/ seamless service Joined up/signposting One person assessing coordinating

Workforce development and transformation.

Rapid assessment of clinical/social need

Appropriate avoidance of hospital admissions

Business principles applied by community services.

Reduced Waiting time

Increased Carer/family benefits

North West Community Provider Alliance Clinical Pathway Workshop 2009

Integrated Budgets

Integrated Governance

Single point of access Marketing

Nobody owns the patient

Community infrastructure

Lack of engagement of GPâ&#x20AC;&#x2122;s and primary care.

Priorities in Transformational Guides • Rapid Clinical Assessment/ admissions avoidance • Identify common reasons for hospital admission or attendance. • Work in partnership with other organisations to provide creative solutions to joined up care. Identify new service solutions to hospital admission or attendance such as community matron facilitated discharge or nurse practitioner triage in A & E. More complex wound care provided in a community setting aligned to the dermatology care pathway, all clinicians must be skilled and competent in providing high quality, safe and competent wound care • Use technology as a virtual means of getting specialist advice or a second opinion from a specialist nurse, allied health professional, GP or consultant. • Deliver new and innovative services in the community such as drug therapies or outpatient services Ensure that community teams and matrons make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay or hospital wait for patients. Implement 'new service approach' - Services have to be seen to be cost effective and deliver the right care, in the right place, at the right time. Community staff should be knowledgeable about the cost benefit involved in hospital admission tariffs and facilitated discharge. This should be balanced against the cost benefit of developing new services in the community • Identify solutions to unplanned hospital admissions and attendance at A & E. Community matron facilitated discharge, nurse practitioners and occupational therapists in A & E • Be clear about the access points for service: a single point of access, triage or referral system • Work with primary care, the out-of-hours provider, adult services, ambulance trust and the acute sector to develop shared care records. This will ensure the most vulnerable, or those at risk of health deterioration are known to all services along the clinical care pathway.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Develop three multiprofessional, clinical urgent care networks in the North West, which will be responsible for driving the implementation of change, auditing the effectiveness of change through clinical outcomes and horizon scanning for innovation. • Regionally, commission the five levels of care recommended by the College of Emergency Medicine. • Shared IT between care providers must be implemented as a priority. • Develop an interprofessional workforce with a culture of joint teaching and learning. • Mental health, alcohol and drug services and social care to be fully integrated into urgent care response.

2. Top 3-5 Improvements 7 Day Working

Benefits for Patients Continuity of care

Benefits for Commissioners Continuity of care

Reduced Admissions Increased speed of discharge

Reduced Admissions

Access to equipment Timely care

Increased discharge

General Benefits to patients Reduced cross infection. Care close/in the home

Access to equipment

Holistic/ seamless service joined up/signposting

Timely care

One person assessing coordinating â&#x20AC;&#x201C; ACM

Population focused

Rapid assessment â&#x20AC;&#x201C; clinical/social need Reduced Waiting time Increased rehabilitation Increased Carer/family benefits

Benefits for System Reform Integrated health and social care Improved quality and better outcomes Innovative Community services applying business principles

Funding/resources

Barriers to Delivery Staff Side

Appropriate clinical priority Agenda for change Flexible workforce Change fatigue

Integrated working with other organisations

Equipment users Use of technology

Workforce development and transformation

Value for money

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Priorities in Transformational Guides • Extend the hours of service according to patient need. This may include telephone access for on-call and out-of-hours home visits making the best use of in-house provision or co-ordinating this through partnership working with the ambulance trust and out-of-hours provider. •

Be clear about the access points for service. This may mean developing a single point of access, triage or referral system.

•

Work with primary care, the out-of-hours provider, adult services, ambulance trust and the acute sector to develop shared care records.

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Use technology to expand access to diagnostics and to seek advice. This may include access to PACS (digital imaging x-ray) in the community. This may also include the development of liaison and care planning systems so that the ambulance trust can admit appropriate patients direct to community services.

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Use technology as a virtual means of asking for advice or a second opinion from a specialist nurse, allied health professional, GP or consultant.

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Replace visits, where appropriate, with a telephone or videophone contact - (monitoring acute illness or LTC).

•

Use technology to empower patients to monitor their own condition.

•

Use technology as a form of documentation i.e. remote access devices - palm tops, tablets which can be synchronised easily with IT systems avoiding unnecessary travel or time wastage.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Any required service configuration will be evidence based, follow audit of patient outcomes and take account of the geography of our region to ensure best outcomes for the public wherever they live.

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Develop and support the regional clinical network, working with commissioners to develop and maintain high quality service delivery.

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Standardisation of out of hours service delivery and access to acute care and diagnostic services across the North West.

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The national number should allow a locally integrated telephone access and triage system and facilitate the development of integrated urgent care and community service access people get the right treatment in the appropriate setting is the provision of integrated urgent care services, available if required 24 hours a day, seven days a week (24/7) .

3. Top 3-5 Improvements Assisted Technology

Benefits for Patients Continuous, automatic and remote monitoring of real time emergencies and lifestyle changes Reduced unnecessary hospital admission, and visits by GP, Community Matron/Active Case Manager, District Nurse Increase patient independence - patients can take control of their condition

Benefits for Benefits for System Commissioners Reform Value for money Integrated health and social care Population focused Improved quality and outcomes

Reduction in health inequalities

Innovative use of technology

Workforce redesign

Reduced cross infection Transformed community services more business minded

Care close/in the home Holistic/seamless service joined up/signposting One person assessing coordinating Rapid assessment â&#x20AC;&#x201C; clinical/social need Reduced Waiting time Increased rehabilitation Increased Carer/family benefits

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Funding the system changes

Barriers to Delivery Fear of technology taking over clinical roles

Training for staff

Systems monitored by the company and maintained

Patient fear/resistance choosing the right company to provide cost effective support and training

Audit effectiveness

Lack of funding

Priorities in Transformational Guides • Make sure services have the right skills in the right place to treat patients safely and competently. Train staff to recognise, assess, diagnose and treat those who unexpectedly fall ill and require care. Practitioners may have to have advanced level knowledge, including physical assessment and non-medical prescribing. •

Priorities in Healthier Horizons for the North West • Review the role of telemedicine for CT scan interpretation and trauma resuscitation review, given the geographical constraints of distance and access in parts of the region.

Develop new roles such as the assistant practitioner role of foundation degree practitioner at NVQ 4 level, working in partnership with other organisations to integrate roles.

•

Use technology as a virtual means of asking for advice or a second opinion from a specialist nurse, allied health professional, GP or consultant .

•

Replace visits, where appropriate, with a telephone or videophone contact - (monitoring acute illness or LTC).

•

Use technology to empower patients to monitor their own condition, e.g. telehealth.

•

Use technology as a form of documentation i.e. remote access devices - palm tops, tablets which can be synchronised easily with IT systems avoiding unnecessary travel or time wastage.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

The national number should allow a locally integrated telephone access and triage system and facilitate the development of integrated urgent care and community service access.

•

Shared IT between care providers must be implemented as a priority.

4. Top 3-5 Improvements IV Therapy

Benefits for patients

Benefits for Commissioners

Holistic/Seamless Care Less disruption and care closer to home

Value for money

Value for money General Benefits to patients

Improved quality Reduction in health inequalities and outcomes

Reduced cross infection

Workforce

Population focused

Care close/in the home Holistic/seamless service One person assessing coordinating – Active Case Manager

Benefits for System Reform Integrated health and social care

Innovative use of technology Transformed community services more business minded

Rapid assessment – clinical/social need Reduced Waiting time Increased rehabilitation Increased Carer/family benefits

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Barriers to Delivery

Skilled workforce

Lack of commissioning

Resources

Lack of engagement from GP’s

Marketing

Lack of resources

24/7 Workforce

Lack of buy in/engagement by secondary care

Secondary care `buy in’ Clear clinical pathway

Public Perception

Priorities in Transformational Guides • Make sure services have the right skills in the right place to treat patients safely and competently. •

Train staff to recognise, assess, diagnose and treat those who unexpectedly fall ill and require care.

•

Practitioners may have to have advanced level knowledge, including physical assessment and non-medical prescribing.

•

Develop new roles such as the assistant practitioner role of foundation degree practitioner at NVQ 4 level, working in partnership with other organisations to integrate roles. This will require commissioning changes in education pathways

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Develop three multi-professional, clinical urgent care networks in the North West, which will be responsible for driving the implementation of change, auditing the effectiveness of change through clinical outcomes and horizon scanning for innovation.

•

Regionally, commission a piece of work together to further refine the five levels of care recommended by the College of Emergency Medicine.

•

Develop an inter-professional workforce with a culture of joint teaching and learning.

•

Shared IT between care providers must be implemented as a priority.

5 Top 3-5 Improvements Integration of social services and health care services

Benefits for Patients Agencies working in partnership to promote health Patients needs prioritised and quicker response promotes improved high quality service Reduced depression, anxiety which causes distress in Long Term Conditions which has major impact on health as causes distress and deterioration of physical health and increase in hospital admission and mortality rates Continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living Reduction in unnecessary hospital admission; improve care home standards Continuity of care Working in partnership with

Benefits for Commissioners Agencies working in partnership to promote health Patients needs prioritised and quicker response promotes improved high quality service Reduce depression anxiety which causes distress in Long Term Conditions which has major impact on health as causes distress and deterioration of physical health and increase in hospital admission and mortality rates Continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living Reduction in unnecessary hospital admission; improve care home standards

North West Community Provider Alliance Clinical Pathway Workshop 2009

Benefits for System Reform Integrated health & social care Quality and better outcomes Innovative Community services applying business principles

Use of technology

Enablers to Delivery Combining social and healthcare budgets Employing social/health workers in social or health teams

Common IT systems Use of Hospital Anxiety and Depression measures Develop clinical pathway for Advanced Practitioners or specialist nurses to refer to mental health services Improve Single Assessment Point

Funding System in place to identify the right patients GP Support Use of available evidence base 48

Barriers to Delivery Resistance to change Services being protective of their role Poor referral system at present. SAP documentation not appropriate Fear of technology taking over clinical role. Patient resistance choosing the right company to provide support and training â&#x20AC;&#x2DC;possibleâ&#x20AC;&#x2122; Lack of funding Lack of training Lack of GP Support

GP, care home staff, families and the patient and other agencies. Reduced cross infection Care close/in the home Holistic/ seamless service joined up/signposting One person assessing coordinating Rapid assessment – clinical/social need Reduced Waiting time Increased rehabilitation

Continuity of care Working in partnership with GP, care home staff, families and the patient and other agencies Value for money Population focused Reduced health inequalities Workforce development

Priorities in Transformational Guides • Work in partnership with other organisations to provide creative solutions to joined up care. •

Extend the hours of service according to patient need. This may include telephone access for on-call and out-of-hours home visits making the best use of in-house provision or co-ordinating this through partnership working.

•

Work with primary care, the out-of-hours provider, adult services, ambulance trust and the acute sector to develop shared care records. This will ensure the most vulnerable, or those at risk of health deterioration are known to all services along the clinical care pathway.

•

Priorities in Healthier Horizons for the North West • PCTs should commission intermediate care that is needs led, not restricted by age.

Use technology as a virtual means of asking for advice/second opinion from a specialist nurse, allied health professional, GP or consultant .

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

Nationally, social and healthcare should be funded as a single service line. Shared IT between care providers must be implemented as a priority.

•

Develop an inter-professional workforce with a culture of joint teaching and learning

•

Urgent care services should be integrated and barriers between primary, secondary and social care should be removed. The key to ensuring that people get the right treatment in the appropriate setting is the provision of integrated urgent care services, available if required 24 hours a day, seven days a week.

PLANNED CARE

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Single point of access

Benefits for Patients Single Point of Access means less confusion for patients as it simplifies the patient journey. This means that patients are seeing the right person, in the right place, at the appropriate time.

Benefits for Commissioners Commissioners know what they are paying for as they have access to the right Business Intelligence

Benefits for System Reform There are benefits for providers i.e. they can forecast demand and make arrangements to manage this. This helps to avoid bottlenecks into the system and supports the development of standardised measures of quality and the capturing and use of patient experience.

Enablers To Delivery Modern IT drives efficiencies and so becoming more effective. Modern staff training enables professionals to give a more efficient and effective service to patients

Barriers to Delivery IT Culture Organisational boundaries

Patients gain good pain management

Priorities in Transformational Guides •

Build and develop multidisciplinary and interagency teams to deliver person centred rehabilitation.

•

Invest in services that maximise a return to work.

•

Use evidence based care pathways as a tool to provide shared vision.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West •

Ensure that care is provided by a provider best able to meet the needs of the patient, and deliver high quality evidence based care which is valued by the public.

•

Care should be provided by the provider best able to meet the needs of the patient irrespective of whether they are an NHS organisation, as long as NHS values are maintained.

2. Top 3-5 Improvements Integrated IT systems that `talk’ to each other and enable rapid communication and the use of real time information.

Benefits for Patients

Benefits for Commissioners

Supports single assessment process and promotes patient choice.

Business Intelligence is upto-date.

Reduces duplication and improves access for patients. Patients understand the process which in turn reduces complaints. Healthcare records are updated and supported, therefore, the most current information is available.

Benefits for System Reform Change in behaviour and culture for a modernised workforce.

Enablers to Delivery

Barriers to Delivery

Able to target finance to ensure care in the right place and at the right time.

Costs.

Modernised staff training.

National agreements. Sharing information across organisations.

IT support for data sharing.

Reduces waiting times.

Priorities in Transformational Guides •

Use assistive technology including telecare to optimise health and wellbeing including maintenance.

•

Use technology such as telehealth to enable and empower people to monitor their own conditions.

•

Use regular telephone support/video linkage as part of the rehabilitation programme

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West • Shared IT between care providers must be implemented as a priority

3. Top 3-5 Improvements Increased business acumen/ business relationships by community services

Benefits for Patients This approach offers value for money to taxpayers and provides efficient & accessible services. There are more opportunities to be involved.

Benefits for Commissioners By using Business Models other providers can be brought into the market place.

Benefits for System Reform

Enablers to Delivery

Using the World Class Commissioning guidelines to identify and incentivise outcomes.

Transforming Community Services - providing services in a community setting in line with Department of Health Policy using the market place to tender for and obtain the best services possible. This will involve competition from other providers and opportunities for collaboration.

Increased collaboration between providers for effective pathway delivery.

Priorities in Transformational Guides

NHS Culture. Economic climate. Change of Government.

Priorities in Healthier Horizons for the North West

•

Maximise opportunities and demonstrating the ability to lead and further develop effective productive services which promote self-referral wherever appropriate and multidisciplinary ordering of investigations and onward referrals.

•

Seeking out business opportunities to develop new ways of delivering rehabilitation services either with existing providers or through new service development. This may include thinking about social enterprise or integrated care organisations.

•

Developing positive risk opportunities when delivering rehabilitation.

•

Understand the business process, impact of the economic downturn and productivity /efficiency measures and how to put together a business case which can evidence value for money whilst ensuring high quality care and patient safety.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Challenges of Transforming Community Services.

•

Deliver Advancing Quality programme to ensure that the payment mechanism rewards the delivery of quality outcomes including the patient's experience of the health service.

STAYING HEALTHY

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Proactive Health Care Screening for vulnerable groups, learning disabilities and older people. This is everyone's responsibility.

Benefits for Patients Staying healthy for longer increases health and well being (physical & mental). This in turn increases economic independence, therefore, reduces ill health payments by the government. Patients gain knowledge, empowerment, confidence which increases their choice of services as they are able to navigate around the NHS system

Benefits for Commissioners Earlier intervention to prevent specialised service requirements i.e. long term conditions. Reduced hospital admissions. Creates independence. Maximises the input of current services.

Benefits for System Reform Focus on health care screening in community services decreases demand for acute care and increases enablement of self care. It also enhances the skills knowledge of community staff to deliver inclusive, comprehensive services. Productivity/ capacity gains in the community from co-location and coordination which enables innovation in the long term which could reverse the increase in lifestyle related illness reliant on professional care. Increases coordination of services which reduces duplication and inappropriate referrals and multiple staff visits. This also reduces DNA's and increases safeguarding of vulnerable adults. Supports common data sets, quality indicators, and measured improved health outcomes through the effective commissioning of health and well being services. This is part of tiered/stratified services targeting vulnerable groups who may be excluded or not available from the current services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers To Delivery Develop the evidence of needs through partnership working through the political/cultural/will/policy context. It should focus on inequalities.

Barriers to Delivery Commissioners will have to decommission secondary services to invest in pro-active care.

Training for the workforce will increase system capacity and capability for prevention.

Professionals may protect their own service area and not engage fully.

Focusing on value for money makes radical change possible.

Balance between quality & value for money.

Through demonstrator sites contestability can be tested.

Shared insight vs buy in.

Professionals can work with patients to re-design services.

Clinical pathway design, people do not follow single pathways neither do services.

Greater use of technology.

Productivity vs personalised services

Priorities in Transformational Guides •

Change is inevitable. There is more in common between services than Embraces a philosophy that health, wellbeing and reducing inequalities is every practitioner’s role.

•

Know the range of intervention which promote positive behaviour Extend their impact of health outcomes through joint working with local partners.

•

All practitioners can maximise their role in promoting health and wellbeing.

•

Make good use of ‘teachable’ moments.

•

Educate teams in accessing and understanding information, initiating an d managing difficult conversations and delivery of health messages in ways that are culturally appropriate.

•

Services are planned and delivered in ways that actively seek to reduce health inequalities.

•

Provide the right resources at the appropriate time in the right place in accordance with need. Overnight/ weekend care/24 hr care. May mean working with other partners to ensure that systems are in place to access care. This may include capacity management systems, access points, and telephone triage.

•

Partners should include the out of hours provider and Ambulance Trusts.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West

____________________________

2. Top 3-5 Improvements Coordination/ co-location of wellbeing services/ lifestyle advice (sensitive/ responsive to vulnerable groups) including links to acute care and mental health to enable opportunistic advice.

Benefits for Patients Increased expectation of own health (breaking negative cycles in communities and families). Experience of co-ordinated care. Easy access to services which are responsive to vulnerable groups. Holistic/ responding to your health needs which are person centred.

Benefits for Commissioners Increase in the uptake of services. Improved outcomes. Increased uptake from vulnerable groups, therefore, reducing health inequalities. Efficiency and productivity gains. Opportunity to innovate across services.

Benefits for System Reform

Enablers to Delivery

Focus on health care screening in community services, therefore, decreases acute care and increases enablement of self care. It also enhances the skills knowledge of community staff to deliver inclusive, comprehensive services.

Develop the evidence of needs through partnership working through the political/cultural/will/policy context. It should focus on inequalities.

Productivity/capacity gains in the community from co-location coordination which enables innovation in the long term which could reverse the increase in lifestyle related illness reliant on professional care. Increases co-ordination of services which reduces duplication and inappropriate referrals = multiple staff visits, This also reduces DNA's and increases safeguarding of vulnerable adults. Supports common data sets, quality indicators, and measured improved health outcomes through the effective commissioning of health and well being services. This is part of tiered/stratified services targeting vulnerable groups who may be excluded or not available from the current services

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Commissioners will have to decommission secondary services to invest in pro-active care.

Professionals may protect their own service area and Training for the workforce will not engage fully. increase system capacity and capability for prevention. Balance between quality & value for money. Focusing on value for money Shared insight vs buy in. makes radical change possible. Clinical pathway design, Through demonstrator sites contestability can be tested.

people do not follow single pathways neither do services.

Professionals can work with patients to re-design services.

Productivity vs personalised services

Greater use of technology.

Priorities in Transformational Guides • Embrace philosophy that ‘promoting health and wellbeing and reducing inequality’ is every practitioners role. •

Priorities in Healthier Horizons for the North West • Work with Care Services Improvement Partnership to ensure that all relevant partners develop their workforces to deliver health improvements and reduce health inequalities.

Provide a personalised care plan, and where appropriate, use joint care planning or integrated assessments such as the single assessment process.

•

Provide patients and carers with a named key worker or case manager to ensure high quality, safe and effective continuity of care.

•

Ensure that you are familiar with your PCT’s local carers strategy, providing all carers with a holistic assessment in their own right and giving appropriate information, support and advise for them to remain healthy and within their own home.

•

Commissioners and provider management teams must be responsible for developing a competent workforce that will deliver current and future services safely, effectively and which have a positive impact on service user experience.

•

Practitioners and clinical teams need to review best practice and prioritise development plans for service delivery.

•

Provide access to robust training and education, clinical supervision and improved clinical leadership, managerial and business skills to improve health outcomes.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

Identify and increase preventative health spend in PCTs, ensuring that health improvement activity is commissioned as part of service level agreements and new prevention services are developed and delivered by a range of providers.

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Work with the North West Regional Development Agency to support the development of workforce capacity and capability to deliver the Staying Healthy agenda through sustainable public sector procurement and the Good Corporate Citizen Group.

•

Develop a new regional, cross sector system that offers regional funding streams, stronger regional accountability frameworks and more space for local services to be tailored to individual need.

3. Top 3-5 Improvements Awareness training to respond to the needs of vulnerable people. (Linked to no 1.)

Benefits for Patients All health professionals trained to be responsive to the patients health needs. Increased flexibility of how services/advice is provided. Consistent advice/support.

Benefits fo Commissioners Essential enabler to realise the benefits of 1 & 2. Increased quality of care. Patient safety benefits and reduces risk of complaints and adverse incidents (reputation of commissioners).

Benefits for System Reform

Enablers to Delivery

Focus on community services, therefore, decreases acute care and increases enablement.

Develop the evidence of needs through partnership working through the political/cultural/will/p olicy context. It should Professionals may protect their focus on inequalities. own service area and not engage fully. Training for the Balance between quality & value workforce will for money. increase system capacity and Shared insight vs buy in. capability for prevention. Clinical pathway design, people do not follow single pathways Focusing on value for neither do services. money makes radical change possible. Productivity vs personalised services. Through demonstrator sites contestability can be tested.

Tiered services targeting vulnerable groups who may be excluded or not available from the current services. Enhances the skills knowledge of community staff to deliver inclusive, comprehensive services. Productivity/capacity gains in the community from co-location and coordination which enable innovation in the long term which could reverse the increase in lifestyle related illness/reliance on professional care. Increased co-ordination which reduces duplication/inappropriate referrals multiple staff visits, DNA's. Improved safeguarding. Supports common data sets, quality indicators. Measured/improved health outcomes through the effective commissioning of health and well being services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Professionals can work with patients to re-design services.

Barriers to Delivery Commissioners will have to decommission secondary services to invest in pro-active care.

Priorities in Transformational Guides • Make full use of ‘teachable’ moments – opportunities to tackle lifestyle factors when people are receptive. •

Priorities in Healthier Horizons for the North West

Explore opportunities for joint working with local services that promote health and wellbeing to maximise the health impact, for example working with health trainers and health and wellbeing partnerships i.e. local councils.

•

Agree joint goals with local partners and monitor whether they are being achieved and the impact. This should include how, together, you are impacting on local health inequalities.

•

Make best use of service users: using this resource in the promotion of health, wellbeing and reducing health inequalities. Use programmes such as peer education, peer-led services, buddying and mentoring.

North West Community Provider Alliance Clinical Pathway Workshop 2009

________________________________

HEALTH IMPROVEMENT

Health Improvement

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Whole systems IT approach

Benefits for Patients No duplication, saving time and money. Easier to track patient pathways (cradle to grave). Easier to identify patient health problems.

Benefits for Commissioners No duplication saving time and money. Robust collection of data information. Easier to track patient pathways (cradle to grave). Smoother integration.

Benefits for System Reform No duplication. Saving time and money. Robust collection of data information. Easier to track patients pathways (cradle to grave). Easier to identify patient's health improvement needs

Enablers to Delivery Funding.

Barriers to Delivery Funding.

Communication.

Timescales to implementation.

Multi-agency working.

Reluctance to change - 'stuck in the mud'.

Agreement of core data set. Dedicated IT resources.

Silo working.

Staff training. Change in culture 'information sharing'.

Easier to identify patients health improvement needs. Smoother integration into mainstream services Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

_____________

North West Community Provider Alliance Clinical Pathway Workshop 2009

______________

2. Top 3-5 Improvements Health Improvement to underpin every community/ acute pathway

Benefits for Patients Reduces health inequalities. Long term health benefits. Helps to reduce Long Term Conditions. Keeps patients on a health improvement programme even when they are on a different pathway. Reduces acute admissions. Reduces morbidity. Improved quality of life

Benefits for Commissioners Reduces inequalities. Tracks patients and money through pathways. Reduces acute admissions, therefore, long term financial savings. Data analysis of local population morbidity etc. Financial benefits as people are included in pathways and are kept healthy for longer, therefore, reducing acute incidents.

Benefits for System Reform

Enablers to Delivery

New culture of delivering Health Improvement through whole pathway system.

Workforce development. 'Buy inâ&#x20AC;&#x2122; of clinicians.

Reduces cost of Long Term Conditions and acute admissions. Training for all health care professionals in health improvement and health promotion.

Training and education.

Time pressure on clinicians.

Quality over quantity.

Time spent on 'fire fighting' not on health improvement.

Patients more likely to change behaviour and keep new lifestyle.

Misinterpretation of evidence based practice.

Health improvement written into every SLA/Contract/Service Specification. Management backing at SHA level. Evidence based practice

Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

________

North West Community Provider Alliance Clinical Pathway Workshop 2009

`Buy inâ&#x20AC;&#x2122; from commissioners.

Barriers to Delivery Commissioners overly focussed on activity and short term targets. i.e. quantity versus quality.

________

3. Top 3-5 Improvements One point of access/contact for health improvement services

Benefits for Patients Reduced duplication of services. More user friendly, Easier to access services. Quicker more direct access to appropriate services at the right time in the right place by the right professional.

Benefits for Commissioners Reduces duplication. Quicker more direct access to appropriate services. Improved 'joined up' working.

Benefits for System Reform Reduces duplication.

Enablers to Delivery Clear vision agreed by all partners.

More user friendly, therefore, easier to access services.

Partnership working in health and local authorities - third sector partnerships.

Improved 'joined up' working with other health care professionals.

Accommodation - agreement of use.

Barriers to Delivery Lack of agreement with all partners. Lack of useful accommodation. Staff resistance.

Communication.

Improved communication with other healthcare professionals.

Inter-agency working relationships

Improved communication Reduced stigma

Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

_______________ North West Community Provider Alliance Clinical Pathway Workshop 2009

_________________ 64

4. Top 3-5 Improvements Addressing health inequalities

Benefits for Patients Long term health gain for children and young people. Reduced social exclusion. Improved healthy lifestyle. Reduced chronic conditions. Reduced Life threatening illnesses. Decreases childhood morbidity. Improved mental health and well being.

Benefits for Commissioners Long term health gain for children and young people. Reduces social exclusion. Improves a healthy lifestyle. Reduces chronic conditions. Reduces Life threatening illnesses. Decreases childhood morbidity. Improved mental health and well being. Financial gains. Better SLAs and service specifications. Reduces long term costs.

Benefits for System Reform

Enablers to Delivery

Change of culture and delivery.

Commissioning through targeted funding.

IT systems to track local population and ethnicity.

Good social marketing.

Long term health gain for children and young people. Reduces social exclusion. Improves a healthy lifestyle. Reduces chronic conditions. Reduces life threatening illnesses. Decreases childhood morbidity.

Data packaging. Total stakeholder â&#x20AC;&#x2DC;buy inâ&#x20AC;&#x2122; with a multi-agency flexible approach.

Barriers to Delivery Lack of funding. Staff, organisations not operating together. Commissioners have a 'blanket' approach - 'one size fits all'.

Community health development. Partnership approach involving all organisations.

Improved mental health and well being.

Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

__________________

North West Community Provider Alliance Clinical Pathway Workshop 2009

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MENTAL HEALTH

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Community single point of access and triage to mental health system that also meets the needs of people with mild-moderate common mental disorders.

Benefits for Patients Encourages a personal pathway plan by phone/person who,what,where, when, why and how. Appropriate referral first time with a faster streamlined service. Outcomes will be more positive with informed choice

Benefits for Benefits for System Reform Commissioners Patients are deflected from A Value for & E and reduced money. inappropriate referrals to secondary care. Earlier intervention Patients are referred to the means a much right person, in the most more efficient appropriate place. This and effective increases capability of care service with reduced queues system to meet mental health needs. and handoffs. Integrated lean system that enables better outcomes

Reduction in prescribing is achieved with improved outcomes.

Enablers To Delivery Strong leadership is needed from providers to maximise the benefits from all resources; (ie financial, estate, workforce). Commissioners with effective investment plans in community services and commitment to pump-prime developments to support resource shift. Critical mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Standard specification across partnership working with benchmarking for quality and data recording. Governance across patient pathways for patient info/data sharing. By using intelligent commissioning there can be collaboration between commissioners and other partners.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Collaboration limited across pathways as a result of different incentives. Insufficient community resources.

Boundaries: registered /resident . Lack of leadership. Commissioner development of market - fragmentation, competition, lack of cooperation, reduced innovation. Capacity and capability within community providers to tender. Staff morale.

Priorities in Transformational Guides •

Priorities in Healthier Horizons for the North West

No specific guide for mental health services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

There is a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

•

Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.

•

This must also streamline access to mental health pathways not only to avoid fragmentation of care but also to ensure the benefit from new provider relationships across the independent, third sector and social enterprise, is sensitively managed.

•

There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

2. Top 3-5 Improvements Alignment of community services - with community mental health expert practitioners working in an integrated way with Primary Health Care Teams.

Benefits for Patients Increased access and improved recognition. Mental Health aligned with other mainstream interventions through comprehensive and coordinated packages of care.

Benefits for Commissioners Value for money. Robust Clinical Governance and national target delivery.

Step up and step down of care.

World Class Commissioning targets are met and QoF delivery is improved.

Clients can return to work, with increased choice, and empowerment.

Improved GP practice based knowledge of population.

Benefits for System Reform Systems will be more efficient â&#x20AC;&#x201C; integrated and person centred.

Clients can have a choice of opting in and out as needed with informed discharge.

Priorities in Transformational Guides â&#x20AC;˘

No specific guide for mental health services

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Barriers to Delivery Pathway/Collaborative across Strong leadership is needed from providers pathways - different incentives. to maximise the benefits from all Resources. resources. Boundaries: registered/resident. Commissioners with Lack of leadership. effective investment plans in community Commissioner development of services and commitment to pump- market - fragmentation, competition, prime developments lack of co-operation, reduced to support resource innovation. shift. IAPT model still being tested. Critical mass of community mental TCS process. health providers. Staff morale. Flexibility for providers to shape workforce e.g. graduate worker.

Priorities in Healthier Horizons for the North West There is a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

3. Top 3-5 Improvements Co-produced (commissioners providers & service users) integrated care pathways and criteria that are dynamic and regularly reviewed in partnership .

Benefits for Patients

Benefits for Benefits for Commissioners System Reform Shift of focus Promotes choice Value for through Money. to address high level of confidence and Reduced stigma need at an clarity of and reduced earlier stage available DNAs. and reduce pathways. worklessness Improved Promotes full engagement and efficiency and outcomes. co-production. Delivers better outcomes and processes, with lack of duplication.

Priorities in Transformational Guides â&#x20AC;˘ No specific guide for mental health services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Barriers to Delivery

Strong leadership is needed from providers.

Pathway/Collaborative across pathways different incentives. Pathway/Collaborative across pathways - different incentives. Resources: finance, workforce, capacity. Boundaries: registered/resident. Lack of leadership. Commissioner development of market - fragmentation, competition, lack of cooperation, reduced innovation. De-stabilising historical pattern of service. Capacity and capability with community providers to tender. IAPT model still being tested. TCS process. Staff moral.

Commissioners have clear investment plans to support resource shift. Critical Mass of community mental health providers with flexible workforce. Benchmarking for quality and data recording. Governance in patient pathways for patient info/data sharing.

Priorities in Healthier Horizons for the North West â&#x20AC;˘ Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.

North West Community Provider Alliance Clinical Pathway Workshop 2009

â&#x20AC;˘

The development and application of clinical pathways such as those in the Map of Medicine offer clinicians and service users the opportunity to access consistent quality of services.

â&#x20AC;˘

Appropriate clinical pathways will be developed and used to ensure access to consistent quality of services.

4. Top 3-5 Improvements Fit for purpose of Community Mental Health Service delivery - non stigmatising, flexible hours, community/ primary care based and mainstream

Benefits for Patients Patients and Professionals promote recognition of common problem. Focus on mental well-being reduces stigma.

Benefits for Commissioners Results in fewer incidents/ complaints with improved access and inclusion. Promotes cultural sensitivity.

Benefits for System Reform

Enablers to Delivery

Patients are deflected from A & E.

Strong leadership is needed from providers with resources, financial, estate, workforce.

Reduce inappropriate referrals to secondary care. Patients are referred to the right person, in the most appropriate place. This increases capability of care re: Mental Health. Reduction in prescribing is achieved with improved outcomes.

Pump-priming by Commissioners and investment plans to support resource shift. Critical Mass of community mental health providers. There is flexibility for providers to shape workforce e.g. graduate worker.

Resources: finance, workforce, capacity. Boundaries: registered/resident. Lack of leadership. Commissioner development of market - fragmentation, competition, lack of cooperation, reduced innovation. De-stabilising historical pattern of service.

Standard specification across partnership working with benchmarking for quality and data recording.

Capacity and capability with community providers to tender.

Governance in patient pathways for patient info/data sharing.

TCS process.

By using intelligent commissioning there can be a collaboration between commissioners and other partners e.g. prison

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Pathway/Collaborative across pathways - different incentives.

IAPT model still being tested.

Staff morale.

Priorities in Healthier Horizons for the North West Priorities in Transformational Guides • No specific guide for mental health services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

•

The development and application of clinical pathways such as those in the Map of Medicine offer clinicians and service users the opportunity to access consistent quality of services.

•

That there is a greater recognition of the need for mental health promotion for the general population particularly those focusing on young people and prevention.

•

There is a need to co-ordinate substance misuse services, recognising the wide range of actual and potential partnerships, not just in health, to reduce the risk of exclusion and ensure early and opportunistic interventions.

•

The links between social issues and mental health from the impact of issues such as deprivation, homelessness and worklessness to be more widely recognised and the need for closer working between health and social care.

5. Top 3-5 Improvements Skilled workforce with capacity and capability to respond to clients in crisis.

Benefits for Patients Better outcomes Increased confidence with more responsive services, Greater enablement of self management, resilience and recovery for patients

Benefits for Benefits for Commissioners System Reform Produces better Encouraging outcomes. innovation means pushing Value for boundaries money. to obtain Promotes continuous improvement Innovation to help sustain . service development and improvement.

Enablers to Delivery

Barriers to Delivery

Strong leadership from providers.

Pathway/Collaboration across pathways - different incentives. Resources: finance, workforce, capacity. Boundaries: registered/resident. Lack of leadership. Commissioner development of market - fragmentation, competition, lack of co-operation, reduced innovation. De-stabilising historical pattern of service. Capacity and capability with community providers to tender. IAPT model still being tested. TCS process. Staff morale.

Resources: financial, estate, workforce. Pump-prime/investment plans to support resource shift. Critical Mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Benchmarking.

Recruitment of innovative and creative staff

Pathway governance + info/data sharing. Intelligent commissioning. Collaboration between commissioners

Priorities in Transformational Guides â&#x20AC;˘ No specific guide for mental health services.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West â&#x20AC;˘ All staff will have the appropriate and up to date skills to support those who access services wherever they access it.

CHILD HEALTH

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Develop a standardised approach across organisations

Benefits for Patients This will enable equity of service for all patients and give quality assurance and raise standards. Develop minimum standards across all partners. Improved communication and better involvement of GPs

Benefits for Commissioners Consistency across organisations will reduce confusion and increase efficiency. Consistency will ensure minimum standards for quality assurance, benchmarking/defining tariffs. This will start to improve efficiency and effectiveness of staff time

Benefits for System Reform A business plan with a standardised approach that can move towards delivering efficiency savings.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers To Delivery A standardised approach will be the driver to enable improved leadership/capacity. Pooled resources and creation of minimum standards will enable cost savings which in turn could increase 'buy inâ&#x20AC;&#x2122; from other stakeholders. IT systems that support a standardised, consistent approach to quality and outcome metrics.

Barriers to Delivery Lack of funding to standardise systems and services will lead to inequity, Reduce clinical autonomy and ownership. Very local interpretation of standards limiting individualised care, innovation and spread and adoption of best practice.

Priorities in Transformational Guides •

Priorities in Healthier Horizons for the North West

Children, young people and families are involved in planning and evaluating services.

•

Work with commissioners to agree outcome data.

•

Work with Commissioners to develop services so that children and young people can be cared for at home.

•

Improving commissioning at local authority level. Joint commissioning of all child health services.

•

Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout.

•

Develop local hub services in collaboration with secondary care - moving towards integrated service models, including maternity pathways and featuring mutual training and education.

•

Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.

•

Research and building of evidence base for healthcare practice and interventions are supported and developed at all levels.

Identify those who may be disadvantaged or marginalised in society Target need based on your Children’s and Young People’s Plan.

North West Community Provider Alliance Clinical Pathway Workshop 2009

2. Top 3-5 Improvements Facilitate partnership and integrated working.

Benefits for Patients Smooth effective care pathways. Timely and seamless care. Care closer to home. Greater involvement of GPs.

Benefits for Commissioners Commissioners can commission a complete pathway (lead provider),

Benefits for System Reform Shared and measured outcomes.

Shared resources and risk assessment.

Shared records/information systems

Opportunities for joint training, better understanding of roles, increased opportunities for clinical supervision

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Development of joint assessment, joint posts, joint training, pooled resources (devolved budgets),shared systems, joint planning, Children's Trust opportunities, shared outcomes . New roles working differently and committed to towards partnership working.

Barriers to Delivery Culture of organisations. Lack of information sharing and record keeping. Commissioning arrangements are not standardised. Commissioners may not have a full understanding of roles required.

Priorities in Transformational Guides •

Priorities in Healthier Horizons for the North West

Strengthen partnership working across Children’s Trusts and children’s social care, community services and organisations such as ambulance trusts, acute trusts, children’s /social services, GP practices (and practice based commissioners), voluntary and independent sectors so that care and treatment can be aligned along a care pathway and co-ordinated around the needs of the service users.

North West Community Provider Alliance Clinical Pathway Workshop 2009

•

Improve commissioning at local authority level. Joint commissioning of all child health services.

•

Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout .

•

Develop local hub services in collaboration with secondary care - moving towards integrated service models, including maternity pathways and featuring mutual training and education.

•

Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.

3. Top 3-5 Improvements Development of clinical pathways for acute/complex needs.

Benefits for Patients Improved access to most appropriate assessment and care packages. Improved choice with greater awareness of available services. Timely access and interventions. Confidence in quality, outcomes and specialist expertise of staff operating in an integrated way.

Benefits for Commissioners Quality assurance and evidence will enable commissioners to develop a strong and complete pathway, Professional roles will be clarified with the potential for wider scope and increased potential for integration. Better governance and audit arrangement. Monitoring of clear standards will be more successful and will also address inequalities..

Benefits for System Reform Shift from Acute to Community i.e. InReach model with patients at the centre. By using standardised, measurable approaches with a local focus, then, shared care/expertise will be attainable. Increased quality and efficiency.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery Pathways will need clinical leadership and â&#x20AC;&#x2DC;buy inâ&#x20AC;&#x2122; from professionals, commissioners, providers and other expert group organisations. Pathways designed with reference to NICE guidance, Lean Thinking, and examples of good/best practice

Barriers to Delivery Current lack of business acumen/support for community services to collaborate or coordinate the pathway delivery.

Lack of quality metrics Organisational boundaries - staff resistance.

Priorities in Transformational Guides •

Know about local health needs and plan services accordingly.

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The voices of children, young people and families are central to planning the pathways and the evaluation of services.

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Identify children who need safeguarding.

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Work collaboratively with others who work with local children and families agreeing and developing a common vision, goals and models of good practice.

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Priorities in Healthier Horizons for the North West

Develop additional healthcare services in their own homes or in settings closer to their homes.

North West Community Provider Alliance Clinical Pathway Workshop 2009

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Children's Clinical Pathway Groups.

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To involve Health Improvement.

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Reduction in obesity, emotional health and wellbeing, teenage pregnancy, sexually transmitted diseases, drug and alcohol use, targeting areas of deprivation.

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Early Identification.

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Poor or ill health managed through Primary Care, and parents.

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Develop a range of assessment tools to support identification, underpinned by clinical expertise through networks, supporting primary and community care.

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Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout.

4 Top 3-5 Improvements

Benefits for Patients

Benefits for Commissioners

Strengthen universal and health improvement role

The underpinning of health improvement within all clinical pathways will provide easier access, earlier identification and intervention, promote patient confidence and self care.

Promotes and enables earlier intervention, better value for money, reduces inequalities and improves outcomes.

Patients will be empowered through a better understanding of services.

Patients are helped towards making informed decisions. Better understanding of local needs in the short, medium and longer term.

Benefits for System Reform Resources can also be targeted appropriately,

Enablers to Delivery

Local Health Improvement evidence, policy documents, and local drivers with dedicated professional staff can all help to prove that Health Improvement is a valuable tool for Value for money underpinning all pathways. across the whole system. Support of Health Protection Agency, Resources used other organisations, agencies and more efficiently. local councils. Existing equal partnerships must drive this initiative Prevention and through to enable a clear service with earlier standardised specifications (look at intervention. national templates). Clear objectives/targets help to reinforce the Health Improvement roles. Relevant information and the standardised use of Informatics to enable consistency across all pathways and opportunity for benchmarking and sharing innovation. Staff and parents engaged in service redesign.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Lack of resources: staff, finance and estate. Governance issues re: partnership, different organisations, cultures, budget controls. Increased contestability of services.

Resources and expertise needed to engage with the hard to reach families. Public expectations.

Priorities in Transformational Guides •

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Priorities in Healthier Horizons for the North West

Use of public data about ill and disabled children to inform and agree local priorities.

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Health Improvement is part of integrated pathways.

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Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.

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Develop local hub services in collaboration with secondary care - moving towards integrated service models, including maternity pathways and featuring mutual training and education.

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Research and building of evidence base for healthcare practice and interventions are supported and developed at all levels.

Empowers parents and carers to be able to deliver health care to their ill or disabled child through the provision of adequate training and ongoing support.

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Equip other partners such as teachers with the skills and knowledge to recognise illness and exacerbations or deterioration in a child or young people.

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Integrate and co-ordinate all services that contribute to caring for a child through an illness or disability, making sure universal, preventative services continue to be offered.

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Develop ‘buddy’ systems to support families.

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Develop services and approaches to support siblings of children with illnesses or disabilities.

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Ensure staff have ongoing joint training.

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People are developed to be high quality community ‘practitioners, partners, leaders’ who can clinically own and lead local change.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Top 3-5 Improvements Joined up adequately financed commissioning group

Benefits for Patients Less duplication, improved service, easier access, economies of scale, better communication, clear roles, responsibilities and single point of access,

Benefits for Commissioners Better use of resources.

Benefits for System Reform All partners signed up to shared Standard and clear target objectives and sand measured outcomes will vision, help with shared monitoring and accountability. Standardised monitoring of outcomes.

NSFs, Healthy Horizons, NHS Plan, Children's Plan, Choosing health will support and enable the above

Improved quality, efficiency and productivity.

Enablers to Delivery Clear standardised service specs enable clear objectives and targets. Increased resources. Relevant information. Audit. A strong steer towards networking and partnership working. Clear and strong governance framework with Child & Family at the centre. Dedicated professional staff producing clear evidence, policy documents, local drivers. .

North West Community Provider Alliance Clinical Pathway Workshop 2009

Barriers to Delivery Lack of resources/capacity. Governance issues Provider/commission er split, where the issue of contestability will increase.

There are also local demographics - age, complex health needs, deprivation and poverty to take into account. Appropriate accommodation plus costs.

Priorities in Transformational Guides •

Work with Commissioners to agree the outcome data that needs to be collected for a specific service area to demonstrate effective intervention.

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Link this to quality framework and, if appropriate, contracts including the payment framework for commissioning, quality and innovation.

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Target needs based on your Children's and Young People's Plan Strengthen partnerships working across Children's Trusts, health and children's social care.

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Support teams to develop creative approaches to service provision, which reflect the five 'Every Child Matters' outcomes and will improve choice and personalisation for children, young people and their families.

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Support and empower practitioners to develop innovative multidisciplinary teams using approaches such as transformational attributes.

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Commissioners and provider management teams must be responsible for developing a competent workforce that will deliver current and future services safely, effectively and who have a positive impact on service user experience.

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This will include thinking about workforce planning aligned to patient need and the commissioning of sufficient education and training places for the future.

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Work with education commissioners and universities to ensure education programmes at all levels.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Priorities in Healthier Horizons for the North West

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Our vision for the future, in terms of the commissioning and provision of services, is one where these are done at the most appropriate level through formal joint commissioning arrangements and integrated delivery.

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Develop local hub services in collaboration with secondary care - moving towards integrated service models, including maternity pathways and featuring mutual training and education.

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Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training

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Improving commissioning at local authority level.

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Joint commissioning of all child health services.

6. Top 3-5 Improvements Improving outcomes for children and families (e.g. admissions, obesity, accidents, smoking will reduce and health will improve).

Benefits for Patients Improved parenting, Children and families are engaged, enabled, empowered. Increased confidence in services. Improved focus on: self/homecare, maternity health, teenage pregnancy, safeguarding, obesity, alcohol, drug use.

Benefits for Commissioners Target resources appropriately to prevent hospital admissions. Evidence will be through measured outcomes, improvement, reduced health inequalities

Benefits for System Reform Better use of workforce skills with succession planning. Improved quality, safeguarding, service improvements, horizon scanning, Reduction in health inequalities.

Clear standardised service specifications. Clear and strong governance framework. with Child & Family at the centre. System engagement and support.

Barriers to Delivery Lack of resources/capacity/recruit ment + retention does not help new initiatives. Partnership governance issues re: partnership, different organisations, cultures, budget controls. Local demographics - age, complex health needs, deprivation and poverty to take into account. Public expectations.

Policies such as Children's NSF, Every child matters used as guidelines.

North West Community Provider Alliance Clinical Pathway Workshop 2009

Enablers to Delivery

Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

• Information to empower children, young people and their families. Clear comprehensive information and support regarding a child or young person’s condition, including sources for further support, enable children, young people and families to retain ownership of their individual lives.

• Health Improvement is part of the integrated pathways . • There should be a 'systematic' programme throughout the North West to reduce the need for inpatient care days, achieved through: Increased conversion to day case care, decreased length of stay for acute admissions through whole pathways redesign.

• Equip parents with skills and knowledge to recognise acute exacerbations/ deterioration and to treat their child or seek expert help as appropriate.

• Better co-ordinated team based and proactive care for children with long term conditions, involving the GP, children's community matrons and the team around the child. • Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout . • Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.

North West Community Provider Alliance Clinical Pathway Workshop 2009

MATERNITY AND NEWBORN CARE

North West Community Provider Alliance Clinical Pathway Workshop 2009

1. Top 3-5 Improvements Commission integrated maternity and child health pathways. Universal Journey Planner signposting access.

Benefits for Patients Continuity of care for the family. Improved access and choice. Improved outcomes for women and children.

Benefits for Commissioners Improved outcomes, access and choice. Greater efficiency in pathway delivery. More integrated care.

Benefits for System Reform High quality and productive pathways. Greater cooperation between providers.

Enablers To Delivery Clear outcomes agreed and monitored with clarity of exactly what is provided.

Barriers to Delivery Maternity services are commissioned with acute providers.

Shared data collection

Culture and organisational boundaries.

Good IT systems will increase staff satisfaction.

Separate IT Systems.

Children's strategy. Better use of workforce skills.

Priorities in Transformational Guides

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North West Community Provider Alliance Clinical Pathway Workshop 2009

Public Health agenda.

Priorities in Healthier Horizons for the North West •

Enhance the midwifery role to include public health approach to care and greater autonomy in midwife led services. This will include outreach work to teenage mothers, asylum seekers, substance misusers and other vulnerable groups.

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Offer all women an individualised risk, needs, preferences and benefits assessment at decision points during their care, where the woman and her midwife will discuss the choices available to her and her family (The Child Health Promotion Programme, DH 2008).

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Increased partnership working between midwives, midwifery assistants, health visitors, social workers and other professionals involved in the woman's care. 89

2. Top 3-5 Improvements Commission specialist pathways.

Benefits for Patients Improved access to most appropriate assessment and personalised care package.

Benefits for Commissioners Improved outcomes.

Confidence in the quality and expertise of service providers. Improved communication.

Improved safeguarding.

High quality and responsive pathways.

Benefits for System Reform Improved delivery of quality and productive care â&#x20AC;&#x201C; right person, right place, right time.

Enablers to Delivery Children's Act.

Barriers to Delivery Separate IT Systems.

Children's plan.

Culture and organisational boundaries.

Department of Health Targets.

Separate performance monitoring, reporting and accountability.

Local targets. Integrated training/modules.

Separate governance arrangements. Same quality measures.

Reduction in teenage pregnancies. Increase in smoking cessation.

Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

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North West Community Provider Alliance Clinical Pathway Workshop 2009

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Collaboration across health communities to ensure women who require specialist care can access what they need without delay and transfer policies are in place.

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Strong commissioning partnerships between the community, hospital, social services, education and the third sector will be developed to ensure that women who require specialist services can access those they need without delay.

With thanks to the workshop participants who shared their expertise and their passion for community services to effectively contribute to addressing health inequalities and improving the health and well being of the people we serve across the North West.

The clinicians and practitioners were from the Community Provider Services of: Blackpool PCT

Manchester PCT

Bolton PCT

Oldham PCT

Bury PCT

Salford PCT

Central Lancashire PCT

Sefton PCT

Cheshire East and Central Cheshire PCT

Stockport PCT

East Lancashire PCT

Tameside and Glossop PCT

Halton and St Helens PCT

Trafford PCT

Heywood, Middleton and Rochdale PCT

West Cheshire PCT

Knowsley PCT

Wirral PCT

North West Community Provider Alliance Clinical Pathway Workshop 2009