Category: News and case studies

We are excited to announce a partnership between NHS Midlands and Lancashire CSU’s Personalised Healthcare Commissioning Team and Bristol, North Somerset, and South Gloucester Integrated Care Board (BNSSG ICB). Over the next six months, our joint venture will focus on providing additional capacity for Continuing Healthcare (CHC) assessments.

Our collaborative efforts will help BNSSG ICB target key areas to improve the CHC assessment process  for their population:

1. Timely assessments: reducing wait times for assessments, ensuring service users receive the care they need when they need it.

2. Enhanced decision-making: we will assist BNSSG ICB in making more informed decisions about individual care needs.

3. Personalised care approach: tailoring assessments to individual needs, recognising the unique circumstances of each service user.

As we embark on this journey with BNSSG ICB, our primary goal is to ensure that all service users referred by the ICB receive appropriate, high-quality assessments in a timely and efficient manner. This partnership represents a significant step forward in our commitment to improving healthcare services and delivering exceptional care to the community.

To find out more about our services visit: https://www.midlandsandlancashirecsu.nhs.uk/personalised-healthcare-commissioning-services/

Welcome to our new podcast series, “Inside MLCSU”, and our first episode about the intricate case of Rose – a patient who divided opinion. “Empowering Rose – supporting patients through the Court of Protection” explores the complexities of Rose’s physical and mental health and tells the story of a multi-disciplinary team as they navigated the Mental Capacity Act and the Court of Protection to ensure that Rose received the care she needed and her wishes were respected.

Listen to “Inside MLCSU” online, or download via Spotify, Apple Podcasts and Amazon Music.

Cases involving the Court of Protection and Deprivation of Liberty (CoPDoL) are a highly specialised aspect of the work carried out by Integrated Care Boards (ICBs). These cases are vital in safeguarding individuals from unlawful deprivation of their liberty while upholding the principles of mental capacity, best interests, and best practices.

How does one provide care for a patient who struggles to follow medical advice and act in their own best interest? What do you have to consider when doubts arise about a person’s mental capacity to make decisions? How are the procedures of the Mental Capacity Act and the Court of Protection applied, and who is best suited to oversee this process? How can the patient’s needs and desires remain at the forefront of decision-making? These are some of the questions answered by Julie Harrington, Head of Safeguarding at NHS Midlands and Lancashire CSU.

Mental health and conducting mental capacity assessments are complex matters. Often, even the professionals can disagree, and a multi-disciplinary team is needed to find the best solution for the patient.

Rose had complex mental and physical health issues, and our team worked tirelessly to support her when she could no longer make decisions about her care. Throughout this process, we made sure to prioritise Rose’s wishes.

However, mental capacity assessment and Court of Protection proceedings can be resource-intensive and add to the workload of your staff. This is where our team excels – with our highly-specialised experts including mental health nurses and social workers with clinical and non-clinical backgrounds, most of whom have Best Interest Assessor training. We help ICBs with complex cases where deprivation of liberty may be in the best interest of the patient, and we prepare the legal documents at a fraction of the cost.

For more information, visit our Personalised Healthcare Commissioning Services pages.

https://www.midlandsandlancashirecsu.nhs.uk/personalised-healthcare-commissioning-services/

We are delighted to announce that Dr Sam Gower, Clinical Director for Personalised Healthcare Commissioning at NHS Midlands and Lancashire CSU, will be a featured speaker at this year’s Access All Areas conference, scheduled for Tuesday, 21st November 2023.

In what promises to be an enlightening session, Dr Sam Gower, alongside Brogan Archer from Access Adam Care Commissioning, will delve into the complexities of the Continuing Healthcare (CHC) process and discuss the tangible returns on investment that can be achieved. This is a must-attend for anyone involved in healthcare commissioning, providing a deep dive into the operational and financial nuances of CHC.

Access All Areas is an annual virtual conference hosted by the Access Group, dedicated to professionals in the health, support, and care sectors. This pivotal event brings together healthcare professionals, local authorities, and care organisations to engage in valuable conversations, share best practices, and explore innovative solutions in the industry.

Don’t miss this opportunity to gain strategic insights and network with your peers. Register for Access All Areas now to confirm your attendance. Secure your seat today and be part of a community driving forward positive change in healthcare provision.

You can register at: https://events.bizzabo.com/548214/home

We supported an integrated care board (ICB) to assess the mental capacity of a patient with complex issues, represented the ICB at Court of Protection proceedings and ensured a person-centred approach to Rose’s care.

Background

The NHS Midlands and Lancashire CSU Court of Protection (CoP) Service was tasked with exploring legal pathways to ensure the best possible outcome for a patient – Rose (a pseudonym) – with suspected mental capacity issues, and participated in a multi-agency approach to delivering their care in this complex case.

The patient appeared to have the ability to understand topics being discussed about their care, however their fixed thoughts and views prevented them from using and weighing the information. They listened to medical advice when they were in severe pain, but once symptoms subsided, they would avoid appointments and treatment. Strategies by healthcare professionals to ensure the patient followed the care pathway were unsuccessful. They also disagreed on whether the patient was consciously making unwise decisions, or they had the capacity to make decisions at all.

Read more about Rose’s story in the Further Information section.

Action

Our CoP service supported and coordinated on behalf of the integrated care board (ICB) a multi-disciplinary team (MDT) approach to Rose’s case. We:

– Completed mental capacity assessments

– Supported the GP to advance their understanding of capacity assessments and the complexity of decision-making

– Encouraged a collaborative approach between services and healthcare bodies

– Due to continued disagreement among healthcare professionals, arranged an independent Mental Capacity Act assessment which confirmed the patient lacked capacity for some decisions

– Ensured the patient was provided with appropriate support for all appointments and these were put forward in MDTs

– Following a cancer diagnosis had assessments revisited to review Rose’s capacity to make decisions about treatment choices and continued inpatient stay

– Facilitated an MDT meeting to support Rose’s care home placement wishes

– Represented the ICB in all court proceedings and provided professional, efficient and specialist advice.

Throughout Rose’s journey, we worked compassionately to ensure that the patient always remained at the centre of every action and that they felt empowered and supported to personalise their care journey.

Impact

We facilitated a collaborative MDT approach to sensitively engage with Rose and ensure her wishes were at the forefront of decisions made. The MLCSU CoP Service and the MDT were commended on the exemplary application of the Mental Capacity Act in practice throughout Rose’s journey and were awarded the NHS England’s Safeguarding Star Award.

We also represented the ICB professionally and efficiently within the Court of Protection and ensured legal services were utilised in a cost-effective manner.

Our involvement championed a person-centred approach which meant that the patient’s voice was heard and considered throughout, whilst ensuring any actions and decisions made were in their best interests.

As an MDT we were able to work together to make sure Rose’s final days were spent as she wanted. Her wishes for a placement by the sea and near animals were prioritised. She lived out her last days supported by professionals familiar to her, at a hospice not far from the sea, in a room with a view to a garden with animals.

Feedback

“You really evidenced the power of collaboration, keeping Rose central, being ever mindful of her best interests, constant dialogue and having difficult conversations, partnership working and ensuring her voice was heard. You made her care personal, and you went the extra mile to respect her wishes and ensure her end-of-life plan was as good as it could be, thank you all!”

Cathy Sheehan, National Safeguarding Clinical Lead, NHS England

 

Further information

For more information about our Court of Protection Service, please email mlcsu.personalisedhealthcare@nhs.net.

Rose’s story

Rose was 61 and had a learning disability classification, but had never undergone formal assessment. Healthcare professionals who knew her well also suspected autism. She had spent time in a mental health unit and her records also noted traits of a potential personality disorder.

She would often get preoccupied with issues that held less importance to her healthcare outcomes, and this would result in her making choices that directly contradicted healthcare professionals’ recommendations and significantly impacted her physical health and wellbeing.

Throughout her adult life, Rose had been challenged by health systems, services and processes. She was a carer for her mother who suffered from cancer. As a result, her previous experiences coloured her perceptions of current issues, making it incredibly difficult for professionals to separate old from new.

She had no other family and a was relatively private person. She had a passion for her garden, her beloved cats and animal charities.

Rose had a complex gynaecological history with concerns surrounding post-menopausal bleeding and a history of disengagement with professionals across all agencies, if she felt things were not moving in the direction she felt was best. When Rose was admitted to the hospital with acute symptoms, healthcare professionals recommended a treatment pathway. While her symptoms were at their worst and causing severe pain, she was able to make decisions that prioritised her health needs. However, once the symptoms had subsided, she did not follow the recommended treatment plans and refused to attend the planned investigative appointments.

Rose had developed behaviours to get what she perceived was the right outcome from the system.  Her negative experiences with healthcare systems led to her avoiding engagement with healthcare professionals and not completing the treatment recommended to her. For example, she would move appointments to different hospitals disrupting and delaying her care pathway.

Healthcare professionals closest to Rose employed different approaches to ensure she followed their advice but with limited success. Her GP had exhausted all options in trying to support her and encourage her, including multiple phone calls, home visits and visits and phone calls in the GP’s own personal time to optimise engagement. Professionals also differed in opinion on Rose’s capacity to make a decision, with some believing she was making capacious unwise decisions, while others questioning her executive functioning to make a capacious decision at all. Legal consideration had started to determine appropriate legal pathways under the Best Interest processes.

Following several mental capacity assessments, an independent assessor confirmed the challenges in relation to executive functioning and reported Rose lacked capacity at that moment in time, but highlighted this could improve with the right therapies to improve her mood. Rose attended investigative appointments benefiting from appropriate support and any reasonable adjustments in accordance with her mental capacity assessment outcome. Unfortunately, the diagnosis confirmed stage 4 cancer and necessitated hospital admission.

Rose formally objected to her deprivation in not being allowed to return home, despite not being medically fit to do so. Her advocates submitted an objection on her behalf. Clinical opinions in view of the poor prognosis, disease progression, observations over a number of months and increasing needs recommended 24-hour nursing care. Rose did understand the significance of her diagnosis and knew she was dying. However, she could not grasp the concept of her life expectancy and the reality of her deterioration.

Rose’s views in relation to accommodation were discussed at length by several agencies.  She wanted to return to her flat in Morecambe to be with her beloved cats, but did not want to die there. Rose wanted to spend her final days somewhere with gardens and where she could have visits from her cats. But several setbacks while in hospital – she acquired Covid, and E-Coli – prolonged her length of stay.

Agencies were working collaboratively and sensitively to engage with Rose and ensure her wishes were at the forefront of decisions made, they were trying to be creative in tailoring packages of care to meet her needs.

Sadly, due to rapid disease progression and increasing nursing and care needs, a return to her flat was not possible. A hospice in Morecambe was chosen with Rose’s input, and a room was allocated with a garden and views of animals, another important aspect she had expressed.

Her final days were spent near the sea, with a view of the garden and supported by the professionals she had known.  The adaptability and compassion of system partners and professionals ensured that Rose’s death was as peaceful and positive as it could be. The reflections of those involved was a sense of accomplishment in that for Rose, they did their best.

Our Medicines Optimisation in Care Homes team conducted structured medication reviews of patients at a nursing home, avoiding potential harm as a result of improper medication and saving almost £5k.

Background

Having identified medicines-related issues at a nursing home, colleagues from Lancashire County Council requested support from MLCSU’s Medicine Optimisation Care Home (MOCH) team.

The objective was to help the nursing home to achieve the necessary standards through improved medicines management. This was to be achieved through tailored advice and training.

Action

The MOCH team began by undertaking structured medication reviews (SMRs) with carers for all residents of the nursing home. They also shared medication review feedback with the GP, the community pharmacist and the nursing home.

They attended quality improvement meetings with the Lancashire County Council and the GP.

All nursing home staff were given access to MOCH medicines training webinars, covering topics including:

-medicine administration
-waste management
-ordering and booking in of the monthly medication order

The team also provided medicines administration audit support, provision of advice on safe storage and monitoring of medicines and accurate documentation of care plans.

Impact

As a result of the MOCH team’s interventions over a six month period, 18 structured medication reviews were conducted for vulnerable residents of the nursing home. The majority (78%) of the patients were aged 75+.

A total of 69 interventions were made:

-23 low impact interventions. This included stopping a controlled drug which was no longer being taken and was removed from the medicine administration chart.
-39 medium impact interventions (moderate risk to patient safety). This included stopping an oral nutrition supplement in a patient who was becoming overweight.
-7 high impact interventions (potential to cause significant harm to the patient). This included stopping a blood pressure lowering medicine in a patient who had low blood pressure and a history of falls and seizures.

Approximately 25% of the patients reviewed avoided potential significant harm as a result of the actioned recommendations.

The team achieved a total of 21 cost savings to the value of £376 per month or £4,892 over a year.

Through the reviews,14 medicines were stopped.

The work of the team resulted in improved ongoing communication between the GP practice and nursing home.

The nursing home progressed from being rated in ‘special measures’ to a status of ‘overall improvement.’

“The Medicine Optimisation Care Home team have done a great job in looking after our patients holistically via doing SMRs which were tailored to each individual patient’s needs, social and clinical background.

“Everything was explained thoroughly and backed with evidence which resulted in a high level of care for our patients and avoided potential hospital admissions or harm.

“Appropriate medicine training was provided to the care home staff.

“We greatly appreciated the support.”

Dr Mohamed Hassan, GP Principal at Lytham Road Surgery, Preston

Our Temporary Staffing Admin Bank is a great starting point for anyone looking for flexible, varied work within the NHS. We are proud to provide a supportive environment where recruits can learn and develop, and have opportunities to further their skills and career.

As part of future succession planning, the Personalised Healthcare Commissioning service recruited a number of young people through the Admin Bank. In this series of blogs, we meet some of them and hear their experiences.

Eilis Wardle, Administrative Assistant, Lancashire and South Cumbria IPA/CHC Team:

In spring 2021, I worked for Midlands and Lancashire CSU as Band 3 Administrative Assistant alongside my studies at medical school. Back in 2020, I had been part of the COVID-19 Taskforce – again whilst studying.

In the Continuing Healthcare (CHC) team, I was tasked with scheduling virtual CHC assessments during the COVID-19 recovery work in Lancashire and South Cumbria. This included communicating with care providers, social workers, nurse assessors, patients, and families, to find a mutually convenient time to complete the assessment.

The experience helped me to build on my communication and time management skills, which I need on a daily basis now I’m a junior doctor in the NHS. I also gained an understanding of the National CHC Framework and referral process, which has been helpful when working with older patients and those with complex health needs.

I am now in my second year as a junior doctor, having worked across a range of specialities. I really appreciate the valuable experience I gained during this placement, and the opportunity to contribute to the delivery of CHC assessments for patients in Lancashire and South Cumbria. Thanks to everyone I worked with.

A project to bring back a considerable number of staff to complete outstanding continuing healthcare assessments attracted skilled people from across health and care.

Background

The NHS Continuing Healthcare (CHC) framework was suspended for six months during the COVID-19 pandemic. To complete 38,484 outstanding NHS CHC assessments within the six-month deadline, a significant number of additional staff were needed with the right skills to handle the workload to ensure patients were assessed and that their care needs were coordinated in a timely way.

In partnership with NHS England and NHS Improvement (NHSEI), we developed a virtual workforce via the Bring Back Staff (BBS) returners programme. Our solution was a rapid, flexible and targeted recruitment and training process on a scale never seen before.

Action

NHSEI commissioned the NHS Midlands and Lancashire CSU to design and implement a national database to capture details of staff recruited or seconded, any training given, and additional working hours completed.

The CHC Workforce Project and talent pool built on ‘bank’ models for clinical commissioning groups to offer a choice of provider for temporary staffing.

We collaborated both internally and externally with recruitment specialists, IT services, business admin support and clinical leaders from a variety of health professional groups to ensure the processes worked smoothly and that we were able to target the training at the appropriate level for all candidates.

Impact

The success of the project was the result of highly-effective collaborative working as one to deliver at pace.

Training BBS returners at pace and then mobilising this agile workforce illustrated just how adaptable and transferable their skills and previous experience as nurses, paramedics, medical support workers, pharmacists and other allied health professionals were, and how useful their expertise is to CHC.

The programme attracted people who wanted to work flexibly in the NHS and retained their commitment, expertise and experience, offering the best use of resources and public investment.

A rapid recruitment, induction and training process enabled us to bring candidates on board in two to four weeks. Candidates were sourced from many healthcare professions and came with a wealth of valuable experience.

We adapted to the challenges of lockdowns and remote working, we provided equipment by courier, and developed a bespoke training package via interactive webinars and training videos.

CHC employers saved at least 260 hours of recruitment, administration and onboarding time. This blueprint for CHC workforce development recruits professionals considering CHC as career option, retaining their skills and knowledge within the NHS.

Feedback from applicants:

“My experience with MLCSU CHC team has been so different from the others. I feel supported in all aspects… I only wish I had started sooner.”

“The recruitment experience was impressively thorough and rapid, with a swift DBS check, provision of a laptop, phone and training.”

Feedback from a manager:

“The recruitment process was straightforward… very easy to navigate and a positive experience all round.”

We codesigned and delivered a transformation programme for the improvement of care for people with learning disabilities and/or autism.

Background

NHS England and NHS Improvement set out key priorities for commissioners within the Learning Disability and Autism (LD&A) Programme and the NHS Long Term Plan. These include improving community-based preventative support, transitions into adulthood, and our understanding of best practice models. They also wish to address issues with workforce, funding flows, and the lack of appropriate housing to prevent admission to hospitals, and to facilitate discharges from hospitals. The NHS Midlands and Lancashire Commissioning Support Unit and Shropshire, Telford and Wrekin health system co-created an approach to develop and deliver a robust Transforming Care Programme (TCP) to meets these priorities.

Action

Our TCP Service provides a case management function for NHS funded individuals outside of continuing healthcare (CHC). The service aims to reduce expensive hospital admissions, and improve care outcomes and experiences for individuals with LD&A and complex needs. We provided an ongoing clinical case management service to offer robust support mechanisms for patients.

Deliverables:

* Supporting TCP policy development and stakeholder management to enable robust referral management
* Overseeing, governing, and attending Care, (Education) and Treatment Reviews
* Developing and maintaining a dynamic support register to update an individual’s risk of admission to inpatient or residential units in real time
* Brokering and sourcing care packages to meet individuals’ needs
* Providing clinical case management which includes engaging the individual, assessing, planning, linking with resources, consulting with families and collaborating with clinical and social care partners
* Providing a quality assurance process for referral management
* Attending inpatient discharge review meetings and discharge planning
* Implementing a robust care review process with local authorities where required.

Impact

* Improved person-centred care and individualised packages of support for people with learning disabilities and/or autism
* Brokering care in the most appropriate environment with effective use of resources
* Effective use of expertise, promoting multi-disciplinary team working
* Individuals are active participants in their care process
* Ensuring the role of carers are active participants in the reviewing process
* The responsibilities of partner agencies, ensuring they are active participants in the reviewing process
* Family members or carers feel well supported
* Individual satisfaction (involvement, decision-making, information, respect and dignity)
* Carer satisfaction
* The individual is treated with dignity and respect

We are delighted to announce that the Midlands and Lancashire Commissioning Support Unit (MLCSU) will continue to work in partnership with Derby and Derbyshire Clinical Commissioning Group (CCG) to provide individual patient activity (IPA) and continuing healthcare (CHC) services in Derby and Derbyshire. Following a competitive tendering process MLCSU have been successful in securing the contract for a further two years from 1 April 2022 with one more optional year after that.

Dr. Sam Gower, IPA/CHC Clinical Service Director at MLCSU, said:

“We are excited to continue working with the Derbyshire health and social care system to ensure value for money and quality service for patients, carers and commissioners. This decision by the Derbyshire health system will allow us to continue improving pathways and developing the use of technology to increase accessibility and inclusion.

“We invest heavily in innovation aiming for both improved experiences for patients and their families and cost efficiency. These innovations have included working in partnership with adam HTT Ltd to develop electronic referral systems and management, an electronic case management system and a range of services supporting personal health budgets with virtual wallets and more.

“Our dedicated team in Derby and Derbyshire has been supporting IPA/CHC activity since April 2017 allowing us to develop and sustain effective relationships with health system leaders. Derby and Derbyshire CCG’s choice to continue their partnership with MLCSU is testament to our staff who approach each case with compassion and care and help individuals and families through what can be very difficult times. We look forward to continuing to find innovative ways to support the people of Derby and Derbyshire and make services as accessible and inclusive as possible.”

We are extremely proud our Continuing Healthcare and Individual Patient Activity (CHC/IPA) team has been shortlisted for the Workforce Team of the Year category of the Nursing Times Workforce Awards 2021.

The awards bring together talent in workforce planning and recognise those making a difference in recruitment, staff retention, wellbeing and inclusion.

The project for which we were shortlisted, the NHS CHC Workforce Development programme, saw NHS England and Improvement and the Midlands and Lancashire Commissioning Support Unit work in partnership. We developed a virtual workforce via the Bring Back Staff returners programme. Our rapid recruitment, induction and training process brought candidates onboard in two to four weeks to begin roles with partner organisations.

Candidates were sourced from many healthcare professions and came with a wealth of valuable experience. This blueprint for CHC workforce development recruits healthcare professionals considering CHC as career option, retaining their skills and knowledge within the NHS.

The awards ceremony takes place on Wednesday 17 November 2021. Well done to our colleagues in CHC/IPA and to all other finalists on the shortlist.

The enormous pressures placed on CCGs to recover from the backlog in CHC assessments following the suspension of the CHC Framework for six months during the COVID-19 pandemic required a rapid, flexible and targeted recruitment and training process not delivered before.

We worked in partnership with NHS England/Improvement (NHSEI) to develop a virtual talent workforce pool via the Bring Back Staff (BBS) returners programme.

We sourced staff from many healthcare professions who came to the project with a wealth of valuable experience to share, and we saved CHC employers at least 260 hours of recruitment, administration and onboarding time.

How we helped

We set up a rapid recruitment process and provided people with equipment by courier, allowing us to function even at the height of the national lockdowns. Our candidates received a bespoke training package, and were trained, supported, mentored and given clinical supervision by experienced CHC professionals via interactive webinars and training videos that we developed in-house.

A number of bespoke, tailored packages of support were developed to encourage returning staff to join the initiative and an offer has been developed with a view to ensuring the future sustainability of the project.

Candidates were able to be brought onboard in between two-to-four weeks, which meant that members of this workforce were then ready to begin their roles with partner organisations already trained and ready for local induction to commence. The programme attracted people who wanted to work flexibly in the NHS and retained their commitment, expertise and experience, offering the best use of resources and public investment.

The impact of our work

Being able to train our BBS returners at pace and then mobilise this agile workforce illustrated just how adaptable and transferable their skills and previous experience were and how useful their expertise was to NHS CHC. The project offered CCGs and providers access to an NHS CHC workforce that is trained to national standards and offered the opportunity to offer virtual assessments so that the workforce could work flexibly nationwide, where needed. This virtual workforce model proposes a blueprint for future workforce solutions across the NHS, not just for NHS CHC and will help to reduce the costs associated with delivering and coordinating a solely face-to-face CHC assessment service.

On the recruitment programme, one applicant remarked:

“I was contacted immediately and the process of recruitment began, swiftly and seamlessly. Once contracted to work for the team I received the equipment required for the role – laptop and phone plus a very comprehensive set of instructions for the necessary IT, contacts, team leaders etc, team meetings etc.

“I feel supported in all aspects. The training is thorough and clear, I have a workbook to progress through, I am currently awaiting shifts whereby I will shadow experienced Nurse Assessors, I have practice care plans to follow.

“As I say, I can compare with recent experience plus 44 years as a skilled Registered Nurse and I am enjoying my experience with MLCSU CHC and only wish I had started sooner.”

In March 2020 the Government published its COVID-19 Hospital Discharge Service Requirements, placing an immediate requirement on clinical commissioning groups (CCGs) to arrange the transfer of patients from hospital as soon as it was clinically safe to do so. It was anticipated this would take no more than three hours, following discharge from the ward. At the time of the COVID-19 outbreak, MLCSU delivered a full tech-enabled CHC service to eight customer CCGs across the Staffordshire and Merseyside regions, via adam HTT – a managed digital platform. The solutions in place covered a population of 11.6 million, with thousands of active patients under management, and approximately 700 referrals and 360 new placements per month.

How we helped

MLCSU liaised with local bodies across the care sector to share important information with their providers. The team at adam took the lead in distributing communications, establishing which would be relevant to specific providers within the region. Subsequent to this, distribution of communications could be automated, improving staff productivity. After the initial phase was over, MLCSU and adam used their Provider Management Tool to help collect data from providers. A survey was sent out via the tool which allowed immediate distribution and management of queries and responses. The responses allowed MLCSU to create a daily dashboard to show where the virus was in the community, and thus where it was safest to move patients to.

Time to place was a key priority. Whilst the solutions MLCSU and adam deliver to CCGs accelerate the placement process, additional efforts were undertaken to improve placement speed. Whereas typically around 50% of CHC placements are coming from hospital, approximately 75-85% of all referrals during March and April were for patients in an Acute setting.

All patients had to be easily identified as COVID-19 patients, so the adam team amended the system within two hours to establish a new DOH stage. This allowed easier management for MLCSU and easier reclamation of funds later if appropriate.

MLCSU was able to further reduce time to place despite the case load more than doubling. With a robust and technology-enabled process, the team in place could take on the additional workload without a long lead time or extensive training.

During March and April MLCSU used the adam commissioning solution to source 1721 placements which represented a 108% increase on normal levels. A new process was established whereby the technology was used to source open care home beds for patients, with calls starting after 60 minutes to supplement the options sourced. Using data held around capacity and availability of local beds, calls were able to be focused on providers most likely able to take new patients.

Impact

With the fast response of MLCSU and adam, time to place for patients needing care homes beds decreased to a customer-wide average of three days.

With the teams working flat-out to engage local providers and ensure that patients were being kept away from local breakouts, they were still able to source two different options per patient on average. Despite caseloads more than doubling during March and April, the time to place patients during this period was halved.

As a result, providers have been able to demonstrate both compliance and the ability to meet the patients’ assessed needs.

Working at scale and underpinning process with technology has allowed CCGs to benefit from a robust and scalable service offering, able to withstand the most serious of events.

Contact our leads to learn more about how our digital platform can help you.

The NHS Continuing Healthcare Framework was suspended from March to August 2020 due to COVID-19. All care that facilitated hospital discharge or prevented admission to hospital during that period was automatically paid for directly by the NHS without assessment. Once the framework was reinstated, there were over 5,000 patients due a ‘deferred assessment’ which needed completing as soon as possible. Clinical commissioning groups (CCGs) would receive funding in November 2020 to support individuals eligible for NHS CHC funding.​

To establish an efficient process, health and social care systems employed a ‘Trusted Assessor’ model, designed to reduce delays when people are ready for discharge. It is based on providers adopting assessments carried out by suitably qualified ‘Trusted Assessors’ working under a formal, written agreement.​
​
Action

The Midlands and Lancashire Commissioning Support Unit (MLCSU) set up projects supporting the CHC activity based on the Trusted Assessment model in five integrated care systems (ICSs). Together with CHC expertise, we also employed clinical and business resource to address the issue.​

Working in collaboration with CCGs, NHS trusts, local authorities, community providers and others was key to completing the retrospective assessments This was achieved through excellent partnerships, the development of key systems and exceptional working practices to ensure deadlines were met.​
​
Impact

All care packages across the five ICSs, which were funded automatically by the NHS during the first phase of the pandemic, have now been assessed against the core NHS CHC Framework. This ensures that the packages:​

* Provide the most appropriate care according to individuals’ needs​
* Are realigned to the correct funding stream
* Eligible patients are now funded by core CCG CHC budgets. For remaining patients, the payment of their care costs has transferred from the COVID-19 budget to local authority responsibility, which has determined a variety of different pathways to support their care costs

The successful completion of assessments also earned the team a nomination for ‘Best working across CCGs and local authorities’ at a national awards ceremony by the CHC Strategic Improvement Programme (SIP) Collaborative.

The Staffordshire and Stoke-on-Trent Continuing Healthcare team has been recognised at a national award ceremony for their work to complete all deferred patient assessments following the COVID-19 suspension of the NHS national framework for continuing healthcare funding. 

NHS continuing healthcare (CHC) supports adults with long-term complex health needs with free social care arranged and funded solely by the NHS. Following a patient assessment, the care can be provided in a variety of settings outside hospital, such as in a person’s own home or in a care home. The NHS CHC framework setting out the assessment process was temporarily suspended between March and August 2020 to protect the NHS when the COVID-19 pandemic hit. All care that facilitated hospital discharge or prevented admission to hospital during that period would be automatically paid for by the NHS, leaving a large gap in patient assessments.

The Midlands and Lancashire Commissioning Support Unit provides CHC services across the Midlands, Staffordshire, Derbyshire, Leicestershire, Lancashire and Cheshire and Merseyside. The Staffordshire team worked in partnership with Stoke-on-Trent City Council to successfully complete retrospective assessments of individuals supported via COVID-19 funding arrangements during the suspension of the framework. This was achieved through excellent partnerships, the development of key systems and exceptional working practices to ensure deadlines were met.

The team was nominated in the ‘Best working across CCGs and LAs (local authorities)’ category by a senior social care worker from Stoke-on-Trent City Council.

Receiving recognition in this category is particularly meaningful given that better collaboration between health and social care is one of the most significant areas of development for the NHS currently. Being nominated by the local authority highlights the effectiveness of employing a multi-agency partnership approach and is a testament to the relationships we have created for the benefit of improving patient and family experience.

The awards were organised by NHS England and Improvement to reflect and celebrate the success of the CHC Strategic Improvement Programme (SIP) Collaborative, which supports local healthcare leaders and CHC experts to work together to help improve services for the population. SIP was key in encouraging multi-agency participation in improving outcomes for individuals in need of care.

Two Merseyside based CCGs recently engaged with MLCSU for support in procuring a block contract for Intermediate Care Beds (ICB) split over both COVID-positive and COVID-negative cohorts. Rebecca Crawford, Care Brokerage Lead at MLCSU, worked with South Sefton and Southport and Formby CCGs to explore the procurement options available. She advised that our existing DPS solution – adam, would allow the bed-base and contract to be in place in a matter of weeks.

Action

MLCSU joined a weekly project group and supported the CCGs to specify their exact requirements, using adam’s wealth of intuitive functionality:

* Creation of bespoke requests including: detailed tender instructions and contact details to guide providers, responses to 18 different key requirements, all in an easy-to-compare format
* Automatic distribution to pre-enrolled providers: automatic email system, automated system ensuring submission of fully compliant offers
* Easy offer analysis and contracts creation: automatic filtering and ranking, offer collation, automatic facilitation of service agreement and payments

The CCGs quickly requested quotes for up to 20 beds for COVID-negative cases and up to 10 for COVID-positive cases, from 76 pre-vetted care home providers (within a desired distance of the CCGs). The bespoke requests meant that providers could easily understand exactly what was asked.

Additionally, providers could ask the CCGs questions via adam’s two-way communication platform, and adam’s support team were on hand to assist providers with any queries and proactively encourage offers.

Impact

Six fully compliant offers were received within six days of the request for quote. Once the CCGs had reviewed and accepted an offer, contracts were created immediately (at a rate of £100.90 per day for care homes [lower than local market average]). From the moment the CCGs engaged with MLCSU, a decision on a provider was reached in less than a month.

With Rebecca’s help and adam’s digital CHC commissioning solution, the CCGs could specify their exact requirements, be it ensuring residents were kept in one place or appropriate disease control.

Offers collated in an a structured and easy-to-follow format enabled the project group to undertake an efficient evaluation and to select the most appropriate provider.
The automatic creation of service agreements and payments resulted in patients placed swiftly in the care homes, in line with the CCGs’ timescales and pre-agreed standards.
The CCGs were so impressed with the result, that they drafted a ‘lessons learnt’ report. MLCSU experts state that block contracts can take several months of resource-intensive procurement.

Professional support

Throughout the process, adam’s and MLCSU’s service delivery teams were on hand to guide and support the CCGs with their daily and strategic use of the system. The teams also made sure that all providers were engaged and supported in using the system.

Nursing care providers across Lancashire and South Cumbria needed to complete and submit a monthly questionnaire for each clinical commissioning group (CCG) that they worked with. Residential care providers in the region were not asked to do this. This agreement was labour intensive for providers and difficult for the CCGs to manage, whilst creating an inconsistency in how they managed local care operators.

The integrated care system, Healthier Lancashire and South Cumbria, wanted to improve the process.

Action

MLCSU, with technology partner, adam, implemented a supplier relationship management module for the group. This highly secure, cloud-based and fully mobile-compatible application incorporates a range of features including:

* automated collation of data from providers
* systemised data analysis and interpretation (including scoring and RAG statuses)
* easy-to-use interactive charts and dashboards
* communication tools to engage and share information back and forth with providers.

Impact

Implementation of the supplier relationship management module resulted in:

* significant time savings for customers in collecting data from local providers around the quality of care
* improved insight over quality of care to inform provider management activities and policy setting
* configuration of communication tools to improve information sharing with providers
* improved quality of care across the region as staff can spend less time gathering information, and more time focusing on areas of under performance.

Just looking at hospital admissions alone, the supplier relationship management tool has helped one CCG save 17 unscheduled hospital admissions per month, which equates to a financial saving of at least £13,000 per month (assuming a minimum 2-day stay per visit).

One CCG has reported the following performance improvements over the first 12 months:

* reduction in average number of falls monthly from 238 to 93
* reduction in providers rated Red or Amber under their quality monitoring guidelines from 12 to one
* urinary tract infections down from 54 to 16 a month
* unscheduled hospital admissions down from 49 per month to 32.

Clinical commissioning groups in Staffordshire wanted to review and change the spot purchase approach to procuring and managing domiciliary care placements and address the lack of a contractual structure. With budgets under pressure due to increasing demand, prices of domiciliary care were also rising. The aim was to move to a robust, effective and faster process that focused on maximising a robust contractual structure with quality of care for patients and value for money for the CCGs.

MLCSU, with technology partner, adam, was already delivering a range of solutions to the CCGs, including a commissioning solution for nursing care provision and a case management system for continuing healthcare (CHC) patient records.

Action

We scoped what was required, engaging with key stakeholders and providers and worked with adam to deliver:

* new policy and process documents
* new procurement and associated provider contracts
* performance and price benchmarking
* system configuration incorporating agreed processes and policies
* electronic invoicing and payment process
* migration and loading of existing package data
* training of all system users
* management of information and reporting design and configuration.

Impact

The new process is expected to result in:

* improved management of risk and compliance
* faster placement of CHC Domiciliary Care patients
* financial savings
* improved process around provider sourcing and quality of care
* all invoices being held online and paid within 30 days without exception
* providers being fully aware of all process, policies and performance metrics as they are held online
* providers having a fair opportunity to provide services for all new cases.

With this development we have now implemented adam’s full commissioning solution in Staffordshire (our first customer to have all key aspects in one system). It includes:

* provider contracting and evaluation
* care and support planning
* e-brokerage and provider sourcing
* e-contracting and placement management
* integration with case management system and finance systems
* e-invoicing and payment process
* supplier relationship management module (starting soon, delayed by COVID-19)
* interactive and real-time reporting tools
* dedicated user support and training
* data analysis and stakeholder engagement teams.

NHS Vale Royal Clinical Commissioning Group (VRCCG) required support to block book eight discharge-to-assess beds (four for the elderly mentally infirm (EMI) and four general nursing).

Action

Two requirements were published (one for each block of four beds).

MLCSU drafted a communication to providers for approval by VRCCG.

adam set up new service categories for discharge-to-assess within the system.

VRCCG held a provider event involving MLCSU and adam. This included a short presentation and a question and answer session.

Impact

The exercise was agreed as a success by all parties, especially when considering the quick turn-around of the required actions (within 17 working days of initial conference call between VRCCG, MLCSU and Adam).

The general nursing beds received eight offers and the EMI beds three. The EMI results, however, were more expensive than expected, so this requirement was rolled back out to the market for a further week to allow for more offers. This produced a new offer at a lower cost than expected from a provider just one mile from Leighton Hospital and this was subsequently selected.

A patient in Staffordshire required a continuing healthcare (CHC) placement in a care home. Her daughter was undergoing chemotherapy and needed her mother to be somewhere easily accessible by public transport so that she could visit her.

Action

We used our dynamic purchasing system, ‘adam’, to source a care home placement. The best value provider it came up with was difficult to get to using public transport. Our CHC placement team were able to use this to negotiate with the family’s preferred care home to get an offer that matched the best value one.

Impact

The best outcome was achieved, both for the family and for Stoke-on-Trent Clinical Commissioning Group. The cost was negotiated down by £105 a week.

Clinical commissioning groups (CCGs) in Leicester, Leicestershire and Rutland (LLR) wanted to improve the wellbeing of children with continuing care needs (complex health) by making personal health budgets (PHBs) the default offer for all those eligible children and young people (CYP) who require home care packages.

PHBs enable people with long-term conditions and disabilities (and their carers) to have greater choice, flexibility and control over the healthcare and support they receive. A Department of Health pilot found PHBs had a positive impact on care-related quality of life and wellbeing, and were cost-effective.

In April 2016 there was one PHB for children and young people in LLR. MLCSU’s LLR Children’s Continuing Care Team then began work to achieve the goal of moving all CYP historical and new cases eligible for homecare packages over to a PHB, through development of local processes and policy.

Action

Firstly, the team reviewed the process for obtaining funding for a complex care package. Barriers to introducing PHBs as a default offer were overcome with support from the CCGs to devise a new policy, in-depth discussions with the local authorities regarding updating their practices, and good working relationships with providers aided by regular update meetings.

A key step was taking the resource allocation system (RAS) tool from paper-based to online and combining it with the decision support tool (DST). The team used a live system called FACE (Functional Analysis of Care Environments) to determine the PHB.

Impact

PHBs are now the default offer for all eligible children in LLR who have home care packages. The biggest value lies in making PHBs more easily available to eligible children so they and their families have greater choice, flexibility and control over their care; which follows through during the transition period into adulthood.

The in-patient hospital experience is enhanced because locally it is agreed that the care package follows the child into the hospital setting. Accessibility to a PHB could assist in reducing admissions, by altering the provision at home to meet the needs of the child during times of illness.

As a result of being the first children’s CC team to have 100 per cent of eligible cases on a PHB (for those who have a home care package), NHSE asked them to share knowledge and best practice to other teams across the country. So far, they have provided training at an NHSE study day and on a webinar. They have also directly helped teams in other CCG areas, receiving great feedback.

A nursing home in Southport was closing down following a high profile criminal investigation. Conviction of the owner left the residents in a very vulnerable position; for many it had been their home for a long time. They all had to leave as a matter of urgency. Most of the home’s registered general nurses (RGNs) had left at this stage and several residents were still there awaiting new placements. There was a period when no nursing home RGNs were available for duty.

Action

Our Merseyside CHC team worked with Southport and Formby CCG’s chief nurse in supporting residents of the nursing home and their families during this difficult time. While suitable nursing home placements were found, our nursing staff went in to the home to perform and oversee nursing duties in order to keep all of the remaining vulnerable residents safe, as agreed with the CCG. Our staff ensured the remaining patients had their dressings applied and ensured medication was given out. They often willingly stayed beyond their normal work hours to maintain residents’ safety and to ensure continuity until their placement was sourced. They assisted in the transfer to other nursing homes to reduce the trauma and impact on the residents.

Impact

Our team ensured the residents’ care was not compromised and helped all to find alternative suitable accommodation.

Morecambe Bay Clinical Commissioning Group (CCG) wanted to review continuing healthcare (CHC) cases to help meet its QIPP target of £1m for 2018/19. With demand on CHC services growing and the priority being patient safety and packages of care for supporting timely discharge from acute trusts, little time was left for step-down reviews.
The CCG required a trained nurse to review high priority CHC cases to ensure:

* quality of care
* safe placement of vulnerable patients
* care packages meet patient needs
* appropriate spending of public funds, in line with National Framework.

Action

* Focus on area of greatest saving opportunity: overdue three-month reviews of patients discharged from hospital with CHC funding in place
* Two experienced CHC nurses recruited from local agencies, employed by MLCSU and integrated with the CHC team
* One nurse covered Lancashire North, the other South Lakes, for six weeks
* Data extracted from the two case management systems to identify patients for review
* Nurses scheduled reviews and tracked patients through the process, with multidisciplinary team (MDT) meetings and decision-making panels as required
* Monitoring arrangements developed for tracking numbers and outcomes i.e. package costs before and after review, along with other benefits for patients and the CCG.

Impact

* Total savings of £425,888 demonstrated a near 12:1 return on the investment of £36,000
* All newly eligible CHC patients recently discharged from hospital were reviewed, ensuring packages of care remained appropriate and necessary
* 24 (45 per cent) of the 53 reviews undertaken resulted in patients stepping off CHC funding or stepping down to funded nursing care (FNC)  
* The additional resource provided welcome support to the CHC teams in the two CCG localities
* Findings confirmed that the correct cohort was selected for review to maximise benefits for both patients and the CCG. Patients recently discharged from hospital with CHC funding in place, often do settle or improve and nursing care needs reduce.

Funding enabled targeted resource only for six weeks – additional resource could enable these priority reviews to be delivered on time on an ongoing basis, potentially realising greater savings.

Continuing Healthcare (CHC) is a growth area in the NHS. In Staffordshire it increased by 13 per cent from 2013-16. Procurement of CHC has historically been made by spot purchasing with little contractual management, limited qualitative measurement and no control over price.

Action

We worked with all six CCGs in Staffordshire to introduce the adam electronic dynamic purchasing system (DPS) to replace spot purchasing of care home placements. The system went live in February 2016 and was the first DPS to be implemented in the field of CHC. It is based on an open framework/fair market approach. Only suppliers that have passed both qualitative and financial criteria are able to bid for new placements. 
The system includes:

* tools for contract management
* automated service agreements and billing
* one weekly consolidated invoice per CCG, as opposed to one invoice per patient.

Impact

By streamlining the process, adam has given clinicians more time to spend with patients. The system provides more assurance regarding quality, and patients and their families benefit from the process being quicker. For commissioners, there is improved market management and development, while providers benefit from fair market opportunity, clarity of requirements, transparency and automated payments.

By January 2018:

* more than 1900 patients had been placed via the system
* time taken to procure a CHC bed had halved
* 208 providers were enrolled on the system – delivering a more sustainable and robust marketplace
* on a like-for-like basis prices were reduced by seven per cent year on year
* quality rating of placements was 90 per cent (deficiencies in quality reduce the likelihood of that provider winning business)
* contracts were in place for every enrolled provider
* significant efficiency savings had been made, for example streamlined invoicing meant two fewer full-time finance posts were required.

Following the success of adam in Staffordshire, we have worked with CCGs to introduce it in Merseyside (May 2017) and Cheshire (August 2017).