Category: News and case studies

The Cheshire and Merseyside initiative, aimed at aligning medication guidelines, has enhanced medication management practices across the region. By improving consistency, streamlining processes, increasing transparency, and promoting continual improvement, the project ensures safer and more effective medication usage, thereby contributing to the overall quality of healthcare delivery in Cheshire and Merseyside. 

Background

With the establishment of the NHS Cheshire and Merseyside Integrated Care Board (ICB), there arose a need to unify the existing Cheshire and Merseyside formularies.

A ‘formulary’ in the context of medicines management is essentially a list of approved medicines for use within a healthcare organisation, like a hospital. Its primary function is to specify which medicines are sanctioned for use under specific circumstances.

NHS Midlands and Lancashire Medicines Management Optimisation team, based in Liverpool, serves as the administrative support team for the newly formed Cheshire and Merseyside area prescribing group (CMAPG) and its five subgroups. The NHS Cheshire and Merseyside ICB acknowledged the expertise of the Medicines Management Team and entrusted them to lead the harmonisation project, with five pharmacists involved in the process.

Formulary harmonisation refers to the process of aligning and integrating medication guidelines from different healthcare organisations or regions. In the case of Cheshire and Merseyside, this initiative aims to unify the medication formularies of these areas, ensuring that healthcare providers have consistent and standardised guidelines for medication use. By harmonising the formularies, the project aims to improve patient safety, enhance the quality of care, and streamline medication management processes across the region.

Action

A set of rules was devised, drawing from common scenarios identified through a review of sections from both legacy formularies. These rules aim to ensure consistency in the review of chapters. In cases where an appropriate action is unclear, matters are escalated to a harmonisation working group.

A paper outlining the general process and rules and defining when actions would be referred to the working group for review and how the information would be incorporated into the harmonised formulary was approved at CMAPG in August 2023. It was then presented to the ICB clinical effectiveness group for consideration and approval, ensuring support and endorsement from the ICB.

The paper outlined the following steps:

• Establish the governance, membership, and purpose of the working group

• Develop draft formulary chapters as reviews are completed

• Present finalised chapters to the CMAPG with a summary of the rationale

• Publish the completed formulary

Impact

The membership of the working group has been established to include pharmacists from primary and secondary care in both Cheshire and Merseyside. The governance and purpose of the group, which convenes monthly, have been agreed upon.

Spreadsheets have been created for each chapter, containing the positions from both the legacy Cheshire and Merseyside formularies, along with individual columns for each matching rule.

Drugs that cannot be matched using the harmonisation rules are compiled into reports for discussion by the harmonisation working group and decisions made during these meetings are documented.

In cases where a decision cannot be reached by the working group, both legacy positions are retained in the new harmonised formulary until a full formal chapter review is conducted by the Formulary and Guidelines subgroup. These reviews are conducted promptly after a chapter is harmonised. As the project progresses, the team continues to identify more harmonisation rules, updating the working document accordingly.

The Cheshire and Merseyside formulary harmonisation project has improved medication management across the region by improving consistency, streamlining processes, increasing transparency, and promoting continual improvement. These outcomes not only ensure safer and more effective medication usage but also contribute to the overall quality of healthcare delivery in Cheshire and Merseyside.

Feedback

Colleagues working on the harmonisation of two historic formularies within Cheshire and Merseyside have undertaken significant work in terms of planning, system consideration, engagement, and delivery of work to date. The team have been flexible in their approach, welcomed feedback with a focus and commitment to get the job done and to deliver the best outcomes for patients, clinicians and the system. The task has not been simple but the commitment, teamwork and leadership within the team has been excellent.

Susanne Lynch | Chief Pharmacist | NHS Cheshire and Merseyside

In this three-segment podcast sequence, part of our Inside MLCSU series, we discuss the lessons learnt from the Clive Treacey Review about the struggles of the health and care system to meet the needs of an individual with learning disabilities (LD). The discussion panel includes Beverley Dawkins OBE, the Independent Chair of the Review; Hafsha Ali, digital transformation lead at NHS Midlands and Lancashire (ML); and special guest Elaine Clarke, Clive’s sister and lifelong advocate.

You can also join Elaine, Beverley and Hafsha in person on 23 April 2024 at NHS England Midlands’ event “Clive’s Way – See the Person, Hear the Family, Recognise the Ambition”. This free conference about the lessons from the Clive Treacey Review invites commissioners, providers and professionals working with people with a learning disability and autistic people in health and local authorities and third sector organisations across England.

Intro to the series

Clive Treacey faced living with LD and epilepsy, desiring a full life, but was often overlooked by the system. He was deprived of his liberty in the last ten years of his life, experiencing institutionalisation. As his mental health and physical condition deteriorated, he died at 47. It was evident that opportunities to aid his independence were missed. In response, his family initiated a campaign named “Clive’s Story,” aiming to inspire change for individuals in similar situations to be treated with more dignity and respect.

Tune in to “Inside NHS Midlands and Lancashire” online at Audio Boom, or download the episode via Spotify, Apple Podcasts, and Amazon Music to listen to the podcast.

Episode 1: About Clive’s childhood

Clive was determined to never let his suffering hinder him and was an incredible artist. His biggest gift was his heart. Unfortunately, epilepsy seizures became a dominant part of his life. Following his diagnosis, he was excluded from mainstream education within the first 12 months, marking the beginning of his deprivation of independence. It was thought that simply accommodating his education on the ground floor of the school he was at could have helped, but instead, he was sent to a school for children with greater needs.

Educational journey and challenges

Despite continuing his education, his illness created significant barriers. He faced challenges and restrictions that he couldn’t understand or accept. After college, he went through a series of 16 placements, moving because the placements he was at couldn’t cope with his illness. There was a placement that he was doing well at, but squabbles over funding put an end to that placement.

Evidently, the places Clive was sent to were completely unacceptable, highlighting a lack of planning in his care. People with LD often do not receive prompt diagnosis or appropriate care, with symptoms frequently misattributed to other causes – in this case, Clive’s epilepsy, leading to late or incorrect diagnoses.

Clive’s last ten years and his hospitalisation

Clive spent the last ten years of his life moving between hospital settings, with hopes of rehabilitation dashed by issues like missing equipment, lack of trained staff, and chaotic care records. This culminated in an unfortunate event leading to his death on 21 January 2017, where emergency staff could not resuscitate him effectively and could not provide the emergency service to the correct post code to attend promptly.

Episode 2: The aftermath of Clive’s death

The family was shocked by the autopsy results, which seemed to bear no relation to their knowledge and understanding of the circumstances surrounding Clive’s death. The inquest into his death highlighted systemic failures. After three years of campaigning by Clive’s family, NHS England commissioned a review, delivered by NHS ML, with Beverley Dawkins appointed as the independent chair.

Episode 3: The review and its impact

The review, published in December 2021, made 52 recommendations across ten themes. It aimed to influence not only NHS England but the entire healthcare system. The campaign to implement these findings has been vigorous, with the team striving to create a movement for change across disciplines. The family has been at the centre of delivering the review.

Continued efforts and future plans

The focus remains on ensuring Clive’s story prompts systemic reflection and change, moving beyond mere action completion to genuinely influencing healthcare practices. The NHS ML team, along with Clive’s sister Elaine, forms a ‘conscience group’ to drive and account for this change, keeping Clive’s story and spirit at the heart of their efforts.

NHS ML continues to work with NHS England and Clive’s family to affect change across nationwide health systems.

Our Business Intelligence team’s data-driven approach led to: improved care access, lowered acute service demand, and empowered patients, making a positive difference for vulnerable residents in Lancashire and South Cumbria.

Background

NHS Midlands and Lancashire CSU (MLCSU) was approached by Lancashire and South Cumbria Integrated Care Board to improve outcomes for the most vulnerable residents during the winter season. Sixty-eight per cent of the targeted cohort continued to experience unmet needs leading to inadequate support or referrals.

Action

To achieve the project’s goals, we used our established infrastructure, specialised skills, expertise, and vision to produce actionable insights. We focused on the prevalence of respiratory conditions in Central Lancashire by using health inequalities and population health management segmentation tools to create a target cohort. Responding to national direction, Core20PLUS5, the project team collaborated with service leads, analysed local data flows, and employed geographical views of data to benchmark across geographies.

The Winter Respiratory High-Risk project aimed to reduce the demand for acute services and admissions and identify unmet needs and address them. To identify wider determinants, the Business Intelligence team used Acorn Geo-segmentation tools which helped improve access, experience, and outcomes for the targeted cohort, and led to disease and medication reviews, immunisation offers and social prescribing.

Impact

MLCSU established a dedicated help desk and provided training support for staff, ensuring data quality through data warehouse processes, and linking primary and secondary care data. The team was able to capture additional patient activities, such as flu vaccinations, and update patient records with a long-term condition diagnosis, enabling referrals to support services.

The Winter Respiratory High-Risk Project identified that fifty-two per cent of the targeted cohort had multiple support needs, emphasising the importance of addressing unmet needs. We also shared best practices from other areas and applied lessons learned to refine the process, leading to an improved experience and better outcomes for the targeted cohort. The client was provided secure access to Information Governance compliant patient data, ensuring data protection and privacy. This initiative played an essential role in reducing the demand for secondary care and lowering morbidity rates, empowering patients to manage their health conditions more effectively.

Simultaneously, the average proficiency of individuals in managing their own health and well-being – measured through a Level 3 status – underwent a remarkable transformation. Starting from an initial low-end Level 2 status, which signifies individuals struggling to understand their role in healthcare, we successfully elevated their perception to an empowered Level 3 status. This designation signifies individuals who recognise their integral role in their care journey and possess the knowledge to proactively engage in self-care.

Feedback

“The MLCSU Business Intelligence Team were an integral part of our respiratory work. The team made time to work with us to fully understand the project requirements and desired outcomes. This allowed the team to make suggestions relating to the selection of appropriate cohort criteria, to ensure the project targeted those most vulnerable and most at risk. One project requirement was to enable members of the Primary Care Network to generate patient cohort lists – The BI Team were able to streamline this process by creating pre-set filters and guidance documents, ensuring buy-in from the Primary Care Network.”

Naomi Coldham,  NHS Lancashire & South Cumbria ​Integrated Care Board

NHS Midlands and Lancashire Commissioning Support Unit (MLCSU), in partnership with national experts at the University of Plymouth, Cornwall Partnership Foundation Trust, SUDEP Action, and Epilepsy Action, among others have supported NHSE Midlands to spearhead a highly successful regional improvement programme to tackle the pressing issue of premature avoidable death among people with learning disabilities and autism living with epilepsy.

Why is epilepsy in people with a learning disability, autism or both a priority for health and care systems?

Successive LeDeR reports and national reviews, such as the  Clive Treacy Independent Review and Norfolk Safeguarding Review into the deaths of Joanna, Jon and Ben, make an urgent and compelling case for action to tackle premature avoidable death and improve the quality of life for people with learning disability, autism or both who suffer from epilepsy. 

Figures are stark – sudden death is estimated to be nearly 24 times more likely for all people with epilepsy than those without. For those with a learning disability, who are significantly more likely to have epilepsy and complex epilepsy, this risk is compounded and estimated to be three times higher.  The most recent Annual LeDeR Report identified epilepsy as the most common long-term health condition associated with an earlier age at death.

The impact on health services is considerable. 40 per cent of (avoidable) emergency hospital admissions for people with a learning disability are due to convulsions and epilepsy. 

Why is now a critical time to drive improvement in epilepsy?

Health inequality is now clearly prioritised in the NHS long-term plan and operational planning guidance with clear expectations set for local healthcare systems to reduce health inequalities. Funding has been made available through core Integrated Care Boards (ICBs) allocations to support the delivery of system plans and includes an adjustment to weight resources in areas with higher avoidable mortality. £200m of additional funding allocated for health inequalities in 2022/23 is also being made recurrent in 2023/24.

Thanks to LeDeR and other national reviews, we understand the experience of health inequality for people with a learning disability in much greater detail than ever before. All Integrated Care Systems (ICSs) are now actively developing plans to address the causes of premature mortality identified through LeDeR, as required by the national LeDeR Policy and there is a real opportunity to ensure that priorities such as epilepsy are embedded in the mainstream strategies to tackle health inequalities and resourced sustainably.  

Why is a systematic whole-system approach to tackling premature mortality for people with a learning disability, autism or both in areas of epilepsy and other big killers needed?

We know there is wide variation in the provision of epilepsy services and support as well as issues in relation to the quality of epilepsy care for people with a learning disability and autism.  It is a similar experience for other health conditions such as pneumonia, and cancer.

Last summer, we started to engage with all health and care systems across the Midlands to understand the experience of professionals supporting people with a learning disability, autism and epilepsy. We were overwhelmed by the level of enthusiasm and appetite for improvement in this area. There were some great pockets of integrated working that had evolved across community learning disability and specialist epilepsy services. The challenges faced by both commissioners and providers in trying to meet the need were:

*lack of awareness and understanding of local needs

*lack of effective strategic commissioning

*lack of understanding of what good integrated epilepsy services should look like and where systems were falling short.

Systems partners called for improved system-wide strategic planning and service design for this vulnerable group of citizens

How did NHSE Midlands work with MLCSU and national experts to drive improvement across health and care systems across the Midlands?

Working with national experts and ICS system leads, MLCSU developed and led the Midlands an LDA Epilepsy Improvement Plan underpinned by five key agreed priorities.

Putting in place the foundations needed to achieve better outcomes consistently across the Midlands was the priority for 22/23, starting with support for health and care systems to understand their local population and appraise current services, support and pathways.

All Midlands ICSs have been supported to appraise epilepsy services and support using a tailored Learning Disability and Epilepsy Benchmarking Tool developed by Epilepsy Action.

Working through a comprehensive self-assessment questionnaire, this digital tool enables systems to collectively review and benchmark how services and support join together to meet the holistic needs of this population.  The tool is based on the Step Together Guidance on Integrated Care for People with a Learning Disability and Autism led by Professor Rohit Shankar of the University of Plymouth and has been developed and tested with four multi-disciplinary teams across the country.

What does the Epilepsy benchmarking exercise involve?

The exercise comprises broadly of three elements as outlined below:

Stage 1: A desktop review with system partners to collate necessary information, input the data and complete the first draft of the self-assessment. A dedicated workshop and drop-in clinics were held to support leads/ champions in coordinating and completing the self-assessment tool.

Stage 2: Consultation: Leads were asked to share the completed first draft self-assessment with all stakeholders to ensure it captures an accurate assessment and submit an updated completed tool to Epilepsy Action for review and analysis.

Stage 3:  System-level workshop: ICS leads were asked to bring systems partners together to collectively reflect on the outcome of the self-assessment and develop plans for improvement. 

To realise the full benefit of this exercise, we asked ICSs to:

1. Leadership and Governance: put in place identified senior leads to drive and oversee the delivery of this work including leads with responsibility for neurology/epilepsy services and learning disability and autism services.

2. Strategic Integration: ensure that this exercise is linked to relevant local strategic programmes relating to epilepsy, learning disability and autism, and health inequalities.  Whilst the obvious place for this programme of work might be with learning and disability and autism programmes, it was essential that this exercise also engaged directly with the commissioning and delivery of mainstream epilepsy provision. We suggested that it would be helpful to connect this work with established:

*ICS Strategic Health Inequalities Programme

*Learning Disability & Autism Programme and LeDeR Programme

*Local CYP Epilepsy transformation programme

3. Coordination & delivery: ensure dedicated leads/ champions are identified with the capacity to coordinate this exercise and complete a self-assessment questionnaire.  These leads were required to engage with a breadth of system partners to coordinate the tasks outlined in the stages above. Our recommendation was that this role is best supported by a mix of both commissioning and provider champions from LDA and epilepsy disciplines.   

4. Stakeholder involvement: engage the full spectrum of system partners who have a role to play in supporting people of all ages with learning disability and epilepsy. It was important that both commissioners and providers worked together to undertake this exercise. Listed below are some key stakeholders we recommended to be involved in the review, but this list is not exhaustive, and we encouraged the system to think widely about who should be engaged. 

*Patients, families, carers and advocacy groups

*Learning disability and autism: NHS and social care LD and autism commissioning leads: community learning disability teams, LD psychiatrists and other clinicians

*Epilepsy: Epilepsy/ neurology service commissioning leads, epilepsy nurses, neurologists, epileptologists

*Primary care: GPs, primary care liaison nurses

*Urgent care: clinicians and practitioners representing A&E

*Social care: directors of adult social care/ Social workers and social care practitioners

*Learning disability care and support providers – specialist hospital, residential and supported living providers.

What happens once the benchmarking exercise is completed?

Once completed, the tool creates a system-level report that can be downloaded and shared. System partners have been asked to use this intelligence to guide system-wide reflection and planning of services for people with a learning disability and autism who have epilepsy.  

Epilepsy Action prepared and made available a regional report detailing the outcome of all 11 reviews.  This provided a helicopter view of epilepsy services and support for people with a learning disability across the Midlands and comparative information for systems on where services and support are advanced and where further attention is needed.

On 31st March 2023, a regional event to share the results of reviews from across the 11 ICSs took place. This provided systems with the space to reflect together on the opportunities for improvement and start the development of improvement plans.

What support was made available to assist ICSs in undertaking this exercise?

Introductory workshop – A dedicated workshop for system leads and partners on how to undertake the review and apply the epilepsy benchmarking tool.   

Drop-in advice clinics: These were informal clinics for colleagues to raise any queries or ask for help with any challenges that might arise. They were also an opportunity for colleagues to share progress and learning between systems.  

Access to specialist advice: Throughout the process, all systems had access to Professor Rohit Shankar and Epilepsy Action to seek specialist clinical advice and practical advice on how to use the tool.

What tangible outcomes do we expect to see?

*Increased focus on improving epilepsy care for people with a learning disability and autism embedded in system-wide improvement to tackle health inequalities

*Bringing together system partners across primary, secondary, social care, and voluntary sectors to drive improvement

*A shared understanding of the extent to which services are working well together to deliver good care

*A shared understanding of where gaps in provision or quality exist, and a springboard for new or enhanced services identified

*A shared understanding of workforce capacity & capability, and where further investment is needed

*Better use of system-wide resources to improve outcomes.

*Foundations in place to support the development of integrated epilepsy care.

*Improved integrated strategic commissioning of epilepsy services and support.

We are already seeing tangible outcomes from the work to date across the Midlands including whole system engagement and leadership to drive improvement and targeted investment in specialist epilepsy nurses and other dedicated resources for the LDA population.

How are the wider Midlands LDA Epilepsy Programme priorities being progressed?

*Development of practical guidance by SUDEP Action & Cornwall FT for commissioners and care providers (specialist hospital and community) to improve the quality of epilepsy care

*Roll out of ‘My Life with Epilepsy Programme, Support & Guidance for Carers’ produced by SUDEP Action

*Design of a quality improvement project to pilot a whole system approach to improving the coverage and quality of epilepsy training

*Design of a quality improvement project to pilot a PCN approach to strengthening the capability of primary care support working with annual health checks and STOMP/STAMP programmes.

*Review of the way in which current pathways engage with assistive technology to manage epilepsy and SUDEP Risk.

What enablers have been critical to the success of the Midlands LDA Epilepsy Improvement Programme?

*The input of specialist expertise: The Midlands Epilepsy Advisory Group is a body of national experts and regional leads (including Professor Rohit Shankar of Cornwall FT, Chair of International League Against Epilepsy, SUDEP Action, Epilepsy Action, Epilepsy Nurses Association) that have been invaluable to the programme from the outset

*Leadership and engagement of NHSE Midlands and Midlands ICSs

*Effective engagement of practitioners across disciplines including, primary, secondary, community and social care

*Dedicated programme support to develop and coordinate the improvement programme working closely with the regional team and ICSs.

Contact for further information:

Hafsha Ali | Managing Consultant

Digital Transformation – Transforming Care

Midlands and Lancashire Commissioning Support Unit

Mobile: 07880 105665

Email: hafsha.ali1@nhs.net

The NHS is undergoing a significant transformation in the way it provides care and support for people with learning disabilities, autism, and specialised mental health needs. To explore what this means for the transformation of care and support, join our panel of experts in a conversation about the new operating framework and Hewitt Review.

Join us to discuss key topics, including:

– Taking a more localised whole system approach to learning disability, autism, and mental health transformation
– Improving the availability and quality of community care and support
– Realigning and localising mental health inpatient services to improve the quality of care
– Tackling health inequalities and premature avoidable death
– Driving improvement through greater accountability and citizen involvement
– Equipping systems with the capacity and capability to drive change and leverage digital transformation.

This event is open to all partners working in the field of learning disability, autism, and specialised mental health transformation. We encourage colleagues from both commissioner and provider organisations to attend. Join us for a conversation about the future of care and support for people with learning disabilities, autism, and specialised mental health needs.

You can register for the webinar here: https://www.midlandsandlancashirecsu.nhs.uk/transforming-healthcare-join-the-conversation/

Data collection and storage is by no means an effortless automatic process; it can be expensive, complex and bureaucratic. In his blog, Andi Orlowski, Director of the Health Economics Unit at the NHS Midlands and Lancashire CSU, explains where analysts can and want to help, and how data – once analysed and formed into something valuable and meaningful, can help you make the best-informed decisions:

““Most hospital discharge data is useless,” said the HSJ headline recently, reporting comments by former NHS CEO and current chair of two NHS trusts Sir David Nicholson. This twitched my antenna because data is obviously neutral; it’s what you do with it that counts. On this, Sir David is spot on, because data only develops value when you analyse it to learn from it. A diamond in the ground is of no value until it has been unearthed, polished, refined, categorised and turned into a product. Data is no different; it is just there, occupying gigabytes, consuming energy and inert until analysed.

“Data collection and storage is by no means an effortless automatic process; it can be expensive, complex and bureaucratic. Beyond naturally created datasets accumulated by activity, there are the manufactured and curated datasets. These are created to demonstrate or prove a point or provide accountability, and can take on a life of their own, spawning data collection industries designed to feed policy-making and political fashions of the moment. Just look at how data has been commissioned and used to support different political agendas, for example by daily newspaper The Times and think tank Reform. The use and analysis of data should mark the credibility (or lack of credibility!) of a story, proposal or policy.

“The NHS produces and amasses vast quantities of data from every aspect of its functioning and misfunctioning. As The Economist said on 15 January 2023, talking about the NHS, “Britain produces excellent data … Other countries have less-comprehensive statistics”. The NHS produces much more data than is analysed and is host to even more data generation through partnership working, clinical research and medical education. Virtually everything that happens in the service is recorded in some way. Where else can you find data on everything from the number of occupants of three-wheeled motor vehicle injured in collision with two- or three-wheeled motor vehicle that were hospitalised (9 people)? Or the average age of those hospitalised due to exposure to vibration (47.143 years old) or the mean length of stay of those bitten or struck by crocodile or alligator (3 days)?

“So, I wouldn’t blame the data, and I actually don’t think Sir David is. I feel the frustration that we are not using this treasure trove of potential knowledge to learn from, to discover new insights and create new outcomes. Discharge data is a snapshot of course – just one element of a patient’s pathway with many other factors contributing to that moment, including, in many cases, avoidable admissions and missed early interventions. Discharge data shows a sausage coming out of the factory; it tells you nothing about the sausage, its quality, the provenance of the ingredients, or even what the ingredients are!

“This is maths, not analysis, and it is discernible to anyone, even if they stopped maths at 16 years old. And if you can’t do the maths, then “Alexa, I have 200 patients fit for discharge out of 1,000”, “yes, you have 20% of your beds blocked”. Sir David is right. It tells us nothing – and context is king. So, what is the context? Who are these patients? Why are they in hospital? How long have they been there? Where did they come from? Where will they go to? How many have we seen before? How old are they? Which teams are they under? Which GP practice covers them? Are they working or retired? Are they mobile, independent, cared for or carers? Are their conditions chronic or acute? What is their level of deprivation? Are they amenable to/impactable by new or additional interventions? What’s their ethnic and cultural background? Are they vaccinated and against what? The context and many other possibilities we can all come up with offer the opportunity for analysis to sparkle like a diamond.

“And this is where analysts can and want to help. They are happy to mine for diamonds, polish them and even set them in a ring, taking all of this additional data and context, forming it into something valuable and meaningful, and providing enough understanding so that you, organisational system leaders, can make the best-informed decisions. There are an estimated 13,500 analysts doing this kind of work in the NHS and elsewhere, helping to improve the population’s health. This is work that makes patients’ lives better, work that ultimately can save lives and which will not only support your systems but will also get most analysts singing ‘Heigh ho’ as they go to do the work!

“You don’t need a whole mining workforce of your own; ICSs offer us a space and have the right people around the table to draw the skills needed from the system, not only helping to find the resource to mine, but also helping people better see the broader context and organise themselves to action the answers across traditional boundaries of both provision and sector.

“Today, the NHS feels overwhelmed by demand – the very thing the government promised its plans were designed to avoid. But if we are simply counting numbers, counting patients in, counting their stay and counting them out, that’s not maths, and it’s not analysis! We need to make our data work for us, by asking intelligent questions of it and testing the results. This takes a vision for how data can enrich our work, the resources of many more skilled people, and the imagination to ask questions that create options for improvement and progress. Otherwise, we are simply making sausages out of diamonds.”

Andi Orlowski is president at AphA Analysts and director of the Health Economics Unit.

Listen to David’s and Alastair’s talk here – https://www.midlandsdecisionsupport.nhs.uk/training-events/insight-2022-day-3-decision-making-in-the-21st-century-nhs-how-does-it-really-work/

The Strategy Unit is excited to be launching its new in-depth report into how the menopause is affecting both individuals and the workforce as a whole, at online festival INSIGHT 2022.

Colleagues are invited to join the expert panel on Monday 28 November, 10-11.30pm, where they will be revealing some of the findings of the report, and exploring the issues it raises, including:

What are the characteristics of NHS women of menopausal age?

What is it like to experience the menopause as a NHS employee?

What does it cost the NHS as an employer?

The panel will include the project leads Abeda Mulla (Strategy Unit), Justine Wiltshire (Strategy Unit) and Lisa Cummins (Health Economics Unit), who will be joined by Jacqui McBurnie (Chair of the NHS England Menopause Network) and Sarah Sheppard (Director of People Services, NHS Midlands and Lancashire CSU). The session will be facilitated by Karen Bradley (Strategy Unit).

Find out more about the festival and book your free ticket: https://www.midlandsdecisionsupport.nhs.uk/training-events/insight-2022-day-6-losing-women/

We helped NHS England roll out a programme of planning support for the increase and improvement of elective care activity at every integrated care system (ICS) in the country.

Background

NHS England has set a national target to deliver 30% more elective activity by 2024/25 compared with pre-pandemic levels, as well as eliminating long wait times.

To achieve this, Integrated Care Systems (ICSs) needed to develop robust plans to ensure delivery of national targets, tailored to their region.

In a CSU collaborative programme, MLCSU worked with South, Central and West CSU (SCW) to provide national co-ordination support and evaluation for this programme.

Action

Our delivery team worked closely with the core national elective programme team, SCW and the NHS England regional teams to scope out the needs of the programme.

After liaising with ICS elective care leads, we identified their specific capability and capacity to deliver elective care plans, ensuring that consultancy packages were tailored to provide optimal support.

We provided risk management, assurance, planning support and budget monitoring throughout, as well as tracking customer satisfaction.

As the programme progressed, we shared best practice and learning among the organisations involved to maximise opportunities to standardise the approach across regions.

Impact

Our expert team of project and programme managers provided both strategic oversight and operational support to NHS England in this complex and extensive programme of elective care planning support.

Our dynamic delivery team enabled the programme to be rolled out at pace, meeting an ambitious national timetable.

Through robust programme management, proactively highlighting risks and identifying solutions, we were able to facilitate consultancy firms to deliver planning support services to every ICS in the country throughout February and March 2022. This was a vital step towards meeting NHS England’s elective recovery target.

“MLCSU were instrumental in helping us to set up and roll out the NHSE planning support programme at pace. They were highly effective in managing multiple stakeholder relationships including external consultancies, NHS systems, and NHSE regional and national teams.

“There was significant complexity and challenge in delivering aspects of the programme, and they not only recognised key risks and issues but proactively identified solutions and resolved issues.

“Without the support of MLCSU, we would not have successfully delivered the programme, and we were very satisfied with the service that was provided.”

Elective Recovery and Performance team at NHS England

We are delighted to invite you to INSIGHT 2022, the annual festival of learning and sharing about analysis for the NHS, local government and other partners across health and care, hosted by the Midlands Decision Support Network in association with the NHS Midlands and Lancashire CSU’s Strategy Unit.

This year’s festival will run over a two-week period from Monday 3 October until Friday 14 October, and will include a mixture of talks, workshops and panel discussions. The theme is ‘The science and craft of decision making’, bringing together inspirational regional and national speakers to explore how insights from high quality analysis can drive change in health and care systems.

All events are online and everyone working in health and care is very welcome to attend. All sessions are free. You can commit as little or as much time as you’d like. Most of the sessions will be recorded so you can fit them into your schedule in a way that suits you.

Confirmed speakers include:

Nigel Edwards (Chief Executive, The Nuffield Trust)
Dr Bola Owolabi (Director – Health Inequalities at NHS England and NHS Improvement.
Sir David Dalton
Ben Marshall and Michael Lawrie (Ipsos UK)
Rony Arafin (Chief Executive Officer, AphA)
Professor Angie Hobbs (Professor of the Public Understanding of Philosophy).

…and many more will be added in the coming weeks.

How to attend

To register your interest simply complete your details on our Eventbrite page: https://www.eventbrite.co.uk/e/insight-2022-3rd-14th-october-2022-tickets-391179326897 – and we will share the full programme when it is available. You can also see the festival details on the Midlands Decision Support Network website: https://www.midlandsdecisionsupport.nhs.uk/training-events/insight-2022/

We look forward to seeing you!

Further information

If you have any questions, please email Kimberley Messam, Senior Consultant at The Strategy Unit: kimberley.messam@nhs.net

The Strategy Unit at the NHS Midlands and Lancashire CSU has written a paper jointly with the Royal College of Surgeons of England (RSC) on surgical hubs as a potential solution to the NHS’s growing waiting list. The report which is out this week presents seven recommendations to government to support this.

The RSC writes: “A key strategy to avoid the cancellation of elective activity involves greater separation of the resources that support elective and emergency patients, to create surgical hubs. This report identifies three categories of surgical hub: integrated (or ‘hub within a hospital’), stand-alone and specialist. These categories are illustrated in the report by case studies of trusts that have successfully adapted the model to their needs.”

Download full version of the report from the link below.

 

We provided a tailored package of strategic and operational support to a newly formed pharmacy team at a primary care network, helping them increase the rate of structured medication reviews.

Background

When a newly established Primary Care Network (PCN) covering thirteen GP Practices in the Northwest of England approached MLCSU for strategic and clinical support, MLCSU responded by developing a tailored package of year-long support that included clinical supervision, joined-up work planning and strategy development. MLCSU aimed to ensure the PCN achieved its Network Contract Direct Enhanced Services (DES) and Investment & Impact Fund (IIF) targets.

Action

An initial workforce survey highlighted learning needs. We provided senior pharmacist expertise in workforce development, outcome reporting methods, training and clinical supervision:

* Training and clinical supervision – monthly sessions with supported discussions forums to review any clinical issues
* Expert support and peer review – monthly one to one’s with senior MLCSU lead pharmacists and individual development plans with agreed objectives for the next 12 months
* Strategy and workplan development – structured workplan developed in line with DES and IIF requirements
* Operational support – a suite of standardised clinical system searches and tools were shared with the team to help them to identify patients for priority Structured Medication Reviews (SMRs).

Impact

The tailored package of support we developed included training on SMRs, the Community Pharmacy Consultation Service, Antimicrobial Stewardship, Area Prescribing Committees (APCs), Chronic pain, Opioids and medicines related safety. Local speakers were brought in to provide expert advice including the North West regional antimicrobial resistance lead, the local Controlled Drug Accountable Officer and the pan Mersey APC Secretariat.

Clinical supervision sessions provided a safe space for team discussions and interaction with experienced leads for mentorship and support. Group discussions often focussed on how work could be standardised. The team have now successfully implemented a scalable, hub-based model and operate as part of an agreed workplan and wider primary care strategy. Six extended training & clinical supervision sessions were held for the PCN Pharmacy team with a forum for team discussions, with mentorship and expertise provided by experienced MLCSU leads. This was complemented by monthly one to ones for all six clinical staff within the PCN.

Outcomes

* The PCN rated the MLCSU sessions as excellent, delivering improved pharmacist competencies through the use of MLCSU resources to meet their learning needs.
* The PCN progressed from 41 to 437 SMRs during the year with an additional 2,462 medication reviews undertaken.

“I really value [MLCSU’s] input and support. I would definitely like to see them support us for at least the next year.

“I enjoy the clinical supervision sessions, and really value the 1:1 support with the team. I hope that our Pharmacy Team relationship with MLCSU can continue as they support the direction of our growing and developing team.”

Pharmacist, St Helens South Primary Care Network

“I would like to say thank you to MLCSU for the service provided to date. I have seen an improvement in the pharmacy team and would like to continue on this trajectory.”

Dr Chibuzo Orjiekwe, St Helens South Primary Care Network

There are millions of people waiting for treatment. How should we decide who gets called first? Peter Spilsbury, Director of our Strategy Unit, discusses in this blog how waiting lists are currently prioritised and how looking at richer data around complex socio-economic factors can help improve equity.

Waiting lists for elective care are in the news. The national plan has been issued, with the expectation that lists will continue to rise for some years – and that long waiting will not disappear anytime soon. Addressing this ‘backlog’ will remain a fundamental challenge for some time to come.

This raises the question of how people on the lists are prioritised. There are millions of people waiting for treatment. How should we decide who gets called first?

Previous Strategy Unit work showed that there is already inequity: richer people tend to get better access to elective treatment than poorer people. This trend emerged over the last decade. And, if we aren’t very careful, the final reckoning of how the NHS ‘recovers’ will see these inequities made much worse.

Who gets treated ahead of whom is a value judgement. No one has a monopoly on those – and there are no right or wrong answers.

To date, the NHS has largely worked by prioritising based on length of wait. During lockdown the NHS/government worked with the Royal Colleges to establish a clinical priority weighting system. So decisions about who to treat started by considering clinical priority, then length of wait.

This seems utterly reasonable, but is it sufficient?

Let me explain why it might not be.

Imagine that two people are waiting for a procedure that has a non-urgent clinical priority. In both cases, they have pain that seriously limits their mobility. The first, Patient A, has waited for 50 weeks. The second, Patient B, has waited for 20 weeks. A slot is available for the treatment they both need. Who gets called?

Based on the information you have at this stage, who would you choose?

Now let me add some more information. Patient A lives in an area that is in the upper quartile of socioeconomic status; Patient B lives in an area from the lower quartile. People living in upper quartile areas typically get greater access to this treatment (relative to need) than people living in the lower quartile.

Would that change your judgement?

Now some more information. Patient A is otherwise well and has a job that allows them to work from home at a desk. Patient B works on a building site, on a zero hours contract, and has underlying mental health issues.

Would that change your judgement?

These are complex considerations. And they are value judgements, so they entail difficult debates where final positions are hard to justify using evidence. So many of us might want to avoid this discussion, treating ‘clinical priority’ as though it were a single, neutral and over-ridding consideration.

But this is an illusion. Carrying on just doing what we’ve always done is as much a value-based position as changing it. There is no ‘neutral’ position. Choosing purely on time waited is a deliberate decision to NOT take into account other issues. So we MUST engage in the question.

And that is why I’m really excited that the Strategy Unit is helping to inform these debates. We are starting with two exciting pieces of work.

The first is with our colleagues at University Hospitals Coventry and Warwickshire NHS Trust. They have developed a waiting list prioritisation system that starts to incorporate socio-economic factors into their approach to working through waiting lists.

They have asked the Strategy Unit and our partners Ipsos MORI to work with them in exploring with their local populations what they think about these issues. This is a vital step as a key challenge to formalising value judgements in prioritisation decisions is about how to secure some form of legitimacy. The project involves running properly designed deliberative events and surveys with people in Coventry and Warwickshire to explore how they think about trade- offs in terms of individual prioritisation. What do they think matters when it comes to making these decisions?

It will then be for the decision makers in that patch, having heard that, to decide how they will prioritise. And they will do that with explicit reference to what they’ve heard from their public. We will then be working with the Trust to evaluate whether the approach they settle upon helps to achieve their objectives.

The second piece of work is more analytical. Following on from our work that showed current inequity, we will shortly publish a report that reviews the various strategies that can be adopted to tackle socioeconomic inequity in planned care. You can find out more about this work, which we are doing for the Midlands Decision Support Network, here.

Both pieces of work are a starting point for us. The scale and importance of the challenge means that the Strategy Unit will want to continue to apply our skills and efforts. And the nature of the questions involved in this topic means that multiple approaches, viewpoints and efforts are needed.

Collaboration is essential. So we would like to hear from other organisations as they approach waiting lists and the question of ‘what is fair?’

We developed a strategic outline case setting out the ambitions and next steps in one of the NHS’s largest hospital transformation programmes.

Background

The Transformation Unit at Midlands and Lancashire Commissioning Support Unit (MLCSU) supported Shrewsbury and Telford Hospital NHS Trust’s New Hospital Transformation Programme over a 12-month period.

The programme required experienced leadership as well as support for the production of an outline business case.

This is one of the NHS’s largest hospital reconfiguration programmes, with a capital spend of £500 million+.

Action

An initial assessment of the programme status showed that the organisation was not yet at the stage to develop an outline business case and, in fact, required significant support to strengthen the work of the programme and re-write the strategic outline case.

Following the delivery of a readiness assessment, which provided us with an overview of the strengths and weaknesses of the programme, we devised a programme plan, engaged with stakeholders, and commenced work to support the areas requiring improvement.

We guided the client helping them understand the stages of each aspect of the project and engaged with NHSEI to formulate a plan for the strategic outline case submission.

We worked with internal clinical leads, the project team, as well as architects, to finalise a design for the new build and worked in partnership with the Programme Director to produce a robust strategic outline case.

Impact

A comprehensive completed strategic outline case was delivered within the agreed timeframe. This allowed the organisation to plan for the next stage of the programme – development of an outline business case – on a solid platform.

The strategic outline case was reviewed and scrutinised through the programme’s governance and assurance framework.

We continue to provide the trust with support to develop and submit an outline business case.

Additionally, we are supporting the client with other business cases not related to the Hospital Transformation Programme.

Our Transformation Unit helped develop a new model of care for acute services at a health and social care partnership alliance.

Background
Cheshire East Partnership is an alliance of health and social care partners (two acute trusts, commissioners, community service providers, one mental health provider, local authority and primary care), that are working together to improve the health and wellbeing of the population of Cheshire East Place (approximate population of 378,000)​.

Cheshire East Place is facing a range of challenges in respect of delivering sustainable health and care services. Key issues faced by acute providers include increasing demand from an older and frailer population, falling demand for some services, financial challenges, workforce challenges and some less resilient services.

Cheshire East Place needed to develop a new model of care for acute services that was aligned with the process for development of the integrated care partnership and redesign of integrated community services.

MLCSU’s Transformation Unit was commissioned to support Cheshire East Place with the redesign of acute services across two acute trusts to meet the needs of the Cheshire East population.

Action
This programme of work was delivered under the backdrop of the COVID-19 pandemic. It required exceptional flexibility and adaptability to deliver a clinical redesign programme with limited capacity from the clinical community. Key deliverables for this programme included: ​

* Confirmation of programme scope – an alignment piece designed to reach agreement between partners about the scope and desired outcomes​
* Decision-making and governance framework to set out the process for approval​
* Data analysis on the current services and population health needs to enable articulation of the Case for Change​
* A clinically-led process of designing a new model of care for acute services ​
* Baseline activity and finance model to inform future options​
* Design of an options development approach ​
* Communications and engagement strategy and support for patient and public engagement​.

Impact

Under challenging circumstances for the clinical community we delivered a co-produced Model of Care that describes acute services within the context of an integrated care model.

Engagement and support from across acute clinical, social care, community and primary care professionals was strong with consensus reached on what future services should look like and what they should collectively strive to achieve in terms of quality, accessibility and sustainability.

Our Transformation Unit was commissioned by NHSX to support in the development of its national digital strategies for ambulance, community, dentistry, optometry and community pharmacy sectors.

Background

There is significant potential for digital technologies to support improvements in care across the whole of the NHS towards the delivery of 21st century world class health care for all patients. This potential could be highest in those sectors which have historically received less digital funding in recent years, namely Pharmacy, Optometry, Dentistry, Ambulance and Community (PODAC) services.

NHSX needed to develop a digital strategy for these five sectors and required an extensive programme of stakeholder engagement to achieve this.

We worked in partnership with Kaleidoscope Health & Care to deliver a full programme of stakeholder engagement across the five sectors to inform development of the NHSX Digital PODAC strategy (2021 – 2026).

Key deliverables were to:

1) develop comprehensive national digital strategies across the five PODAC sectors
2) facilitate the building of social capital between stakeholders for long-term engagement and development.

Action
Our support included:

* delivery of desk-based review of digital developments across the sectors
* wide-ranging engagement activities to seek views and input to identify key needs, priorities and recommendations. Stakeholders were drawn from NHSX, NHS Digital, NHS England and Improvement (NHSEI), staff representative bodies, sector membership organisations, individual practitioners, patients and patient representative bodies, system leads and digital champions
* focused workshops to test and challenge the recommendations and implementation plans
* authorship of the sector strategies, working collaboratively with NHSX PODAC Sector Leads
* support for stakeholder management.

We engaged with over 500 key stakeholders nationally (via one-to-ones or group meetings, bespoke workshops and online feedback) to successfully facilitate the deliverables.

Impact

Our approach ensured that the digital strategy remained closely aligned to the clinical vision for each sector and built relationships with key stakeholders so that they can continue to be involved in planning and implementing the priorities set out in the strategy.

The resulting strategy was endorsed by NHSEI clinical leadership for each sector and the strategy underpinned a case for investment for the programme.

This is the first in a series of blogs on decision making by the Midlands Decision Support Network, follow the series on midlandsdecisionsupport.nhs.uk. The Network comprises a collective helping health and care system leaders to make better, evidence-informed decisions through high-quality analysis and evaluation. It is developed by Midlands and Lancashire Commissioning Support Unit’s Strategy Unit.

This is a blog by Fraser Battye, Principal Consultant at the Strategy Unit.

There are two main routes for health and care services to improve the health of the populations they serve. They can: 

* Decide what to do.  
* Do it well. 

Obviously, both are needed. But do services make the most of both routes? Or do they pursue one and neglect the other? And if they do, where is the room for improvement?  

I would say that Route 2 (improving what is done) gets a great deal of time and attention, while Route 1 (deciding what to do) is neglected. This is a tricky claim to substantiate, but a quick look provides some evidence.  

Service improvement is not a specialism of mine. Yet, even as a very distant spectator, I can cite multiple methods and approaches that services use to get better at what they do. Lean. Six Sigma. Agile. PDSA cycles. QI. LGA Toolkits and support, Design Thinking, Skills for Care Guides, NICE Guides, service improvement and redesign (QSIR) tools. Services can use tools, such as Right Care, to see where to improve, before consulting large-scale programmes, such as Getting It Right First Time (GIRFT), to get it done.  

Even this casual glance reveals a wealth of tools, techniques, organisations and programmes dedicated to helping services improve what they do.  

So what are the equivalents for deciding what to do? Where are the programmes, guides, checklists, training courses (etc) for decision making? If you wanted to improve the quality of decision making in your organisation, where would you go?  

The lack of an immediate or obvious answer suggests something. And further research turns up little. Hence my claim: we don’t invest enough time, attention and effort into deciding what to do. Decision making is undervalued **.  

So how are strategic decisions made in health and care services? And how do we assess the quality of these decisions? Would we know good quality decision making if we saw it? Is there shared understanding of this? What about individual skills and attributes: do we know what makes a good decision maker? 

These questions spurred the Strategy Unit, as part of our work to develop the Midlands Decision Support Network, to design an education and training offer focused on decision making.  

For example, our ‘Decision Quality for Leaders’ programme will shortly complete its first run. We gathered and structured the best approaches, frameworks and tools we could find, before guiding a senior group through their use. It has been well received. And we have left participants with a clear sense of what better quality decision making looks like – and how to achieve it.  

Our work on decision making will continue to develop. We are preparing the leaders programme for future cohorts; we have added decision making sessions into our ‘Leadership for Analysts’ course; and we have developed a specific training workshop on ‘Thinking Tools’. More is needed and more is planned.  

This is not in any way, or even for a minute, to say that time spent improving service delivery is time wasted. It isn’t. But it is to say that we pay strangely little attention to the practice of decision making. It determines so much, yet we focus on it so little. Our efforts are a small step towards correcting this.  

** Here it is important not to confuse a ‘how’ with a ‘who’. I don’t doubt that the question of ‘who decides’ can generally be answered. An organisation, a committee, an individual: governance arrangements are usually well-focused on this type of question. The gap I see is in the how of decision making: the disciplines and methods that these decision makers use.  

Join us tomorrow, 15 October for the grand finale of the Insight 2021 festival of analysis and learning.

‘Insight to action: lessons from think tanks’ brings together the leaders of the Health Foundation, The King’s Fund, Nuffield Trust and the Strategy Unit for a panel discussion on how to move insight into action for the improvement of health services.

Insight 2021 is an annual festival of free events on learning and sharing for the NHS, local government and other partners across health and care. It is hosted by the Midlands Decision Support Network, in association with the Midlands and Lancashire Commissioning Support Unit’s Strategy Unit.

The Midlands Decision Support Network exists to support health and care leaders generate insights from high quality analysis and evaluation and move these into action – better, evidence-informed strategic decisions in Integrated Care Systems.

But moving insight to action is challenging – particularly for those without a direct hand on the levers of power, such as think tanks and researchers. How do we ensure that the insights we generate get converted to meaningful change? What needs to be in place in health and care systems in terms of capacity, capability and culture? What can we learn from the experience of responding to the COVID-19 pandemic?

An expert panel of the leaders of the national analytical collaboration of think tanks, which worked to support the health and care system in the fight against COVID-19, explores these questions:

* Dr Jennifer Dixon – Chief Executive, the Health Foundation
* Richard Murray – Chief Executive, The King’s Fund
* Nigel Edwards – Chief Executive, the Nuffield Trust
* Peter Spilsbury – Director, the Strategy Unit

…alongside the Director of the newly formed IMPACT centre for implementing evidence in adult social care.

* Professor Jon Glasby – Professor of Health and Social Care, the University of Birmingham

To register for the event, please search for the Midlands Decision Support Network and scroll down to ‘Upcoming training & events’ .

This year’s festival is running from Monday 4 October until Friday 15 October, and includes a mixture of talks, workshops and panel discussions.

Recordings of all the excellent sessions already taken place, are available from the full programme of events on the Midlands Decision Support Network website.

The Midlands Decision Support Network in association with the Midlands and Lancashire Commissioning Support Unit’s Strategy Unit are hosting INSIGHT 2021, our annual festival of learning and sharing events for the NHS, local government and other partners across health and care.

This year’s festival will run over a two-week period from Monday 4 October until Friday 15 October, and include a mixture of talks, workshops and panel discussions. The theme is Insight to action, bringing together inspirational regional and national speakers to explore how insights from high quality analysis can drive change in health and care systems.

Sessions will be delivered virtually. The festival is open to everyone working in health and care and every session is free.

Last year’s festival had over 3500 attendees and was highlighted in the International Journal of Health Governance as one of the most ‘interesting and inspirational’ virtual conferences of 2020, alongside offerings provided by the World Health Summit, the European Observatory on Health Systems and the Nordic Health Movement.

Attendees can commit as little or as much time as they’d like. Most of the sessions will be recorded so you can fit them into your schedule in a way that suits you.

Confirmed speakers include:

Nigel Edwards (Chief Executive, The Nuffield Trust)
Jennifer Dixon (Chief Executive, The Health Foundation)
Richard Murray (Chief Executive, The Kings Fund)
Andi Orlowski (Director, The Health Economics Unit)
Professor John Wright (Director, Bradford Institute for Health Research)
Dr Kathryn Mannix (Clinician and author)

…with many more expected to be added in the coming weeks.

To register your interest:

Please search the Midlands Decision Support Network and follow the instructions to book a session.

If you have any questions, please contact Rachel.Caswell@nhs.net or Gareth.Wrench@nhs.net

We worked with commissioners, providers and other stakeholders across Stoke-on-Trent and Staffordshire to improve the quality of service for patients and cut costs across planned care.

Background​

Planned care is a top priority for Staffordshire and Stoke-on-Trent Sustainability and Transformation Partnership (STP). The current acute cost is £348million and has been growing by 14 per cent over the last four years, well above the rate of population increase.

National standards are not being met and backlogs are increasing. The target is to improve quality and patient experience in addition to delivering savings of £14million by 2020/21.

Action​

* A planned care workstream was set up with clinical and management representatives from commissioner and provider organisations, and other major players​
* National and local data was analysed and ophthalmology and musculoskeletal (MSK) conditions were prioritised as the two highest-spend areas where changes could most easily be made​
* Engagement events were held with a wide range of stakeholders, and guest speakers from NHS England universities and other trusts​ were brought in
* Seven task-and-finish groups were created, focusing on specific ophthalmology and MSK conditions​
* Site visits by the groups were arranged to map current processes and then use improvement techniques – such as the five whys – to determine why activities were not adding value. Action plans were then established.

Impact

* The programme is predicted to save between £1.9m and £4.4m per annum across seven pathways
* Data sharing at a system level has led to a greater understanding of the way planned care has been provided and has led to changes in practice
* Standard service specifications have been introduced
* The referrals process has been improved and the number of referrals has been reduced
* We have noted improved theatre productivity
* Unnecessary scanning and injections have been eliminated
* Commissioning around pain management has been improved
* Follow-ups are now being carried out in the community, closer to patients’ homes.

Mark Seaton, Staffordshire and Stoke-on-Trent STP Planned Care Workstream Programme Lead, said:

“During our planned care project in Staffordshire, it was clear we needed to forge much stronger relationships across a number of organisational boundaries and change cultural thinking.

“The CSU has been instrumental in helping us put clinical engagement at the centre of our work. Organising, facilitating and designing workshops to gain insight and involvement; the CSU also invited guest clinicians to share learning.

“This was not an easy process but together we worked hard to share expertise and design pathways to bring real benefits to patients.”

The Hard to Source Items (HTSI) team sources timely and sufficient quantities of required equipment and consumables to complement conventional channels and safeguard against supply chain disruptions. COVID-19 led to a surge in demand for clinical consumables and services globally, with conventional procurement channels exhausted and struggling to meet demand. This was made worse by restrictions on border movements and local production capacity constraints such as workforce availability, raw materials and procurement mechanisms in place of usual trading conditions.

MLCSU’s Improvement Unit were rapidly deployed to support a dedicated global team put in place by the DHSC to consider alternative approaches, including sourcing items from international suppliers previously unknown to the NHS and looking at appropriate clinical alternatives.

Action

The Improvement Unit were tasked with managing the largest product category range, NIV/CPAP and HEPA/HMEF filters, which included NIV masks, filters, breathing circuits, exhalation ports and reservoir bags totalling over 3 million individual items. With stocks rapidly depleting and the winter surge looming, the team liaised with British Embassy colleagues in Beijing and managed to:

* Find suppliers
* Track delivery of products into the UK keeping the NHS Supply Chain updated
* Coordinate the validation of products through a rigorous due diligence process involving clinical scientists and gaining approval from the MHRA
* Hand products over to the supply chain for distribution to Trusts for use by the most vulnerable COVID-19 patients in the event of a winter surge.

Impact

* Sourced sufficient quantities of ICU consumables and equipment for COIVD-19 patients in preparation for the winter surge.
* Secured approval from the DHSC and Cabinet Office to source millions of individual products from global suppliers and monitored their progress through to delivery into MoD airbases and warehouses.
* Opened up new international markets and future supply chain channels previously unknown to the NHS.
* Managed the technical, clinical and regulatory due diligence validation process of first-of-type items into the UK.
* Produced documentation and communications for each product to encourage uptake of novel devices in NHS Trusts.
* Forged strong relationships and built new networks of stakeholders by working collaboratively with the DHSC, NHSSC, MoD, MHRA, FCDO, external consultants, other CSUs and * Trusts involved in the testing and adoption of the products sourced.
* Contributed to the creation of the HTSI ‘playbook’ which outlined the scope, structure and processes of the HTSI team in the event of being mobilised at pace in the future.

Primary Care Support England (PCSE) provided by Capita, supplied the administration support for the National Cervical Screening Programme on behalf of NHS England, sending invitations, reminder letters and test results to patients.

On 20 March 2019, NHS England (NHSE) Chief Executive Sir Simon Stevens advised the Public Accounts Committee into failings with adult health screening programmes, and confirmed that action was being taken to bring the service back to the NHS.

Action

The Commissioning Support Units were requested to work collaboratively to provide an overview of the service and establish a programme office to manage its transition back to the NHS by 1 August 2019.

The expertise of MLCSU’s Improvement Unit was requested for the immediate mobilisation and transition of the service, along with providing operational oversight, leadership, management and improvement support.

Impact

* Cervical Screening Service “in-housed” within timescales from Capita to NHS England on 1 August 2019
* Exemplar of collaborative working with experienced, skilled and dedicated expertise, resulting in a successful transfer and continuity of service delivery
* Consistent leadership and operational management support in the absence of a head of service, providing stability and consistency
* Creation and implementation of a streamlined case management system, including dashboard reporting functionality to support operational management
* Support in the redesign and implementation of a complaints service
* Creation and implementation of a dedicated call handling service, improving customer experience and improved processing of operational queries and enquiries
* Identification of areas for improvement, prioritisation and development to enhance service delivery
* Responsive and inclusive communication and engagement, resulting in improved staff morale, staff and customer satisfaction.

The Strategy Unit developed EPIC in response to national challenges facing primary care, informed by the GP Forward View and the ‘Ten high impact actions’. EPIC is an evidence-based and experience-informed local primary care development programme.

The aim was to enhance the capacity and capability of general practice staff to develop and implement innovative ideas and to transform service delivery: focusing on quality and efficiency of care; patient experience and collaborative working.

Action

EPIC had three workstreams:

* 1. ‘Business management’, providing core business skills to every practice in Dudley, to improve productivity, workflows, data management and reporting
* 2. ‘Performing as a team’, supporting practices to improve what they do through ideas generated in joint learning sets, with bespoke support within individual practice settings
* 3. ‘Transforming’, facilitating practices working in partnership with external organisations to design and deliver ambitious new pathways, through a supported programme of action learning.

Impact

EPIC evaluated well. It received very positive feedback from practices. It showed improved skills and knowledge within the practice teams, hence empowering staff, as well as improving relationships with local partners.

Cost savings were demonstrated, arising from reduced repeat prescription processing, as well as reduced paper flow and document transfer – saving time. There were also reductions in GP appoint-ments for pill reviews and a reduction in avoidable appointments, saving GP time.

NHS England (NHSE) wanted to find opportunities to provide more effective and efficient ways of delivering the Revalidation Service – Payment of Appraiser process. MLCSU, NEL, AGEM and NECS CSUs worked collaboratively with NHSE on an options appraisal and implementation plan.

Action

The CSUs worked collaboratively with NHSE to find opportunities to provide more effective and efficient ways of delivering the service. The review highlighted:

* substantial variation in the process between all of the local and regional offices
* two teams outsource to HEE, 13 use PO, four use non-PO, five use NHAIS, five use the RMS template, 11 send invoices sent direct to SBS, six submit direct to the team
* invoicing frequency varies
* trade shift usage varies
* substantial workload pressures
* every query about payment from an appraiser requires input from the local office
* use of a variable number of FTE, dependent on the structure chosen in local office
* average invoice is between £700-800, £23million per annum, 46,000 doctors, 3,000 appraisers.

Following an options appraisal, NECS CSU delivered a three-day workshop with NHSE colleagues to process map and understand the current and future state of the service.

Impact

The revised and automated process is enabling NHSE to free up resource in the move to STPs and support administration work required for the substantial uplift in revalidation recommendations commencing from March 2018.

The review led to creation of a process which will result in:

* one consistent process for the payment of appraisal work undertaken by GP appraisers
* no POs – no invoices – no receipting, saving substantial time and effort in the local offices managing and reconciling invoicing
* removal of variation between the local offices, reducing confusion for appraisers
* speeding up of the production of reports to understand payment and pension position for local offices
* reduced accrual amounts for local offices because payment does not need to wait for an invoice
* reliable indication to appraisers of payments paid and outstanding, removing queries that had to be handled by the local office

RMS developments included:

* revised email templates
* holding supplier information (not bank details), holding and processing pension information
* holding history about payments made by the team
* reporting on payments
* consultancy agreements moving online – one click acceptance by the appraiser.

Planned care is a top priority for Staffordshire and Stoke-on-Trent Sustainability and Transformation Partnership (STP). The current acute cost is £348million and has been growing by 14 per cent over the last four years, well above the rate of population increase. National standards are not being met and backlogs are increasing. The target is to improve quality and patient experience in addition to delivering savings of £14million by 2020/21.

Action

* Planned care workstream set up with clinical and management representatives from commissioner and provider organisations, and other major players
* National and local data analysed and ophthalmology and musculoskeletal (MSK) conditions prioritised as the two highest spend areas where changes could most easily be made
* Engagement events held with wide range of stakeholders, and guest speakers from NHS England universities and other trusts
* Seven task and finish groups created, focusing on specific ophthalmology and MSK conditions
* Site visits by the groups to map current process and then use improvement techniques, such as the 5 whys, to determine why activities were not adding value and create action plans.

Impact

* Predicted to save between £1.9million and £4.4million per annum across seven pathways*
* Data sharing at a system level led to greater understanding and changes in practice
* Standard service specifications introduced
* Referrals process improved and numbers reduced
* Theatre productivity improved
* Unnecessary scanning and injections eliminated
* Commissioning around pain management improved
* Follow-ups now being carried out in the community, closer to patients’ homes.

(*the lower figure of £1.9m will be saved if NHS volumes remain constant following implementation of the new pathways. The higher figure of £4.4m illustrates the savings available if the created capacity is used to repatriate the volumes going to the private sector.)