Clinical Senate Forum 7th July 2016

“Delivering Seven Day Services” 9 July 2015 King’s Fund

Welcome and introductions Dr Andy Mitchell, Clinical Senate Forum Co-Chair Medical Director, NHS England (London Region)

Jane Clegg, Clinical Senate Forum Co-Chair Interim Chief Nurse, NHS England (London Region)

9 July 2015 King’s Fund

System level respond to the challenge Introduction and Background Sir Bruce Keogh National Medical Director NHS England 9 July 2015 King’s Fund

Session 1

Patient and carer experience personal challenges with access

Angeleca Silversides Patient Representative at NHS North West London and Chair of Healthwatch, Kensington & Chelsea 9 July 2015 King’s Fund

Urgent and Emergency Care networks Thursday 7th July 2016 Dr Simon Eccles, Consultant in Emergency Medicine; Clinical Director for Emergency Care, NHS England (London region); Chair, SEL UEC Network

U&EC Networks – what and where Five U&EC Networks have been established across London

The role of U&EC networks is to operate strategically to deliver whole system transformation to improve consistency and quality 7 days a week by bringing together a range of stakeholders to address challenges in the U&EC system. 6

What do the public want from UEC? Understanding Londoners’ expectations A survey of 1,000 Londoners and over 800 interviews with people attending A&Es has emphasised expectations that, in and out of hospital, U&EC services should be: •

Available with shorter waiting times, longer opening hours and efficient coordinated systems;

•

Consistent in their service offering and across the seven days of the week; and

•

Clear and instill confidence by being seen by the right clinical expertise at the right time.

Implementing the U&EC Vision in London National priority areas The three broad national priorities to be delivered by networks through UEC element of STPs:

Provide responsive urgent care services outside of hospital, ensuring care close to home

Single point of access for clinical advice

For people with serious or life threatening needs – physical or mental, ensure treatment in centres with the best expertise and facilities

days a week

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Implementing the U&EC Vision in London Primary Care:

Urgent Care Centres:

•

•

Strategic Commissioning Framework – 8-8 access 7 days a week

Specialist care:

London Quality Standards • – consistent services 16 hours a day, 7 days a week

Stroke, Trauma, heart attack and vascular centres of excellence

Emergency care: • •

Integrated Urgent Care:

Community and social care:

• Integrated Urgent Care Commissioning standards – • 24/7 linked to a robust DoS

Foundations of Good Community Services

• •

London Quality Standards London Clinical Interdependency Framework Mental Health Crisis Commissioning Standards New HBPoS specification 9

What this means for Londoners

Primary Care I can access my GP from 8am to 8pm, 7 days a week

I can call or click 111 and I’m confident to be supported to treat myself if possible or directed to the most appropriate care, quickly

Integrated Urgent Care

Urgent Care Centres I know exactly where to go if I have a minor urgent ailment that I’m unable to treat myself and I’m confident that the service will be consistent wherever I am in London

I will be supported to stay out of hospital and maintain my independence, and following admission supported to get home as soon as possible

Community and social care

Specialist care If I have a life threatening emergency, I will be taken to a centre with the right facilities to maximise my chances of survival and recovery

I’m confident if I need to be admitted to hospital I’ll receive safe and high quality care, 7 days a week

Emergency Care 10

London Quality Standards “All quality standards cover the seven days of the week” Including: • A consultant in emergency medicine to be scheduled to deliver clinical care in the emergency department for a minimum of 16 hours a day. • All emergency admissions to be seen and assessed by a relevant consultant within 12 hours of the decision to admit or within 14 hours of the time of arrival at the hospital. • Prompt screening of all complex needs inpatients to take place by a multiprofessional team including physiotherapy, occupational therapy, nursing, pharmacy, psychiatric (if required) and medical staff. • Senior decision making and leadership on the acute medical/ surgical unit to cover extended day working, seven days a week. • All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds • All hospitals admitting medical and surgical emergencies to have access to all key diagnostic services in a timely manner 24 hours a day, seven days a week 11

Mental MentalHealth HealthCrisis CrisisCare Care This includes transforming the care for those in mental health crisis

In 2014 the London Health Commission recommended:

Health and care commissioners should develop a panLondon multi-agency case for change and model of care for child and adult mental health patients in crisis

•

•

London is now leading the way nationally with a Pan-London approach to improve consistency and quality of care for those in mental health crisis through the development of: •

A consistent pan-London section 136 care pathway

•

All age Health Based Place of Safety specification

A multi-agency professional group was established in 2015 and has led the development of this work involving stakeholders across the crisis care system.

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Engagement across London’s Crisis Care System

Implementation will mean changes in practice across the crisis care system, the development of centres of excellence and a culture of treating mental health crisis with the same urgency as physical health to achieve parity of esteem, 7 days a week 13

Clinical team presentation on integrated urgent care

Dr Phil Koczan GP and Clinical Informatics Lead

Dr Sam Shah Clinical Lead for Integrated Urgent Care, NHS England (London 9 July 2015 Region) King’s Fund

London NHS 111 Patient Relationship Manager Clinical Senate Thursday 7th July

What is the London NHS 111 Patient Relationship Manager? NHS 111 Patient Relationship Manager (PRM) for London - Developed using Agile project methodology - Innovative cloud-based technology designed to improve the patient experience in urgent care - Sharing of patient data with clinicians in NHS 111, GP out-of-hours and Ambulance Service Care or Crisis Data Partners:

Technology Providers:

London 111 providers:

Live NHS 111 PRM Cloud

NHS 111 London GPOOH Providers

This network of stakeholders of Commissioners, Clinical leads, 32 CCGs, SRG networks and the London Integrated Urgent Care team 16

How was the Patient Relationship Manager Developed? A technology supplier (Redwood) was procured to support the iterative development of a viable technical solution through a series of agile Beta phase roll outs from September 2015. The objective was to produce a live, working system to improve the 111 patient experience in the Urgent & Emergency Care services. The pilot went live within 3 months and the Patient Relationship Manager now intelligently routes all London 111 calls for all four 111 providers in London; connecting with local partners so that clinicians can access crisis and care plans in real-time. Jan 2015

March 2015

July 2015

Sept 2015

May 2017

Business As Usual

Agile project management focussed on the scope in manageable chunks governed by fortnightly sprints and allowing clinical feedback from across the Urgent & Emergency care system.

Improved London Patient Data flow through the PRM

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How does the PRM Support Londoners with Complex Needs? The London Integrated Urgent Care (IUC) team have been using the digital technology which the Patient Relationship Manager provides to support the roll out of specialist services to particular groups of patients using the 111 phone service.

MyBrainBook is a digital platform designed with input from patients, caregivers and professionals to promote self-care and prevent escalating need for people living with dementia.

Health Analytics enables a coordinated approach to healthcare by linking patient data from primary, secondary, social and community care.

CMC is a clinical service delivering digital multi-disciplinary urgent care planning focused on coordinating urgent care around a patient’s preferences and clinical needs.

NeuroResponse is a model of care which gives patients with complex neurological conditions better management of their care through an advice line staffed by specialist nurses and designated clinical pathways minimising emergency department attendance. 19

How does the PRM Dashboard Improve Patient Experience An interactive and real-time dashboard supports Integrated Urgent Care system resilience and clinical safety across London by providing in-depth analysis of 111 London call volumes and performance.

The PRM dashboard functions as a support tool during periods of stress on the Integrated Urgent Care system by monitoring actual call volumes against expected volumes by provider and identifying variations in cases of flu, diarrhoea and vomiting symptoms in each CCG area across London. The PRM has the capability to support call diversion between 111 providers in London to mitigate operational pressures and maintain access for patients.

How do we know that the PRM has been successful? Whilst early reports from 111 clinicians have been positive, we have commissioned the London CLAHRCs in partnership with NELCSU and the Picker Institute to complete an evaluation to assess patient and user experience, effectiveness and economic impact on the whole system.

Benefits to Patients •

•

•

Patients will receive more personalised care and advice, particularly for those whose crisis / care records are available to 111 who are directly routed within 111 to the relevant clinician

Benefits to Staff •

Clinicians can use crisis and care information from more provider systems to guide their clinical conversations and decisions

•

On-site clinicians, including paramedics, have key data items such as conveyance, medication and other data, including cardiac resuscitation decisions, critical to safety of care

Patients calling within 96 hours of a previous call will be saved repeating their information Patients' care information can be sent to urgent and emergency care providers

UEC Systemwide benefits

•

Out-of-Hours GPs can assure greater continuity of care with a patient's regular GP

High Level Evaluation Interim Report of Initial Progress (up to end July 2016)

•

Supported by previous evaluation, fewer referrals to the Ambulance service and Emergency Department admissions for complex / highrisk patients as their care preferences can be accessed and followed

•

Larger proportion of referrals to out-of-hospital services (primary, community and social care services, including Mental Health, Community Response and Crisis teams

Scope of detailed evaluation of the extended Pilot (December2016)

What’s the long-term vision? High level view of LHCIE capability Architecture:

Data Controllers

Care Providers

Citizens

Health and Care Information Exchange Gateway Trust, Identity and Consent

Online Account

Document and Image Exchange

Subscription and Notification

Workflow Management

Integrated Digital Care Services

What to know more…? Please contact the team if you’d like to learn more…! Dr Sam Shah Regional Clinical Lead, Integrated Urgent Care (London)

Dr Phil Koczan GP and Clinical Informatics Lead

Email: [email protected] Twitter: @healthyopinion

Email: [email protected]

Eileen Sutton Head of Service Redesign and Innovation (Integrated Urgent Care)

Mark Bamlett Integrated Urgent Care Programme Manager

Email: [email protected] Email: [email protected]

Craig Tucker Integrated Urgent Care Project Manager

Email: [email protected]

Patient and carer experience personal challenges with access

Kana Evans Patient

9 July 2015 King’s Fund

Table discussion and feedback What do we need to focus on to deliver 7 day services as a whole system?

Coffee break and networking 11.00-11.30

Innovative approaches to early delivery The North West London Success Story Dr Susan La Brooy, North West London 7DS Programme Clinical Lead Dr Zoe Penn, Medical Director, Chelsea & Westminster NHS Foundation Trust and Consultant Obstretrician & Gynaecologist Mr David Ahearne, Consultant Trauma & Orthopaedic Surgeon, The Hillingdon Hospitals NHS Foundation Trust Dr Brynmor Jones, Imperial College Healthcare NHS Trust 9 July 2015 Tustin, North West London 7DS Programme, Associate Director Rachel King’s Fund

Session 2

North West London Hospital Transformation 7 Day Services Programme

Innovative Approaches to Early Delivery The North West London Success Story London Clinical Senate Forum 7th July 2016

London Clinical Senate Forum

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North West London Hospital Transformation 7 Day Services Programme

Introduction & Approach Dr Susan La Brooy London Clinical Senate Forum 7th July 2016

London Clinical Senate Forum

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NWL 7 Day Services Programme Introduction & Approach

The NWL Landscape • 8 CCGs & 8 London Boroughs • 4 Acute Trusts (2 with Specialist Services) • 7 A&E Departments • ~400 GP Practices

Harrow

Northwick Park

Hillingdon

Brent

History of Sector-Wide Working • 4 years of service reconfiguration • Clinical leadership • Lay partner co-design

Ealing

Central Middlesex Hammersmith

Hillingdon

St Mary’s

Ealing

Kensington & Chelsea

Westminster

Charing Cross Hounslow

West Middlesex

Hammersmith & Fulham

Chelsea & Westminster

Royal Marsden

Royal Brompton

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NWL 7 Day Services Programme Introduction & Approach

Our Tried & Tested Approach

Agree the clinical imperative

Focus on clinical outcomes

Baseline data to establish gaps in service and capacity

Agree practical solutions to achieve clinical outcomes

Establish outcome metrics for success

Implement, collaborate and share

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North West London Hospital Transformation 7 Day Services Programme

An Inpatient Model of Care to Meet Standard 8 Dr Zoe Penn, Chelsea & Westminster NHS Foundation Trust Mr David Ahearne, The Hillingdon Hospitals NHS Foundation Trust London Clinical Senate Forum 7th July 2016

London Clinical Senate Forum

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NWL 7 Day Services Programme An Inpatient Model of Care to Meet Standard 8

Agreed Clinical Outcomes Diagnosis • Establish a diagnosis as rapidly as possible • Identify patients with existing care/management plans or in the last phase of life Management • appropriate recognition of and response to the deteriorating patient • ensuring the management plan is implemented and changed as appropriate with minimum delays • ensuring decisions about care are not delayed • ensuring that the patient progresses through their journey and this is not delayed • detecting deviations from the care pathway and acting on these • ensuring that investigation results acted on promptly • ensuring that decisions of further investigative or therapeutic interventions are not delayed Discharge • ensuring that discharge planning is appropriate and not delayed Communication • ensuring that patients and their carers/relatives are communicated with in a timely fashion Training • improving the support, development and training of the teams caring for patients

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NWL 7 Day Services Programme An Inpatient Model of Care to Meet Standard 8

High Acuity

High Dependency ICU/ HDU/ NICU/CCU

Acute Assessment AAU/ MAU/ SAU/CCU

(2x Daily Consultant Review)

Downstream Specialty Wards Category 1

De-Escalation

Category 2

De-Escalation Category 3

A daily consultant review A consultant review is The patient is is required to achieve a Escalationnot likely to influence the Escalation medically fit and successful clinical outcome patient’s pathway awaiting discharge Reviewer: Consultant Review Frequency: Daily Patient Description : All • New patient to hospital & ward/ unit • Sick/Unwell patient • No diagnosis or unconfirmed • Deteriorating patients, appropriately identified and responded to • Patients awaiting consultant input for discharge Medicine Only • Non invasive ventilation Surgery Only • Patient awaiting theatre

Reviewer: To be determined by the consultant. Review Frequency: Daily Additional Consultant Reviews for Surgical & T&O patients at least weekly and for Medical patients twice weekly Patient Description • Patient is physiologically stable • Diagnosis either confirmed or appropriate tests underway • On correct care pathway and progress on schedule • No specific communication tasks or care strategy questions outstanding • Stable but discharge not imminent

Reviewer: To be determined by the consultant. Review Frequency: Daily Patient Description • Medically Fit patients waiting for discharge • Patients waiting for external agencies input for discharge • Or waiting to be discharged that day via Nurse Led / AHP or Criteria led discharge 34

NWL 7 Day Services Programme An Inpatient Model of Care to Meet Standard 8: Draft Proposed Surgical Model

Downstream Specialty Wards Patient default Category 1

Category 1

De-Escalation

Category 2

De-Escalation

Escalation

Daily Surgical Consultant Review (AM) Daily Surgical Consultant Board Round (PM) Patient undergoes operation

Discharge Category 3

Escalation

Daily review by Registrar/ SHO/ ANP/ Therapist (as specified by consultant) Weekly review by consultant*

Daily review by Nurse/ AHP/ FY1

Daily Surgical Consultant Review (AM) Daily Surgical Consultant Board Round (PM)

Patient discharged

Consultant Handover*

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NWL 7 Day Services Programme An Inpatient Model of Care to Meet Standard 8: Draft Proposed Medical Model

Weekday Minimum Model High Acuity

Downstream Specialty Wards

Acute Assessment AAU/ MAU

(2x Daily Consultant Review) Patient default Category 1

Discharge

Every Patient Daily Consultant Board Round

Category 1

De-Escalation

Category 2

De-Escalation

Escalation

Category 3

Escalation

High Dependency ICU/ HDU/ NICU

Patient discharged

Specialty Consultant Review

Daily review by Registrar/ SHO/ANP/Therapist

Daily review by Nurse/ AHP/ FY1

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NWL 7 Day Services Programme An Inpatient Model of Care to Meet Standard 8: Draft Proposed Medical Model

Weekend Options Option 1: Continue Weekday Minimum Model • Model is consistent across all 7 days of the week If this is not deemed necessary because of the small number of Category 1 patients: Option 2: AMU Consultant Outreach

• AMU consultants with capacity to review existing ward patients and categorise new patients transferred to wards at the weekends Option 3: On-Call Medical Ward Consultant • Consultant(s) on call specifically to review existing and new Category 1 patients on all medical wards

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North West London Hospital Transformation 7 Day Services Programme

The Challenge to Deliver Standard 5 for Radiology Dr Brynmor Jones, Imperial College Healthcare Trust London Clinical Senate Forum 7th July 2016

London Clinical Senate Forum

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NWL 7 Day Services Programme Delivering Standard 5 Radiology

Baseline NWL Position

Diagram: Existing NWL Radiology Reporting Networks

• Critical and Urgent imaging meeting standard • 80-85% of CT scans for all inpatients meeting the 24hr turn-around time • Limited weekend Consultant presence • Local radiology reporting networks in place

Gaps against the 7 Day Standards • 24hr turn-around for MRI and Ultrasound for inpatients

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NWL 7 Day Services Programme

Solutions

Challenges

Process

Delivering Standard 5 Radiology

Imaging request

Imaging performed

Increasing demand

Insufficient inpatient scanning capacity

Imaging reported

Reduced reporting capacity

Workforce

Clinical Decision Support (CDS) System

Capacity levelling across the week

NWL Radiology Network

NWL Radiology Workforce Initiative

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NWL 7 Day Services Programme Delivering Standard 5 Radiology

NWL Radiology Workforce Initiative Suggested areas of prioritisation:

Retaining the workforce

Increasing the ultrasonography workforce

• •

•

Develop career pathway Consistent pay and banding

Developing an ultra sonographer faculty

Maximise the workforce

• •

NWL Bank NWL recruitment campaign

Increase reporting

• •

NWL Radiology Network Reporting radiographers

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North West London Hospital Transformation 7 Day Services Programme

A Sector-Wide Approach to Standard 9 Rachel Tustin, North West London Assistant Director for 7DS London Clinical Senate Forum 7th July 2016

London Clinical Senate Forum

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NWL 7 Day Services Programme An Approach to Standard 9

What was the problem?

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NWL 7 Day Services Programme An Approach to Standard 9

Progress So Far

Single NWL Needs-Based Assessment Form

Single Points of Access

• ONE needs-based health and social care assessment form for ALL NWL community services provided in a patient’s own home on discharge • Co-designed with CCGs, community providers, acute trusts and lay partners

• SINGLE points of access for in-scope services in 6 of the 8 CCG areas • Significant work in other 2 CCG areas to reduce access points from 12 to 5 • On-going work to achieve remaining 2 SPAs

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Developing meaningful outcome measures

Mrs Celia Ingham Clark, MBE Medical Director for Clinical Effectiveness, NHS England 9 July 2015 King’s Fund

Session 3

Developing Meaningful Outcome Metrics Developing never events and Network clinical governance

Clinical governance role of UEC networks Challenges

Opportunities

•

Fragmented clinical governance results in lost opportunities for sharing lessons

•

‘Two-way dialogue’ between U&EC facilities with U&EC service at all levels - local, network and regional

•

Infrequent thorough reviews of patient care throughout the entire U&EC patient pathway

•

Replicate effective aspects of clinical governance models set-up for NHS 111

•

Embed structures across the U&EC network to support better communication and intelligence sharing

•

Integrate Mental Health Crisis Care

•

Disparity between clinical governance structures for IUC and for U&EC facilities

• Potential governance roles of the UEC Networks: • Maintain a strategic oversight of UEC system across the Network. • Maintain strong clinical leadership and have clearly defined links to SRGs and regional clinical governance structures, with clear lines of accountability to commissioners. • Share broader learning from serious incidents, audits and reviews of patient pathways • Pan-London development, with UEC Networks, of UEC dashboard/balanced scorecard of key system indicators for Autumn 2016 47

Potential UEC Network Indicators There are a number of indicators under development across U&EC that could inform a network dashboard:

U&EC Clinical Leadership Group Proposed never events and network indicators

NHS England Integrated Urgent Care KPIs

CCG Improvement & Assessment Framework: Progress in delivering IUC

NHS England National System Wide Outcome Measures

Development led by the CLG has considered never events and a set of network indicators that could be implemented across London’s U&EC networks. NHS England will publish (Spring 2016) new KPIs for IUC which will require close collaboration across 111, GPOOH and other services (including, for example, attendances at ED).

NHS England assessed progress in the delivery of Integrated Urgent Care

NHS England U&EC review programme are developing new system-wide outcome measures

High level indicators to be drawn upon for U&EC Networks strategic overview of U&EC system Workshop is planned for 28 July with U&EC networks and the national U&EC team

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Work in progress: never events and indicators

Never events

Original Never events proposed have been split between 2 “Never events” and a range of Network indicators – these will be developed for UEC Network governance 1.Life threatening self-harm and attempted or completed suicides should never occur in an emergency department 2.Children should never be held in a police cell or police vehicle as a place of safety.

Potential Network Indicators

• Delays in transfer due to lack of availability/ access to a suitable care facility • A&E attendances/ admissions that could be cared for in the community • Patients with long term conditions/under palliative care who attend A&E due to a deterioration of their condition. • Patients with an end of life care plan that have died in hospital where their care plan stipulates another preference. • Patients in mental health crisis taking longer than 72 hours to be transferred from a health based place of safety. • Patients attending A&E with a crisis care plan that states they should go to A&E when in crisis. • Patients in the emergency department waiting longer than 1 hour to be seen by liaison psychiatry.

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What approaches could be taken to support measures/ governance currently being developed in relation to 7-day services?’

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Table discussion and feedback 1. How can metrics currently in development be enhanced to provide measures meaningful to patients and providers?

2. Could the ‘never event’ approach augment those measures currently being developed in relation to 7-day services, and if so, how?

Closing remarks Andy Mitchell