transformation update joining it up together · 2016-12-18 · draft specialised commissioning –...

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1

Assessment of key programmes and high level approach

Completed STP chapters (v25) working with HoD, PoC, STP leads – positive feedback

from London STPs

Financial & activity model tested, ready for internal engagement and quality assurance

Secured resource to support transformation & capacity/capability to end of November

Developed approach for joining up QIPP/Improving Value with STP

Mobilised South London programme team, development of single overarching plan

Next steps

• Development of Clinical Advisory Group paper – prioritisation & ensure

recommendations, benefits, ‘levels’ clear

• Finalisation of South London programme plan & scope (see final 2 slides)

• Model engagement, including opportunity assessment, initially internal & then external

• Improving Value approach agreed ready for 17/19 planning round

w/c 24th October - Spec Services Planning Board & Executive Board

Transformation update – joining it up together

• The Clinical Advisory Group are requested to reconvene and produce a prioritised set

of recommendations for transformation opportunities based on both quality and cost

benefit drivers (both at an STP and Pan London level). This will need to include:

• A clear overview of the scope of the work and next steps

• Identification of intended quantified (where possible) quality and financial benefits

• An articulation of how the change will be best delivered – (at STP/Regional/National level and via what “vehicle” eg pathway transformation,

improved prevention, improved operational effectives, service reconfiguration,

improved patient flow etc)

• How the proposed packages of work link to any national programmes of work and/or work underway within the STPs (including mapping any dependencies)

• Proposed governance arrangements (STP interfaces)

• Proposed delivery timelines including the identification of quick win opportunities

for 2017/18, and how this will be improved based on lessons learnt from previous

change attempts

• An outline of the engagement that will also need to be undertaken

2

Our task from the Specialised Planning Board

(Sept 16)

DRAFT

Specialised Commissioning – Extract from STP chapters 1 of 4

Specialised services are those provided in relatively few hospitals,

accessed by comparatively small numbers of patients but with

catchment populations of usually more than one million. These services

tend to be located in specialised hospitals that can recruit a team of staff

with the appropriate expertise and enable them to develop their skills.

Key Challenges

We need to do more to manage demand and the rising costs of provision: At a national level we are seeing a rising demand for specialised services, driven by

advances in science and an ageing population, which has prompted an increased demand for specialised care. We are also experiencing an increase in spending at a

much greater rate than other parts of the NHS which is expected to continue, in a large part due to the increasing volume of expensive new drugs and new technologies.

In London we also experience significant flows from areas outside of London (up to 1/3rd of specialised activity)/

We are not always joining up services and treating patients in the most appropriate place: Across London there is pathway fragmentation in specialised services,

with duplication of activity, gaps in provision, disconnects between specialised, non-specialised and local services, and t reatment not being provided in the most

appropriate place. London patients are sometimes being referred to beds/services outside of London and children and young people cannot always access age

appropriate inpatient mental health services when they need them.

The quality of our services varies and we are not always meeting our own standards: There are some performance issues, including challenges on RTT, and a

continued challenge to achieve the 62 day cancer standard.

Our financial challenge

As well as addressing quality and performance challenges, we are considering ways in which we can address our projected financial gap in specialised services. In

June, the ‘do nothing’ specialised commissioning financial challenges was estimated at £800m across London. This figure was a high level provisional estimate and was

presented as a cumulative figure over five years. Since then there has been an intensive effort to review and refresh this position through the development of a finance

and activity model that will estimate at a greater level of detail the financial challenge associated with pan-London specialised commissioning. We are working with

providers/CCGs & NHS England to reconcile the growth assumptions underpinning this model and agree the scale of the challenge. We are also working with our

neighbours and surrounding regions as we plan initiatives to address our challenges.

Context

3

DRAFT


We are committed to delivering high quality and sustainable specialised services in London, both for our own population and for those that travel here to receive

care. To achieve this, we, together with STPs/NHS England, are considering alternative ways to deliver and plan specialised services. We will :

• Reduce the number of people requiring specialised services by developing a whole system, pathway led approach to provision and commissioning of services,

maximising primary and secondary prevention;

• Eliminate unwarranted variation to ensure equity of access, outcomes and experience for all;

• Build on our knowledge of patient flows and the relationship between services to determine new and innovative ways of commiss ioning and providing services to

improve quality, safety and cost effectiveness

Areas of focus

Through reviewing our performance and quality issues and areas of highest spend, we are suggesting three area of focus to explore further: Pathway transformation,

Drugs and Devices and Improving Value. In delivering these, we will take a more collaborative approach to commissioning servi ces on a STP or multi STP footprint.

This will include planning and designing services together and providing financial incentives for pathway improvement, supported by the pooling or delegation of budgets

as appropriate as well as reforms to the payment and contractual system. As part of New Models of Care work will put Lead Provider/Alliance arrangements in place to

develop proposals to secure future sustainability and improve the quality of service.

Our aims for all STPs in London

4

DRAFT


Pathway transformation

We are working to improve the quality and effectiveness of services for patients and ensure resilient provision by concentrat ing on five key themes:

• Pathway inefficiencies

• Ineffective prevention

• Operational inefficiencies

• Fragmented service provision

• Inefficiencies due to patient flows

This work could lead to some changes in service delivery, so we will take the views of patients and a wide range of other stakeholders before taking these forward.

i. Pathway reviews

We are reviewing how we deliver the most effective and high performing services, with an initial focus on:

Paediatrics – supporting and implementing the recommendations of national and London reviews to address fragmentation and coordinate servic es

Cardiovascular – supporting and implementing the recommendations of the London review to improve value, reduce variation and address issues wi th referrals

Specialist Cancer – working with the cancer vanguard/alliances to ensure the delivery of commitments for improved quality and cost effectiveness

Renal – reduce variation, empower patients and improve the patient experience

Neurosurgery - deliver improvements alongside other STP developments

Neuro-rehabilitation – streamlining pathways and enabling better, more efficient services, with a particular focus in supporting patients who are stepping into

mainstream rehabilitation

Adult secure mental health – working with our key providers to ensure appropriate demand and capacity, and ensure long term viability

HIV - share the findings of the service review of HIV and begin to implement changes which will streamline pathways and enable better and more efficient services,

focusing on infrastructure costs and the control of excluded drug spend

CAMHS – review services and implement changes with the ambition by 2020/21 that there will be no inappropriate admissions of children and young people with mental

health needs to adult or paediatric beds and patients will be treated in local care pathways

Transforming Care Partnerships – minimising the number of patients admitted into specialised mental health services and facilitating appropriate discharge int o the

community

5

DRAFT


ii. Drugs and Devices

• We will work closely with clinical colleagues and partners to bring forward system-wide benefits to improve the value that the NHS gets from our significant

investment in high cost drugs and devices through:

• Aligning priorities and improving efficiencies relating to medicines optimisation and the “Hospital Pharmacy Transformation P rogramme”.

• Working with NICE and the CRGs to ensure that treatment algorithms for medicines reflect optimal use of the most cost effective treatments and enable a

reduction in unwarranted variation.

• Implementing digital developments such as e-prescribing, electronic prior approvals and standardised contract reporting.

• Completing the centralisation of the high cost device supply chain and reducing the variation of specifications for devices.

• Incentivising Trusts with a medicines optimisation and devices CQUIN for 2017-19 to support implementation.

• We will engage with patients and carer representatives on the CRGs on the medicines optimisation programme to improve the value and outcomes for patients.

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iii. Improving Value

• In line with the national commissioning intentions we will engage with these important areas of work to drive improved value:

• Fragile services – reduction in occasional practice, non-contracted activity, and address non-compliant services which do not meet agreed activity thresholds;

• Improved clinical and operational efficiency, and reducing variation, including the use of the clinical utilisation reviews, Rightcare and Getting It Right First Time;

• Implementation of national reviews;

• Clinical Reference Group initiatives which will set out opportunities to deliver improvements, whilst achieving a reduction in overall cost; • London QIPP programme for 17-19, and use of national CQUINs.

https://www.england.nhs.uk/wp-content/uploads/2015/12/spec-comm-intent.pdf

https://www.nao.org.uk/wp-content/uploads/2016/04/The-commissioning-of-specialised-services-in-the-NHS.pdf#page=16

https://www.nao.org.uk/wp-content/uploads/2016/04/The-commissioning-of-specialised-services-in-the-NHS.pdf#page=16

www.england.nhs.uk

October 2016 November 2016 December 2016 Q1

17

Q2

17

Q3

17

Q4

17

2018 2019 2020

Contract &

Planning Round

17/19

Opportunity /

Improving Value

Identification

Financial Base

Case/ Financial

Model

Plan

development for

Transformation

Pathways,

Improving Value,

South London

programme

Engagement

Enablers

High Level Plan for Specialised Services – input to STP

Opportunity identification (Clinical Advisory Group &

financial analysis)

Develop Programme Mandates

Develop full PIDs and detailed implementation

plans 18-24months

Early Dec fully developed project

mandates

Ongoing contract/ planning discussions and finalisation of contract/plan & financial agreement, including contract form, work with STP control totals etc

Understood commissioner and

provider position

Improving Value opportunities (incl

QIPP/CQUIN/other)

Finalise model and agree growth assumptions to

understand scale of challenge

Engage STPs on alignment of their emerging work programme, and agree interdependencies and roles and responsibilities

Prioritised improvement

areas based on

quality, performance,

and financial benefits

Chapter finalisation & sharing outputs

from analysis

Develop engagement plan with STPs and London Region

National & Local Commissioning Intentions

& contract guidance

Active on-going engagement with patients, public, and stakeholders as relevant to programmes, aligned to STP and regional forums and approaches

Transformation of pathways

Delivery Contract

round Delivery

Improving Value delivery

South London programme

Development of transformational capacity within specialised services to support implementation along the pathway, working with commissioners and providers

Assessment of requirements for successful implementation

Pathway programmes proposed include – paediatrics, cardiac, cancer (in collaboration

with vanguards/alliances), renal, mental health, HIV, neuro rehab etc, as well as work on

drugs, devices and other elements of the improving value programme.

Prioritisation will enable focus on phasing, and alignment of STP priorities, and ensuring

the right skills/capacity in place to support benefits realisation

Alignment with national service reviews and priorities

Development of contract model approach – supporting risk/gain share and work with STP control totals (links to 17/19 contracting

round above)

Programmes enabled with effective support and aligned resources/governance

South London programme scoping and scenario development, with supporting engagement

8

Sustainability and Transformation Plans- local priorities for Improving Value

(NCL draft example for illustration)

NCL spends a slightly higher proportion on Cancer Services compared to other STPs – the average spend by

STPs on Cancer Services is 14% of their total spend

In north central London the main providers of specialised acute services are University College London Hospitals (£355m) and the Royal Free London (£250m). A further ten providers account for a further £128m. This includes three specialist hospitals: Royal Nat ional

Orthopaedic Hospital, Moorfields Eye Hospital, and Great Ormond Street Hospital. Barnet, Enfield and Haringey Mental Health p rovides

specialised mental health services

Improving Value

• Working with fragile services

• Cut tail/non

contracted/derogated

• Improved clinical utilisation and

operational efficiency

• Implementation of national

review

• Implementation of CRG

recommendations

• 17/19 London QIPP programme and national

CQUINs

Drugs and Devices

• Hospital Pharmacy Transformation Programme

• Reduction in variation

• Implementation of digital

developments

• Centralisation of high cost device supply chain

• 17/19 medicine optimisation

and device CQUIN

Pathway Transformation

Realising the benefits of service consolidation

Pathway reviews:

1. Paediatrics

2. Specialist Cancers

3. Renal

4. Cardiovascular

5. HIV

6. Elective Spinal

7. CAMHS

NCL: Highest spend per capita

on HCDD. Maximise savings

from HIV generic prescribing

NCL: Develop local QIPP and

CQUIN schemes with providers

NCL: Work with STP to develop

pathway transformation,

including working with UCL

Cancer Vanguard.

Key focus areas of STP

Key pathways identified, and all need involvement of STPs to help take work forward along the pathway with

specialised commissioners, some best coordinated/led once across London

9

Pathway Transformation – initial analysis

Clinical Specialty/ Pathway

Quality Political risk Size of

f inancial

opportunity

Level: National/

London/ STP

London Clinical

Netw ork in

place or

Healthy

London Partnership

group (*)

National

Review

Outstanding

recommendations

from London

previous reviews

(e.g. Model of Care 2010/11)

Paediatrics H H London and

STP+ Yes via HLP

(3)

Cardiac H

RBH/ CHD

H STP /STP+ (some – NSTEMI)

Renal L H STP

X X

Cancer M H Dependent,

suggest STP + for

majority

MANY – vanguard/ alliance

(some model of

care)

Mental Health L H STP + Yes via HLP

X

CAMHS L M (if no

change) STP Yes via HLP

X

Neuro L M STP

X X

HIV M H

(Drugs) STP +

London review

X

Transforming

Care Prog M L (if no

change) STP +

* Key:

Network

funding due to

end this year

DRAFT

10

Service groups

Service Line 2015/16 spend**

Pathway Prevention Operational Fragm. Pat.

Flows Priority by STP?

Paediatric

Services

(£399.4m)

Neonatal Intensive Care £145.4m NCL, NEL, SEL

Paediatric Surgery £114.1m NCL, NEL, SEL

Paediatric Intensive Care £97.8m NEL, SEL

Paediatric GHN £42.1m NEL, SEL

Cardiovascul

ar/Thoracic

(£213.4m)

Cardiac Surgery £115.6m NEL, SEL, NWL

Complex Thoracic Surgery £54.6m SEL, NWL

Complex Invasive Cardiology (PPCI)

£43.2m NEL, SEL, NWL

Cancer

(£391.6m)

SCS (Chemotherapy) £194.0m NCL, SWL, NEL SS

Rare Cancers £133.4m SWL, NEL, SS

Radiotherapy £64.2m SWL, NEL, SS

Renal

(£270.9m)

Renal Dialysis £221.3m NEL, NCL, SEL, NWL,

SWL

Renal Transplantation £49.6m NEL, NCL, SEL, NWL,

SWL

Neuroscienc

es

(£292.7m)

Neurology £161.3m NCL, SEL

Neurosurgery £131.4m SEL

Mental

Health

(£270.3m)

Secure Mental Health £225.6m NEL, SEL, NWL, SWL

Tier 4 CAMHS £44.7m SEL, SWL

HIV*

(£263.1m)

HIV Drugs/ARVs £195.2m SEL, SWL

HIV Infrastructure £67.9m SEL, SWL

Blood and

Infection

(£148.6m)

Haemophilia £88.2m NCL, SEL

BMT £60.4m n/a

Specialised

Medicine

(£95m)

Hepatobiliary £49.0m n/a

Cystic Fibrosis £46.0m n/a

Summary of findings – priority service groups

*- Majority of issues addressed as part of HLP Programme

STRONG

£ impact

MEDIUM

£ impact

WEAK

£ impact

**- Prior to any adjustments

Pa

n-L

on

do

n o

wn

ers

hip

S

TP

SS = Single Speciality

11

Summary of findings: key themes

Pathway inefficiencies

Hypothesis: specialised services are provided by the most

expensive staff, using expensive equipment and through

complicated procedures. Addressing the condition through

less complex procedures or providing care in a non-

specialised setting could have a signif icant f inancial and

quality benefit. This may include decommissioning some

service lines or more careful evaluation of how effective

new technologies are before applying them.

Inefficiencies due to patient flows

Hypothesis: There are substantial f lows of patients from

other parts of UK to London for services and procedures,

which can be provided more locally. Cross regional planning

of patient movement can shift the activity to more cost-

effective providers and allow better f inancial planning in London.

Ineffective prevention

Hypothesis: Demand for specialised services often

constitutes the end of the disease pathway. Investment in

primary and secondary prevention could have a signif icant

effect on improving f inancial sustainability.

Operational inefficiencies

Hypothesis: there is a substantial variation in eff iciency

and cost for the same specialised services and procedures

across London providers. Standardisation and sharing of

best practice to bring all providers to the top quartile in

efficiency can greatly reduce costs.

Fragmented service provision landscape

Hypothesis: signif icant amount is spent on providers, which

provide specialised services at small volumes, not benefiting

from economies of scale and the advantages of centres of

expertise. Providing services to these patients at major

specialised centres might reduce costs and improve quality / outcomes.

The diagram below sets out some of the recurring issues/themes, which have been identified in the clinical areas assessed. Collectively, they could

account for a significant portion of the financial sustainability challenge London NHS system is seeking to address. Three themes have a HIGH financial impact, and two themes have a MEDIUM financial impact.

Pathway

inefficiencies

Ineffective

prevention

Inefficiencies

due to patient flows

Operational

inefficiencies

Fragmented

service provision

landscape

Financial

sustainability challenge

Strong link: pathw ay improvements may lead to a

better secondary prevention

Strong link: strong correlation betw een

cost per activity and number of activities

performed by provider

High financial impact (potential)

Medium financial impact (potential)

DRAFT

Assessment of key areas

(previous reviews &

opportunities)

v0.1

• Paediatric projects

• Cardiac projects

• Renal projects

• Cancer project

DRAFT Renal projects

13

Key findings/problems: - Demand: Renal activity in London has increased and demand for renal services is set to rise, especially as London is a hub (a round a fifth of all end stage renal diseases in

England is treated in London)

- Financial: Spend on renal cannot continue to increase without impact on other areas of Medicine, and London has lagged behind England in achieving Best Practice tariffs - Fragmented: Commissioning tends to reward activity, rather than support value and patient experience – providers assume responsibility for patients very late along the

patient pathway, and care has often seemed fragmented - Prevention: Early diagnosis and prevention is key: In 2011/12 there were just under 183,000 people aged 18+ years on London C KD QOF registers, and it is estimated that

there could be a further 150,000 people with CKD in the SCN who are currently undiagnosed

Key recommendations: - Understand and reduce variation

- Stabilise prevalent dialysis population in London by 2019

- Reduce incident patients by 20% p.a. - Reduce late presentation cases to <10%

- Improve delivery and experience of care in AKI (Deliver London’s AKI through LAKIN)

- Improve men and women’s experience of renal care

- Establish and share pan-London best practice - Support shared-decision making and patient autonomy in care

- Support greater take up of transplantation – live related and other donors

Report name Date published Author Stage £ problem Scope

The London Renal Network

8 Dec 2015 Neil Ashman, Clinical Lead, London Renal

Clinical Network

Case for Change

n/a Whole renal pathway

Letter to Andy Mitchell and Michael Marsh (in confidence)

24 Aug 2016 Neil Ashman, Clinical Lead, London Renal

Clinical Network

Options on future Models of

Care

Limited – reference that £ status quo

cannot continue

Whole renal pathway, with focus on specialised end

Proposed next steps - Ensure current renal network doesn’t finish (short term funding solution required), ensuring a forum to share and disseminate best practice - Validate and refresh the information to confirm what has already been implemented and if any other new problems have emerged

- Conduct in-depth detailed analysis of size of the financial opportunity for the proposed Model of Care - Prioritise on improvements that can have the biggest financial impact, consider capitation type model

- Develop detailed implementation plans

Suggested Model of Care to deliver recommendations:

Evolve commissioning through provider collaboratives, or Networks of Care (incentivise provider collaboration and openly

report any variation on outcome, experience and value to promote best practice

DRAFT

14

Renal opportuntiies

Serv ice Line Description Impact Ev idence / Case Studies

Prevention Renal Access, Renal

Access for Dialysis/Renal

Dialysis

Opportunity 1: By reducing the prevalence of risk factors for chronic kidney disease (CKD) through primary and

secondary prevention, improving diet, physical activity, smoking cessation; early identification and adequate

control of diabetes, hypertension, hypercholesterolemia.

Opportunity 2: Improving early diagnosis and management of CKD; early identification and management of

anaemia and mineral and bone disorders; adequate nutritional management and psychological support to reduce

the prevalence of end stage renal disease (ESRD) this will significantly reduce the need for renal replacement

therapy.

Wouters et al. 2015. Early chronic

kidney disease: diagnosis, management

and models of care. Nature Rev Neph

11, 491-502.

Pathw ay ineff iciencies Renal Access, Renal

Dialysis

Opportunity 1: By redesigning renal replacement therapy services: modifying the renal dialysis pathway to

increase the take-up of peritoneal dialysis over haemodialysis, surgical creation of arteriovenous fistulae, savings

can be unlocked through reduced expenditure on equipment and staff.

Opportunity 2: By launching a campaign to perform kidney transplantation earlier in the treatment process,

significant savings can be unlocked through reduced expenditure on renal access and dialysis.

Opportunity 3: Improving multidisciplinary pre-RRT (renal replacement therapy) and conservative care.

Secondary/tertiary care colleagues working with primary care to improve education and understanding about

CKD, establishing incentives to increased the active identification and management of patients with early stage

CKD, eGFR surveillance with direct communication to patients as well as primary care .

Wouters case study (2015)

Annual Report On Kidney

Transplantation (2015)

Rayner HC, Bharani J, Dasgupta I

et al. Does community-w ide

chronic kidney disease

management improve patient

outcomes? Nephrol Dial Transplant (2013)

Changes/additions to above?

How change best delivered? Quick wins?

Lessons learnt from previous work?

DRAFT Paediatric projects

15

Key findings/problems: - Fragmentation – there is no link between services and they remain fragmented, as well as fragile in some cases. This hugely affe cts the patient pathways - Interdependencies – the critical clinical interdependences between services (as mapped in 2008 report, Commissioning Safe and Su stainable Specialised Paediatric

Services – A framework of critical interdependencies by the Department of Health) are not adequately accounted for. This has imp lications for quality and safety - Critical mass – some services are not undertaking an adequate level of work to be considered safe practice. This has implication s for quality and safety

- Workforce and training – there is a shortage in adequately trained specialist staff and overall the workforce is not organised e ffectively

Key recommendations: 1. Fewer hospitals should provide a more comprehensive range of in-house specialised children’s services, and cover defined geographical areas 2. Establish a tertiary paediatric network(s) that coordinates specialised services in a defined area through the provision of c lear pathways based on clinical standards and

interdependencies – proposed 2 networks: South London and North London (view from Andy Mitchell as still valid) 3. All specialised children’s services could be provided as part of an integrated tertiary paediatric network

4. Ensure hospitals delivering specialised children’s services meet all interdependencies 5. End the provision of severely isolated services that are reliant on out-reach services or adult services to meet critical clinical interdependencies 6. Assess what would be an appropriate critical mass for individual specialities, as well as within a designated tertiary service

7. End clinically defined inappropriate low volumes of activity 8. Ensure the most efficient use of resources in the provision of services

9. Determine an appropriate organisation of the workforce that would support the proposed model of care, and especially take account of training needs 10. Specialised children’s services networks planning and coordinating clinical services, as well as academic programmes 11. Effective collaboration with maternity services, neonatal networks, secondary paediatric care networks, child mental health s ervices and community services

12. Ensure age appropriate care is provided including managing the transition of children with long-term conditions to adult services


London’s specialised children’s services The case for change

2010? Healthcare for London

Case for Change

n/a (outcomes led)

23 specialised services chosen: most likely to have critical interdependencies and most likely to drive the process of service reconfiguration:

(Blood and marrow transplant, cardiology, haematology, ENT, immunology, major trauma, neonatology, neurology, oncology,

respiratory medicine, specialised paediatric anaesthesia, urology, burns, cardiothoracic surgery, endocrinology, gastroenterology, infectious diseases, metabolic medicine, nephrology, neurosurgery,

paediatric critical care, orth and spinal surgery, specialised paediatric surgery)

London’s specialised children services: Guide for commissioners

Mar 2011 Commissioning Support for London

Model of Care

n/a (outcomes led)

As above Most data and case studies used in the analysis is from 2004-2008

Proposed next steps: - Validate and refresh the information to confirm what has already been implemented (e.g. service specifications and interdependencies) , and get pan London group to be re-

established

- Conduct in-depth detailed analysis of size of the financial opportunity for the future Model of Care - Prioritise on improvements that can have the biggest financial impact

- Develop detailed implementation plans - Involve Healthy London Partnership = ensure engaged and aligned

DRAFT

16

Paediatric opportunities


Prevention Neonatal Critical Care

Opportunity 1: Improving early booking and antenatal care indicators in all practices at CCG level; reducing

teenage pregnancy and inequalities, improving community midwifery services, early identification and

management of maternal risk factors through timely antenatal assessments (eg smoking or substance misuse in

pregnancy, obese or underweight mothers, mental health issues in pregnancy + physical health issues eg

diabetes, hypertension) can aid in reducing risk of low birth weight babies, prematurity and perinatal outcomes

where the risk of perinatal or neonatal mortality is high.

Opportunity 2: Equitable distribution of neonatal critical care services will address variation in health outcomes

and possible impact on specialised services demand.

Pathw ay ineff iciencies Neonatal and Paediatrics

Intensive Care

Opportunity 1: Current neonatal critical care pathw ay, current practice of managing premature and

underw eight babies across providers, comparison of outcomes from ICU, HDU, SCBU use and tariff

used by different providers, should be review ed to ensure uniformity in practice for good outcomes

achievement and reducing unw anted costs and variation.

Opportunity 2: A number of pathw ay improvements to reduce out of area placements, speed up

discharge, better step-down and home care, and improve child health in general. Suggested areas

include transitional care, hypoglycaemia and jaundice

N/A

Paediatric Surgery and Paediatric GHN

Opportunity 1: Analysis made on paediatrics surgery and paediatric GHN show potential to achieve

savings through use of alternative treatments instead. N/A

Haemophilia Opportunity 1: Establishing true netw orks with common arrangements and specif ication

N/A




DRAFT Cardiovascular projects

17

Key findings/problems: - There is a significant fragmentation of provider landscape – sufficient economies of scale and scope are not achieved - Earlier diagnosis and treatment (e.g. heart failure and valve disease) in the community could reduce spend on hospital admission

- There are some more cost effective and improved patient outcomes treatment alternatives - There is a significant variation in length of stay (often by non-pathway issues e.g. intensive care full), even for the same procedures, waiting time issues remain

- Inadequate referrals for some procedures sometimes end up if sub-optimal care for patients - There is no organised, pan-London plan for procurement and roll-out of new technology

Key recommendations: - Provide cardiovascular specialist services in big, specialist centres, which can provide appropriate co -dependent clinical services - Sharing best practice and concentrating services in the best performing centres can reduce the variation in the length of sta y

- Networking and transport arrangements need to be improved to reduce wait times and improve outcomes - Set-up of formal comprehensive networks, with 5 central units linked with several local units (for vascular)

- Sets out specific standards that need to be adhered to and proposes improved pathways - Focus on NSTEMI pathway, which will reduce waits and improve outcomes (unfinished work), and get flow working - Clinicians to work across primary/secondary/tertiary care boundaries - improved management of patients, improved professional liaison/education, greater awareness of the

‘big picture’ and less simple allegiance to bricks and mortar


Cardiovascular - the Case for Change

2010 August Healthcare for London

Case for Change

n/a (outcomes led)

Vascular services (emergency and specialist), cardiac surgery (all cardiac surgery), cardiology (emergency and elective). Remaining cardiovascular service lines were not analysed.

Most data and case studies used in the analysis is from 2004-2008 (some

even 2003).

Cardiovascular - Models of Care


Models of Care

n/a (outcomes led)

Vascular services (emergency and specialist), cardiac surgery (all cardiac surgery), cardiology (emergency and elective). Remaining cardiovascular service lines were not analysed.

Most data and case studies used in the analysis is from 2004-2008 (some

even 2003). This work includes implementation plan and financial analysis

Cardiovascular Cardiac Surgery Service Spec


Implementation

n/a (outcomes led)

Cardiac surgery (all cardiac surgery)

Proposed next steps: - Validate and refresh the information to confirm what has already been implemented (e.g. Barts/UCLH consolidation) and if any other new problems have emerged - View that this should be worked at with STP footprints, or across 2, where natural flows (e.g. like NCL & NEL)

- Conduct in-depth detailed analysis of size of the financial opportunity per each recommendation - Prioritise on improvements that can have the biggest financial impact

- Develop detailed implementation plans and hold implementation parties accountable for the identified size of opportunity

DRAFT

18

Cardiac opportunities


Prevention Cardiac Surgery

Opportunity 1: Primary prevention initiatives such as stopping smoking, reducing obesity levels, increasing

physical activity levels, excess salt consumption, improved healthy diet, reducing high risk alcohol consumption,

tackling exposure to air pollutants as well as reducing stress affecting mental wellbeing will have a significant

impact on development and progression of cardio-vascular diseases such as hypertension, coronary heart

disease and stroke which often need significant emergency clinical interventions to prevent death or disability. If

the mean diastolic blood pressure was reduced by 2mm Hg it is estimated that there would be a 15% reduction in

strokes and a 6% reduction in coronary heart disease.

Opportunity 2: Early detection of cardiovascular diseases through community surveillance and screening

programmes such as NHS Health Checks along with use of new technology e.g. using new BP machines to

detect AF; plus optimum management of long term conditions such as hypertension, coronary heart disease,

diabetes, atrial fibril lation in primary care (through QOF) – using modern technology (such as telemedicine or

mobile monitoring devices),as well as patient education and awareness, will have substantial benefits by

preventing complications leading to episodes of MI or stroke that often need invasive surgical intervention if not

controlled appropriately. Health inequalities are avoidable differences in health status that can be avoided by

equitable provision of health resources to reduce variation in outcomes.

Pathw ay ineff iciencies Cardiac Surgery, Complex

Thoracic Surgery and

Complex Invasive

Cardiology

Opportunity 1: In patients who need invasive surgical intervention; redesign cardiac surgery care pathways

ensuring timely and early intervention to prevent complications, use of alternatives to invasive surgery where

available, national procurement of cardiac devices, standardising tariffs for expensive but cost -effective minimally

invasive and/or sophisticated procedures, and centralising specialist services to reduce variation, are few

examples of opportunities that will have a significant impact on spend and patients’ outcomes in specialist CVD

care.

Opportunity 2: In cardiovascular patients who need invasive surgical intervention; use of alternatives to surgery

where available, timely and early intervention to prevent complications, standardising tariffs for expensive but

minimally invasive and/or sophisticated procedures that are cost-effective, redesigning cardiac surgery care

pathway and centralising specialist services to reduce variation, are few examples of opportunities that will have

a significant impact on spend and patients’ outcomes in specialist CVD care.

Opportunity 3: Improve pathw ays for Atrial f ibrillation (AF), Heart Failure (HF) and Cardiac surgery –

one-stop shops and community surveillance/case f inding. This could lead to financial savings through

reduced admissions, early identif ication leading to low er morbidity and severity

Opportunity 4: Signif icant savings could be achieved by review ing and standardising local tariffs, by

improving the discharge pathw ay reducing the proportion of critical care beds occupied by patients after

4 hours of the decision to discharge; implementing the Clinical Utilisation Review CQUIN ensuring

patients are cared for in the most adequate and cost-effective setting

N/A


How change best delivered?

Quick wins?


DRAFT

Methodology/process (financial): Financial assessment to construct a detailed business case followed the following methodology/approach:

- Savings were quantified by adding up savings to the providers and to the commissioners based on an NPV calculation

- Savings were modelled over 34 years (useful life of the building) - The following buckets of cashflow were considered in the analysis:

- Fixed cost savings (equipment, facilities)

- Fixed cost increases (equipment facilities) - Post reconfiguration synergies (e.g. need less nurses etc.)

- Private patient contribution (incoming patients due to a more centralised, world class centre)

- Research contribution (due to a more centralised, world class centre)

- Void contribution (using of vacated space)

Cardiovascular & Cancer (case study)

19

Overview: Cancer and Cardiovascular review in 2010 recommended a consolidation of providers and creation of specialised, multi -disciplinary centres. As such, detailed options appraisal, and analysis was performed, underpinned by a comprehensive financial analysis to identify how the consolidation sh ould be performed and what services should

move where.

This case study is particularly useful as it sets -out the approach, which was successfully carried out to perform consolidation


Improving Specialist Cancer and Cardiovascular Services

in North and East London and West Essex

2014 May Cancer/Cardiac programme

team

Implementation – business

case

£94m over 34 years

Cardiovascular and cancer services in east London and west Essex. The consolidation was performed in UCLH and Barts trusts

Methodology/process (overall): The diagram below demonstrates the process followed for developing the solution, which included public consultation.

DRAFT

20

Example: Integrated care continuum for Chronic Kidney Disease

(CKD)

• Potential savings

Multidisciplinary care for Renal Replacement Therapy - Redesigning Dialysis pathways - Surgical creation of arteriovenous fistula - Improve access to kidney transplantation and increase organ donation - Psychological support

Primary/Secondary care collaboration to prevent progression of CKD and its complications - Prevent CKD complications, especially end-stage renal disease, heart disease, stroke and peripheral vascular disease - Treatment and management of anaemia and mineral and bone disorders - Nutritional management - Reduce CKD –related presentations to tertiary centres

Prevent or delay onset of CKD - Healthy eating - Physical activity - Smocking cessation - Detection and control of high blood pressure, diabetes and hypercholesterolemia - Early identification of CKD risk in primary care

Modified from: Wouters et al. 2015. Early chronic kidney disease: diagnosis, management and models of care. Nature Rev Neph 11, 491-502.

DRAFT

21

Key findings/problems: - There is a need to diagnose cancer earlier in order to improve survival outcomes; - Differences in clinical and organisational practice cause variation in the quality of services offered to cancer patients across London;

- In London there are unnecessary follow-up attendances and these can be in non-optimal settings

Key recommendations: - The centralisation of specialist services has benefits for both patients and the services themselves - Some of London’s rarer cancer services should be further centralised

- Specific guidelines how cancer networks should be set-up

Cancer project

Report name Date published Author Stage £ problem scope

Cancer – Model of Care 2010 August Healthcare for London

Model of Care

n/a (outcomes led)

This clinically-led project built on the case for change developed in December 2009. The scope entails all cancer services, from common to rare.

National Cancer Strategy 2015 July NHS England

Strategy Overall approach set out

This national strategy has provided a clear approach to drive improvement, aligned to five year forward view

Proposed next steps: - Work with Cancer Vanguards, SEL cancer alliance and Transforming Cancer Services Team to ensure clear programme in place, whi ch will deliver the outstanding

recommendations, and drive improved value

- The Vanguard agenda encompasses a range of financial improvements which are embedded within the STP. It is however clear that the financial opportunity in cancer is far

greater, hence the inclusion of additional cancer workstreams within the STP which reach to the edges and often beyond the Vanguard scope. These include: - Medicines optimisation: the spend on cancer drugs is very significant. Opportunities to reduce spend are well defined, assisted through the Cancer Vanguard

Pharma Challenge process, which includes programmes on biosimilars, home administration and system intelligence.

- Interventions in the last days of life: evidence points to variation in chemotherapy administered to patients during the last 30 days of life. There are serious concerns over informed patient choice and quality of life which require significant further investigation.

- Research and Commercialisation: Our cancer systems occupy a unique position nationally in cancer which provides a natural competitive advantage in developing clinical research programmes which benefit patients and augment the sector financial position. Research will both generate additional revenues to augment patient care as well as generate efficiencies as a result of realising the potential of personalised medicine to avoi d unnecessary interventions

DRAFT

22

Cancer opportunities


Prevention Cancer (all service lines)

Opportunity 1: Cancer epidemiology supports early behavioural interventions to minimise the individual's risk of

contracting cancer; interventions such as smoking prevention/cessation, adequate advice on dietary factors

(including alcohol), physical activity, reduction of obesity, reducing environmental exposure in leisure time (sun,

smoking, alcohol), and in the workplace. The STPs should set goals to reduce alcohol related admissions

through targeted advice at the point of care as well as improved access to alcohol treatment services.

Commissioners should consider the introduction of alcohol care teams in acute trusts.

Opportunity 2: Secondary prevention such as increasing screening uptake across all practices in the CCG

through peer review of screening related QOFs, dissemination of good practice, introduction of mobile screening

units, use of community pharmacies as screening hobs pair with public campaigns to increase awareness and

uptake.

Secondary prevention tackling smokers as well as obese individuals and those at risk due to poor diet and

excessive alcohol intake.

Opportunity 3: Implementation of a survivorship model w ith stratif ied follow up pathways (breast,

prostate and colorectal) for the increasing number of patients surviving the disease w ill improve the

management of the complications of treatment, provide clear pathw ays into follow up and provide a more

structured and comprehensive response to the needs of cancer survivors and their carers. This w ill avoid

emergency and reactive responses to complications and/or recurrence.

Pathw ay ineff iciencies Cancer (all)

Opportunity 1: STPs need to focus on improving performance along their cancer pathw ays by ensuring

there is suff icient diagnostic capacity and primary care education on early detection and referral. This

should result in more cancers diagnosed at Stage 1 and 2, fewer emergency presentations and

improved 1 and 5 year survival rates. The STP needs to take relevant examples from the Vanguards on

optimal models of care for cancer care that consider population health as w ell as reducing variation and driving up standards in hospital care.

Opportunity 2: Timely access to adequate evidence based treatment through establishing adequate

referral pathways; improving connectivity between primary and acute care IT systems, improving of QOF

Ca referral and treatment indicators across all practices in the STP. Ensuring standardisation of chemotherapy and radiotherapy through consistent dose banding and adequate utilization of modern

technology to deliver better targeted more effective treatments.




DRAFT

23

Key findings/problems:

- Inconsistencies in the patient pathway – creates bottlenecks and blockages for patients accessing and being discharged from the service.

- Resources not aligned to where they are most needed for patient care – leads to inefficient way of commissioning and providing the service. - Inconsistent levels and access to care – and care that is not always joined-up around the patient.

- Provision of level 1 and 2a specialist rehabilitation services is inequitable in London, and often access is delayed

Key recommendations: - There has been a London wide review of neurorehabilitation which focused on opportunities to reduce waits, duplicate referral s and deliver longer term cost

benefits through a better understanding of patient pathways. The review recommended:

- Developing a data system to collect referrals, which will be used for bed management and waiting list initiatives. - Referring centres which will be linked with CCG and NHS provision.

- Neuro-navigators to support people moving into CCG and NHSE funded beds.

Neuro Rehabilitation

Proposed next steps: - Implement the review’s recommendations, a small team is working on this, and we need to align these plans within each of Lond on STPs, particularly to ensure

services are commissioned in lower cost and more community settings, which will deliver financial and quality benefits.




DRAFT

Serv ice fragmentation analysis 2) Stakeholder engagement

Serv ice Line % of serv ice offered by 'small' prov iders (<5% total cost) NHS England/STP priorities Rating

Neonatal Intensive Care 26.44%

Service fragmentation analysis and the engagement exercise revealed that there is significant fragmentation in specialised

children’s services across the capital. Larger ICUs may improve the capacity of providers and unlock efficiency savings.

Paediatric Gastroenterology, Hepatology and Nutrition

21.30% Service fragmentation analysis and the engagement exercise revealed that there is significant fragmentation in specialised children’s services across the capital

HIV Infrastructure/Outpatients Caseload

13.66% Priority for North West London STP: consolidation of HIV infrastructure

Specialist Cancer Services (Chemotherapy)

13.63%

Paediatric Surgery 10.19% Service fragmentation analysis and the engagement exercise revealed that there is significant fragmentation in specialised children’s services across the capital.

Secure and Specialised Mental Health Services (adult)

9.40% Priority for North East London STP: consolidation of 3 secure mental health wards for women

Tier 4 CAMHS 6.43%

Paediatric Intensive Care 5.06%

Larger ICUs may improve the capacity of providers and unlock efficiency savings. It may also be possible to negotiate a

cheaper local tariff for critical care.

Service fragmentation opportunities - detail

DRAFT

25

Operational inefficiencies – service lines

25

1) Non-PBR local tariff analysis 2) Stakeholder engagement

Serv ice Line Total spend Total non-

PBR spend

Size of

opportunity NHS England/STP priorities Rating

Neonatal Intensiv e Care £145.4m £130.4m £12.8m

Local tarif f analy sis and engagement exercise indicates that there is currently signif icant v ariation in the cost of

neonatal intensiv e care serv ices and that there is potential f or improv ement. There is a need f or a shared

understanding and plans ‘f or prov ision of robust PICU serv ices to address the capital’s f uture requirements’

Neurology £161.3m £45.5m £6.2m

Paediatric Intensiv e Care £97.8m £86.2m £4.8m

Local tarif f analy sis and engagement exercise indicates that there is currently signif icant v ariation in the cost of

paediatric intensiv e care serv ices and that there is a need f or a shared understanding and plans f or prov ision of

robust paediatric intensiv e care units.

Secure and Specialised

Mental Health Serv ices

(adult)

£225.6m £154.6m £4.2m

Renal Transplantation £49.7m £19.4m £2.8m

Local tarif f analy sis rev ealed that there is considerable v ariation across London in the amount paid f or renal

transplantation. This is supported by conv ersations with SMEs within NHS England on the v ariation in local tarif f s for

renal transplantation.

Cardiac Surgery £115.6m £40.9m £2.7m

Engagement with stakeholders indicated that there is currently signif icant v ariation in the cost of cardiac surgery

across prov iders and that there is potential f or improv ement. There is also opportunity f or cost sav ings through

changes to local tarif f s.

Access f or Dialy sis/Renal

Dialy sis £220.3m £3.4m £0.1m

Engagement with stakeholders rev ealed transf ormation schemes to improv e the both the ef f iciency and the quality of

renal serv ices, f or example through inv estment in self -care (such as home dialy sis), modernising the renal serv ice f or

those requiring care. One STP Footprint’s priority is to deliv er the Community Kidney Serv ice through electronic

adv ice clinics, and to rolling out v irtual clinics, to improv e the ef f iciency and quality of the serv ice.

Paediatric Surgery £114.2m £3.3m £0.1m Engagement with stakeholders indicated that there is currently signif icant v ariation in the cost of paediatric surgery

across prov iders and that there is potential f or improv ement.

DRAFT

• What are we missing?? - points below came from discussion with Andy Mitchell/Mark

Spencer/Michael Marsh & feedback from CAG members via email

• Intervention rates at end of life – Example of Christie’s work on oncology, working with cancer

vanguards/alliances

• Drugs – HIV in particular

• Procedures of lower clinical effectiveness

• Neonatal interventions, putting in place clearer guidelines for very early births

• Neurosurgery/neuroscience, improving the pathway and get more appropriate referrals

• Other feedback:

• Burns provision , not a major spend area, but clinical risk due to level of resilience

• Cross cutting themes:

• Making it happen: Need to understand the cultural and organisational factors which have

prevented the previous recommendations being implemented. There will be up front costs.

• Specialised Services Outpatients – how they are done, when necessary and use of new

technology, building on the work in STPs

• Rehabilitation services overall, gaps impacting on effective flow and use of specialised

services

26

Other key points

DRAFT

South London Specialised Acute

Services Programme

DRAFT

• Specialised services account for £1.3bn of expenditure in South London and as such the disposition of these services is hugely significant in ensuring the delivery of successful STPs. Credible STPs for south west and south east London depend on a detailed understanding of the challenges and opportunities inherent in acute specialised services and their interrelationship with other CCG-commissioned acute services.

• A review has been initiated of specialised services in South London. This review will support NHS England and the STPs for south west and south east London in delivering plans that will ensure the clinical and financial sustainability of acute specialised services in South London, including understanding relationships with specialised services in the South region.

• The work will support STPs in understanding relationships with the provision of non-specialised acute services (e.g. interdependencies with major trauma centres and stroke units, dedicated elective centres) and ensuring that their broader plans for service development fully reflect the current and likely future provision of acute specialised services.

Scope of the review • Evaluate the clinical and financial sustainability of NHS England-commissioned acute specialised

services in South London, backed by a mapping of this provision in Kent and Medway, and Surrey and Sussex.

• Support NHS England in developing proposals for potential service change across these areas in order to ensure that future provision is clinically and financially sustainable through to 2020/21 and beyond.

• NHS England has carried out a number of reviews and pieces of modelling to date and has developed a financial ‘base case’. Existing work will be built upon wherever possible.

28

Background and context

DRAFT

• Culture for success to drive the programme forward is established

• Generated clinically valid scenarios for priority service lines that can be discussed

• Modelled clinically valid scenarios

• Understanding of which scenarios are financially sustainable in the longer term to enable more efficient delivery/increased quality

• Review is linked in with existing communications and engagement plans

29

Outcomes of phase 1 review

In the context

of the broader

programme…

Oct ‘16 Dec ‘16 17/18

South London

Spec Comm acute

service provision

Embed service

delivery changes

into ‘business as

usual’, realise

benefits and

continuously

improve

Integrated programme and benefits management

Understand the

health economy

need, generate

insights and

provide options

for change

Design service

delivery changes

to optimise

benefits

realisation

Build and test

service delivery

changes needed to

deliver benefits

Roll out and

stabilise service

delivery changes

and plan

subsequent

benefits delivery

Integrated change management and communications

Design Construct Implement Operate &

Review

Strategy &

Assess

Phase 1

Where we are now:

transformation update joining it up together · 2016-12-18 · draft specialised commissioning –...

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