the best of clinical pathway redesign - practical examples of delivering benefits to patients

NHSNHS Improvement

HEART LUNGCANCER DIAGNOSTICS STROKE

The best of clinical pathway redesignNHS Improvement

Practical examples delivering benefits to patients

CANCERDIAGNOSTICSHEARTLUNGSTROKE

CONTENTSForeword

About us

The approach: NHS Improvement Frameworkfor Service Improvement

2010-11 achievements

Helping to deliver quality and productivityimprovements and sharing the learning

The external assessor perspective

The staff perspective

The stakeholder perspective

Best practice case studies• Cancer• Diagnostics

Audiology• Heart• Lung• Stroke

www.improvement.nhs.uk

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The best of clinical pathway redesign - Practicalexamples delivering benefits to patients

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FOREWORDInnovation has always been important inthe NHS – new ideas, listening andlearning from each other andimplementing what works best are at theheart of many of the major steps forwardwe have made for our patients over theyears.

The examples here showcase just some ofthe innovations that have enabledthousands of patients to enjoy betterhealth and well-being thanks to practicalservice improvements implemented onvarious clinical pathways.

I urge each of you to read this report.Some of its practical examples of serviceimprovement have also been endorsed byNICE as best practice examples on theNHS Evidence website and I would likeyou to ask yourselves whether you couldtake the learning here and replicate someof these achievements within your ownorganisations.

Whether you are based in a local hospital,GP practice, consortia or PCT cluster,strategic health authority, clinical networkor within a community based settingworking with social care partners, thereare initiatives here that could help youdeliver your own quality and productivitychallenges. In addition, there are 200more QIPP case studies on NHSImprovement’s website that provideadditional practical examples ofimplementation for health organisationsthroughout England.

It is critical that we continue to innovatefor our patients as we design the healthand care system of the future, ensuringwe improve the quality of care for ourpatients, while making historic levels offinancial savings to reinvest in frontlineservices. NHS Improvement working withand through clinical networks has beenproven as an effective and productivemodel and it ensures that positivelearning is spread more widely acrossthe system.

As we move forward, we will strengthenand widen clinical involvement incommissioning decisions. To helpfacilitate this I have asked Sir BruceKeogh, who leads the NHS MedicalDirectorate, to work with the nationalclinical directors to begin longer termwork to strengthen our multi-disciplinarynetworks and engage with the networksto understand how best to improveoutcomes for patients. There is a centralrole for networks in the new system asthe place where clinicians from differentsectors come together to improve thequality of care across integratedpathways.

While these examples demonstrateinnovative solutions to major healthchallenges such as cancer, heart disease,stroke and chronic respiratory conditions,there is no reason why theseimprovements could not be applied toother areas. That is why it is essential tocontinue the good work delivered by NHSImprovement, the NHS and its partners –we must take this opportunity to achievethe best outcomes for our patients.

Sir David Nicholson KCB CBE,Chief Executive of the NHS in England

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• NHS Improvement was formed inApril 2008, bringing together twoexisting national improvementprogrammes – the CancerServices Collaborative (includingDiagnostics) and the HeartImprovement Programme. It alsoextended its work to create athree-year Stroke programmewithin existing resources.

• Its current work programme isdefined through the Departmentof Health on behalf of the NHS inthe key policy areas of Cancer,Heart, Stroke, COPD andDiagnostics and forms part of theNHS Medical Directorate led bySir Bruce Keogh

• NHS Improvement employs 74staff, the majority workingperipatetically on a nationalbasis, and has a smalladministration team based inLeicester. It is a relatively leanorganisation which ‘contracts in’most of its specialist support(e.g. IT) on an as required basis


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ABOUT USNHS Improvement’s strength and expertiselies in practical service improvement. It hasover a decade of experience in clinicalpatient pathway redesign in cancer,diagnostics, heart, lung and stroke services.The organisation demonstrates some of themost leading edge improvement work inEngland which supports improved patientexperience and outcomes.

Working closely with the Department ofHealth, trusts, clinical networks, otherhealth sector partners, professional bodiesand charities, over the past year it hastested, implemented, sustained and spreadquantifiable improvements with over 250sites across the country as well as providingan improvement tool to over 800 GPpractices.

NHS Improvement is:• Demonstrating the practical

application of quality improvementand service redesign with a trackrecord of delivering quantifiableimprovement

• Leading improvement work inprimary, community, secondary andtertiary care

• Providing clinical engagement andleadership by working with over 50clinical leads

• Aligning with policy direction,providing a bridge between nationalstrategy and local engagement andimplementation, often throughclinical networks

• Having skilled expertise in full rangeof quality improvement tools andtechniques including high level Leanand Six Sigma plus experience fromacross the healthcare sector as well ascommercial knowledge gained atToyota, GE, Aviva, Boots and privatehealthcare

• Showing measurable results fromconcept to delivery

• Working in partnership with leadingcharities, professional bodies, RoyalColleges and other associationsensuring a strong alignment toresearch, patient-facing organisationsand third sector work

NHS Improvement’s priorities across cancer,diagnostics, heart, lung and stroke havebeen aligned to domains one, two andthree in the NHS Outcomes Framework2011-12. However, they could equally alignto domains four and five.

Dr Janet Williamson, National Director,NHS Improvement

The case studies contained in this report aretaken from across the clinical pathway andare helping to deliver the objectivescontained within each of the domains. Itwas only possible to feature a selection ofgood examples from around the country,however, there are numerous sites out therethat could have been featured for the workthey are doing. NHS Improvement wouldlike to thank its partners for their ongoingwork in improving services and bringingbenefits to patients.

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Define the need/outcome objective

Strategic alignmentScopingAgree approach

•••

3 months scoping

Pilot/test

Definition/proofof principleTest hypothesisBuid interest andcapability

•

••

12 months

Prototype

Test widerapplicabilityProof the ‘how’Identify emergentleaders

•

••

12 months

Frame ‘the storyto tell’

Align learning forspreadDefine what andhowRecruit leadersfor spread

•

•

•

3 months

What What & How What, How & How What & How

CLINICALTEAM

SPECIALTY

SERVICES/SPECIALTIES

SITE/ORGANISATION

LOCATION/REGION/CLINICAL NETWORK

WHOLE SERVICE

SPREAD

1-

3Y

EAR

S

NHS Improvement applies a framework for service improvement and clinical pathway redesign to ensure a consistent andsystematic approach to its work.

The work falls into five key categories:• Long term programmes of work to support delivery of a key national priority (Stroke Improvement Programme)• Bespoke improvement work which is time limited (review of seven day services across England)• Tailored support to assist delivery (working with SHAs to implement primary angioplasty)• Establishment, development and support of clinical networks (cardiac and stroke networks)• Advisory and development work (service improvement training for clinical and managerial staff)

It utilises the following approach as part of any service improvement work:• Proof of principle: Piloting and testing new ways of delivering services – redesign and quality improvement (usually12 month duration),

• Testing wider applicability of pilots: Prototyping new service models, innovations and improvements (usually 12 month duration)• Spreading and disseminating learning and innovation more widely (two year plus duration).

THE APPROACH: NHSIMPROVEMENT FRAMEWORKFOR SERVICE IMPROVEMENT

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could be saved by halving the length of stay forthose patients having day case/one night staybreast surgery

could be saved each year if the Accelerating StrokeImprovement aim for 40% of stroke patients leavinghospital to have access to early supported dischargeis achieved.

1 millionwomen

290,000 patientsnow waiting less time for test results,saving 655,940 waiting days, with up to


2010-11ACHIEVEMENTS

this has

removed 10mwaiting daysand savedreceived cervical cancer

screening test resultswithin two weeks at 16pilot sites £1.6m

123,000

£10.5mUp to

£300,000saved at some sites

If every trust applied the Winning Principleswe promote, which includes: reducing lengthof stay; enhanced recovery; and avertingadmissions, this one initiative has thepotential to reduce bed utilisation by 20%,

1msaving the NHS

could be saved nationallyon home oxygen servicesbased on a minimum reducedspend of £600k across nineproject sites.

£45m

Working with health sector partners over the past year NHS Improvement has helped to deliver anumber of patient-centred improvements and identified many future benefits. These are just some:

bed days

Over

bed days

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£106mof savingscould be released by workingwith local hospitals to freeup avoidable bed days fornon-elective cardiac patients

by giving nearly 66,000patients direct access to atinnitus audiologist or hearingtherapist

£5.9m

for cancer survivors could bereleased over the next five yearsthanks to testing on four tumourpathways

1.2moutpatient appointments

650 health staff

Over

have been trained to use theDiscovery Interview™ techniqueto engage with patients andcarers

could be saved£1.8m

£64k

by increasing access topsychological support forstroke patients by 30%.

8,000 strokes every yearcould be preventedby using the GRASP-AF detection tool.

£96mThis could savethe NHS

per year could be saved

Approximatelyper strokeclinicalnetwork

£3.25mcould be savedover the next five years by usingsafe risk stratified pathways forChildren and Young People cancersurvivors

NHS Improvement’s tools and techniques,combined with its expertise and experience,could be applied to other service areas tosupport delivery of the five key domainswithin the NHS Outcomes Framework2011-2012 and priorities within theOperating Framework 2011-2012.

It is committed to continue deliveringquality improvements that are clinician-ledand patient-focused to enhance patients’outcomes and experiences.

Practical support for the deliveryof QIPPDelivering the Quality, Innovation,Productivity and Prevention (QIPP) challengesuccessfully will be key to delivering £20bnof savings across the NHS by 2015. NHSImprovement’s approach to systemimprovement aligns closely with the QIPPagenda QIPP and over the past year morethan 200 good practice examples have beenidentified across the country. These are nowshowcased on the QIPP section of itswebsite www.improvement.nhs.uk/qipp

Examples can be viewed by specialty (heart,lung, cancer, etc) or across the patientpathway – primary care, referral, diagnosis,treatment, aftercare and end of life care. Inaddition to the case studies there is usefulinformation and tools and since summer2010 the site’s pages have been viewedover 25,000 times.

Demonstrating theevidenceNHS Improvement’sleading edgeimprovement workwith partners across the country has beenrecognised on a number of occasionsduring the past year by NICE and it nowhas six case studies which have beencommended on the NHS Evidence website1.

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Most recently its works on developing theone day/one night stay breast surgerymodel and computer modelling on thepotential impact of serum natriureticpeptide blood tests to GPs practices havejoined commissioning for stroke in primarycare, and the optimal detection of AtrialFibrillation; Cytology 14-day standard fortest results and its work as part of theenhanced recovery programme.

In addition to its contributions to thenationally-renowned NHS Evidence site,NHS Improvement continues to encouragethe identification and scoping,development, piloting, prototyping andspread of best practice through theImprovement System2 - a comprehensiveonline resource to support shared learning.It provides service improvement tools andresources, practical guidance, case studies,useful contacts and signposting for furtherinformation.

HELPING TO DELIVERQUALITY AND PRODUCTIVITYIMPROVEMENTS AND SHARINGTHE LEARNING

NHSEvidence

1www.library.nhs.uk/qipp/SearchResults.aspx?searchText=ambulatory%20breast%20surgical%20care2http://system.improvement.nhs.uk/ImprovementSystem/Login.aspx?ReturnUrl=%2fImprovementsystem%2fdefault.aspx

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Sharing the learningNHS Improvement has captured the latestlearning and innovative thinking on a rangeof healthcare topics and disseminated thisknowledge during the past year through anumber of channels. These have included:• Review workshops with clinicians, cancersurvivors and representatives from arange of NHS organisations and thirdsector

• Social marketing training session forthose working in cardiac rehabilitation

• Sponsorship and facilitation of FiLM(Frontiers in Laboratory Medicine) 2011 -a forum where global influential leadersaddress the key challenges facinglaboratory medicine

• A collaborative event jointly-led anddesigned by GPs looking at the challengesfacing those working in the newcommissioning landscape

• Website which was accessed by 75,000unique visitors last year from 140countries

• an e-seminar on heart failure end of lifecare which attracted 100 participants andis being explored further to help supportstakeholders facing resource and financialchallenges in the current climate

• Working with local, national andspecialist media

Involving public and patientsEngaging the public and patients in itsactivities is one of NHS Improvement’s coreprinciples in the way it works. It iscommitted to designing and deliveringhealth and care services around the needsof patients and carers and now has a newsection on its website showcasing thispartnership approach. The patientexperience website supports peopleworking with patients and carers, offeringeasy to access engagement resources,examples of good practice and links to

useful information including personalaccounts from patients of their conditionsand explanations of how work involvingNHS Improvement has helped improve theirlives.

Working with clinical networks, NHSorganisations across England and inpartnership with charities we supportclinical teams and managers, providingpractical tools and techniques thattransform, deliver and build lastingimprovements across care pathways makinga difference to patients, services and staff inmeeting the quality goals as part of theQIPP agenda. Most recently we haveworked in partnership with the StrokeAssociation to co produce Community Voiceevents around the country designed to hearthe experiences of stroke survivors andcarers.

Following successful testing thetrademarked ‘Discovery Interview™3’innovative approach is now used by anumber of specialties in the UK healthsystem to improve care by understandingpatient and carer experiences and bygaining insight into their needs. They arebased upon a philosophy that puts patientsand carers at the centre, and valueslistening to their experiences as a way ofgaining insight which is unavailableelsewhere to stimulate qualityimprovement.

3The Discovery Interview™ technique was originally developed by the Coronary Heart Disease Collaborative in 2000

www.improvement.nhs.uk/cancer

NHS improvement - Cancer’s work hasgained national recognition and continuesto work closely work with its keystakeholders including the Department ofHealth and other members of the Cancerprogramme team, cancer networks,charities, local organisations and clinicalteams. It is also liaising more closely withsocial care organisations and professionalcolleges to further enhance outcomes forpatients.

Integral to the Improving Cancer OutcomesStrategy (2011), NHS Improvement’s workincludes Transforming Inpatient Care, acrosselective and emergency care, Living withand Beyond Cancer (Survivorship) for Adultsand Children and Young People,

Transforming Inpatient Care promotes thespread and adoption of the four winningprinciples (one: unscheduled (emergency)patients should be assessed prior to thedecision to admit. Emergency admissionshould be the exception not the norm; two:all patients should be on a defined inpatientpathways based on their tumour type andreasons for admission; three: clinicaldecisions should be made on a daily basis topromote proactive case management andfour: patient and carers need to knowabout their condition and symptoms toencourage self-management and to knowwho to contact when needed. Tried andtested models of care include:

• Day case/one night stay for majorbreast surgery

• Approaches to reduce avoidableemergency admissions and reducinglengths of stay for those who do needto be admitted as emergencies

• Supporting the spread and adoption ofenhanced recovery approaches acrosscolorectal, gynaecology urology andmusculoskeletal. The DH EnhancedRecovery Partnership Programme endedMarch 2011 but this partnership workcontinues to support implementationwithin Transforming Inpatient Care

CANCER CAREIMPROVING

• Specific emergency pathways work isfocused on aligning with otheremergency initiatives such as NHS 111pathways, emergency care practitioners,spread of tried and tested innovationssuch as communication alerts, promotingacute oncology models and preventingunnecessary readmissions

Adult Survivorship aims to improve theoutcomes for adults living with and beyondcancer. Over the past year it has completedthe pilot phase of testing elements of thecare pathway, which are summarised in thecase study section. Over the next year it willwork with 13 tumour projects in breast,prostate, lung and colorectal cancer acrossseven communities in England to test riskstratified pathways of care based on theindividual needs to:

• Improve the patient experience andreported outcomes of care

• Reduce outpatient attendances by 50%• Reduce avoidable admissions by 10%

All patients will be offered an assessmentand care plan at key stages of theirpathways.

The enabling projects which are testingremote monitoring and care coordinationwill support the effective delivery ofsupported self managed care.

In the Children and Young People (CYP)Survivorship workstream there has beentangible progress since September 2010.The initial 10 CYP tests sites have continuedevaluating and testing models of care,identifying proposed models of follow upcare, and other non clinical initiatives tosupport CYP cancer survivors. Achievementshave included four existing sites movinginto prototyping phase; definingmeasurable outcomes; developing after carepathways with clinicians, commissioners,patients and local teams and a patientexperience workshop held with test sitesand Teenage Cancer Trust.

Priorities for 2011-2012 now include:continuing to support the 10 initial siteswith ongoing testing and a package ofevidence by October 2011; supporting thefour prototype sites to present evidence offour proposed models of care being testedand defining the quality key indicators thatneed to be in place within services toprovide effective care of patients within alllevels of after care. NHS Improvement is alsoworking towards providing evidence of a20% reduction in CYP cancer survivorshiphospital-based outpatient appointments(those patients already routinely followedup) and achieving the goal that 100% CYPsurvivors have a treatment summary andcare plan.

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Our aspiration is that Englandshould achieve cancer outcomeswhich are comparable with thebest in the world. However, thechanges required to deliver onthis aspiration are complex andwill take time. However, I amconfident that we are moving inthe right direction and will seemore of the positive results thathave already been achieved byNHS Improvement. Working witha range of NHS partners,national charities and patients,they have delivered improvedoutcomes in some key areas. Butwe can and we must go muchfurther if we are to achieve thelevels of ambition for cancerpatients.

Professor Sir Mike Richards (CBE), NationalClinical Director for Cancer and End of Life Care

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In areas such as cytology, pathology andradiology, NHS Improvement has beenworking with teams nationwide tore-design services, focusing on efficiencyand quality.

In cytology, it has used Lean methodologyto support the new Vital Sign that allwomen have their screening test resultswithin two weeks. At 16 pilot sites, this hasbenefitted one million women, removed 10million waiting days and saved £1.6 million(around £100,000 per site).

In histopathology, NHS Improvement hasbeen working with nine pilot sites, aimingfor 95% turnaround results in seven days,with half of those sites processing testswithin three days. 290,000 patients are nowwaiting less time for test results saving655,940 waiting days with up to £300,000saved at some sites (extrapolating thisacross England could deliver £3.375 millionsavings).

In radiology, NHS Improvement has beenworking to reduce waiting times andworking towards creating a ‘no wait’imaging service. The radiology team iscontinuing to support the National StrokeStrategy and contributing to theAccelerated Stroke Improvementinitiative.

A programme of clinically-led SHA imagingevents and local site visits is helping to takethis work forward. The new radiology workfocusses on interventional radiology andearly diagnosis to support the ImprovingOutcomes: A Strategy for Cancer (2011).

DIAGNOSTICSIMPROVING

NHS Improvement provides awealth of information andsupport to imaging servicesacross England. Serviceimprovement changes promotedand delivered by NHSImprovement working withimaging departments haveplayed a large part in thereduction in waiting times forimaging services seen in recentyears. The implementation ofLean methodology to radiologyservices has delivered massiveimprovements for patients andalso for the staff working inthese departments. NHSImprovement is seen as a beaconof excellence in service deliveryboth nationally andinternationally.

Dr Erika Denton,National Clinical Director for Imaging

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www.improvement.nhs.uk/diagnostics

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I have been extremely impressed with the work of NHS Improvementand the contribution they have made to the diagnostics agenda,particularly their work on pathology. Improving turnaround times forhistopathology and cytology is a vital step in the wider canceragenda and the evidence shows that this will have enormouslypositive effects on patients and trusts alike. Phlebotomy is one of themain ways in which patients experience pathology testing first handand so dramatically improving that experience - through reducedwaiting times and a more streamlined service - will have a profoundeffect upon a huge number of people.

Dr Ian Barnes, National Clinical Director for Pathology

www.improvement.nhs.uk/audiology

NHS Improvement has worked inpartnership with the Department of HealthNational Audiology Programme since July2008 supporting service improvementsacross England. Assisting 12 challengedsites to reduce waiting times for patientsand later 18 sites to improve the quality ofpatient experience, four key winningprinciples were identified and tested:

• Direct access• One-stop clinics• Care closer to home – community services• Developing protocols for patients withcomplex hearing problems

Amidst economic adversity and thechallenges posed by times of change in theNHS, these teams rose to the challenge ofdeveloping their services and deliveringsuccessful projects that will influence thefuture practice of audiology services acrossEngland.

Central to their philosophy was amultidisciplinary approach whereconsultants, clinicians, scientists, managerialand administrative staff worked together todeliver truly patient focussed services –across primary and secondary care.

Fostering the right project approach waskey to planning, implementation anddeveloping the new services. The audiologypilot and prototype sites have proved theyare the epitome of today’s forward thinkingNHS staff.

Crucially, these teams are keen to sharetheir learning. Their onward aim is toembed the approach that has beenachieved locally and the national goal isadoption and replication across the country.

AUDIOLOGY

IMPROVING

Emerging learning from the pilot andprototype sites was shared via strategichealth authority clinical lead networks, aswell as through presentations andworkshops such as the British Academy ofAudiologists (BAA) and via an audiologye-bulletin subscribed to by nearly 300interested stakeholders. Strong partnershipswere forged with third sector partnersincluding the National Deaf Children’s

Society (NDCS), the Royal National Institutefor the Deaf (now Action on Hearing Loss)and the British Tinnitus Society Association(BTA) to gain support and input for theimprovement work.

Essentially these are proactive teams.Clearly, these are leading departments.More importantly, patients are benefiting.

DIAGNOSTICS -

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These pilot sites, working with NHS Improvement have applied Leanprinciples to demonstrate how improvements can be made acrossthe pathway that will change the way audiology services should bedelivered in the future.

Professor Sue Hill,Chief Scientific Officer, Department of Health

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Heart disease is still the second biggestcause of death in England despite hugeprogress and reductions in mortality andmorbidity since the publication of theNational Service Framework for CoronaryHeart Disease in 2000.

NHS Improvement – Heart, continues tobuild on its excellent record of improvementwork across the cardiac agenda over thepast 10 years.

The current work programme is tackling avariety of contemporary issues which spanthe cardiac patient pathway including:preventing strokes caused by atrialfibrillation; improving efficiency in usinghospital beds in acute cardiology andcardiac surgery; pioneering a new way ofcommissioning cardiac rehabilitation andimproving efficiency and quality across theheart failure pathway from early diagnosisto end of life.

NHS Improvement has worked alongsideDepartment of Health colleagues to supportdelivery of national priorities such as theimplementation of primary angioplasty fortreatment of heart attack and jointly on thedevelopment of a Commissioning Pack forCardiac Rehabilitation.

The programme provides ongoing supportto cardiac networks across England, as theycontinue to be a key resource in the deliveryof local improvements to services throughwork with commissioners and providers ofcardiac care.

Collaborating with charities andprofessional bodies has always been animportant part of NHS Improvement’s workand recent examples include an awarenesscampaign with the Stroke Association andthe Arrhythmia Alliance and also developeda cardiac rehabilitation resource andpartnership working on end of life care inheart failure with the British HeartFoundation.

HEART CAREIMPROVING

The work is promoted through a range ofpublications, presentations on national andinternational platforms, e-seminars andmore recently as a publishing partner forthe NICE Quality Standards on chronicheart failure.

www.improvement.nhs.uk/heart

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Service improvement does not happen spontaneously. It requiresorganisation, leadership and a great deal of hard work. This is whatNHS Improvement has provided in spades over the years. Theirindustry and commitment have been consistent levers for changeover the years working with the local delivery mechanisms and the28 cardiac networks.

I would like to thank every one of them for their outstanding effortsand their determination to extend healthy life and reduce suffering inour population.

Professor Sir Roger Boyle,National Director for Heart Disease and Stroke, Department of Health

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As one of NHS Improvement’s newerprogrammes, 2010 saw completion of NHSImprovement – Lung’s first full 12 months.During this time the team worked withstakeholders across the country incontributing to the Department of Health’sconsultation on the national ChronicObstructive Pulmonary Disease (COPD)strategy.

In addition, the team linked up with theBritish Thoracic Society, Primary CareRespiratory Society (PCRS) UK, Asthma UKand the British Lung Foundation,established a web presence and launchedthe Lung Improvement News e-bulletin,which now has over 1,200 subscribers.

The programme has continued to supportthe SHA Respiratory Clinical Leads and helpguide clinical network and community ofpractice development across the country. Inaddition, the website contains over 70examples of good practice alongside otherresources, case studies, tools and practicalsuggestions to guide improvement activitiesin clinical teams and organisations.

It has also provided direct support to over40 COPD and asthma national improvementprojects and trained a number of staff inproject management and improvementmethodologies and approaches. As theCOPD projects come to the end of thetesting phase of work, the results have seendemonstrable improvements as well as the

RESPIRATORYCAREIMPROVING

publication of emerging learning, examplesand key measurable improvement principlesand approaches.

Through developing new and sustainablemodels of care, using capacity differently,reducing variations, and focussing on theimplementation of good practice, the teamis aiming to:

• Reduce overall spend on home oxygenservices and prescriptions

• Reduce avoidable unscheduledadmissions by 20%

• Reduce the length of stay by 25%• Reduce readmissions within 30 days by20%

• Increase patient satisfaction, experienceand outcomes

Priorities for 2011-2012 include furtherdevelopment of respiratory networks asvehicles to spread good practice andimprove the access of data, and establishhigh quality and cost effective commissioningpathways with the new GP consortia.

Its work going forward will continue toconcentrate on six core areas of care, whichare aligned to the NHS OutcomesFramework 2011-2012, domains and QIPPworkstreams. The six areas are: earlyaccurate diagnosis, improving oxygenservices, transforming acute care, chroniccare and self-management-models, end oflife care and asthma.

www.improvement.nhs.uk/lung

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People who are training Olympicteams at the moment will befocusing on even very smallcomponents of their team and howthey can improve to ensure thatthey will win a medal rather thangoing out in the heats. That’s whatevery single clinical team needs tobe doing, making the outcomes forpatients amongst the best in theworld. On the NHS Improvement -Lung web pages there is a wholehost of resources, the result of 10years experience - which can beused to help clinicians at a locallevel understand and improve.

Professor Sue Hill, Joint National ClinicalDirector for the Respiratory Programme

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NHS Improvement is a collection of clinicians and experts in improvement science that help totranslate a clinical vision into a sustainable service improvement. They have been invaluable inlung work in actually helping clinicians realise their ambitions and vision in terms of qualityimprovement and improving clinical effectiveness, patient experience and patient safety.

Dr Robert Winter, Joint National Clinical Director for the Respiratory Programme

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The role of NHS Improvement - Stroke wasset out very clearly in the National StrokeStrategy (2007) as supporting itsimplementation and establishing clinicalnetworks in stroke care.

A system of Stroke Care Networks, coveringall services in England, was completed in2009 when they were audited againststrategy specifications. Since then, NHSImprovement has continued to guide anddevelop networks, providing coordinationand support for local improvement activitiesand links to national initiatives.

Four years on from the strategy its roleremains as crucial, leading on theAccelerating Stroke Improvement initiative -launched by the Department of Health inresponse to the National Audit Office’s(NAO) report on stroke services. The NAOnoted the importance of NHS Improvementand Stroke Care Networks in improvingservices for people affected by stroke andcalled for further work to build on theprogress in service development.

NHS Improvement is also working closelywith the Care Quality Commission to driveservice improvements identified in its 2011report ‘Supporting life after stroke’. Thisincludes leading the drive to ensure thatfocus on improving outcomes extends tothe whole stroke care pathway, includingcommunity services, nursing homes andsocial care.

On the ground, it has also provided directsupport to over 40 stroke projects, resultingin demonstrable improvements in clinicaloutcomes and patient experience as well asthe publication of learning, examples andkey development principles which havebeen subsequently used nationally to guideservice improvement.

Accelerating Stroke Improvement initiative,aiming to ensure effective servicedevelopment along the whole strokepathway throughout England.

STROKE CAREIMPROVING

In addition, the NHS Improvement websitecontains over 200 examples of stroke goodpractice alongside other resources, casestudies, tools and practical suggestions toguide improvement activities in clinicalteams and organisations. The most recentaddition - the Community Stroke Resourcepage - is a comprehensive collection ofmaterial including evidence from literatureand research, business cases, presentationsand documentation to show how todevelop community stroke services.

New developments include joint ventureswith two major stroke charities - The StrokeAssociation and Connect - to improvestroke survivors’ experience in post-hospitalcare and develop practical tools to ensurepatients with aphasia can fully participate inthe planning, delivery and evaluation oftheir care.

Priorities for 2011-2012 include guidingstroke care networks through the transitionto new commissioning arrangements andsupporting their role in developing pathwaycommissioning for stroke patients withinthe new GP consortia. NHS Improvement -Stroke will continue to lead the

www.improvement.nhs.uk/stroke

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There has been a revolution in the improvement of quality strokecare in recent years, and the work of the stroke networks and NHSImprovement has been at its centre. In particular, great progress hasbeen made in raising public and professional awareness and indelivering comprehensive specialist acute stroke care. NHSImprovement will continue to guide and inform the work prioritiesin the stroke networks to address these areas in a timely, effectiveand productive fashion.

Damian Jenkinson, National Clinical Lead, NHS Improvement - Stroke and Consultant StrokePhysician, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

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EXTERNALASSESSORPERSPECTIVENHS Improvement was formed as a result ofthe Hosted Services Review (November2007). The review endorsed thecontinuation of work delivered by theCancer Services Collaborative ‘ImprovementPartnership’ and the Heart ImprovementProgramme and requested that they beintegrated and extended to include otherclinical specialties such as stroke. Theobjectives were to: share learning acrossclinical specialties, increase impact andshow value for money.

NHS Improvement was asked to deliver thisagenda by having:• A clear programme of work aligned tonational priorities with measurableoutcomes

• A focus on the delivery of high qualityimprovements based on latest evidencebased practices

• Clinically led and patient focussedworkstreams

• A close working relationship with othernational organisations, stakeholders andprofessional organisations

• Robust monitoring and performance

To determine just how effective NHSImprovement has been since its creation,an external evaluation was commissioned.Tribal Consulting carried out a robust,independent assessment and produced itsfindings in September 2010.

Tribal based its work on a series ofquestions: “Has the work of NHSImprovement led to an improved quality ofservices? Does it continue to do so? Does itrepresent good value for money?”

Reviewing both ‘what we do’ and ‘how wedo it’, the consultants looked at NHSImprovement’s identity, value creation andoperational factors. They evaluated casestudies from the Heart, Stroke, Cancer and

Tribal did identify some areas where NHSImprovement could strengthen its offer tothe NHS. These included: ensuring systemsand processes demonstrate return oninvestment; supporting and developing staffso they can maximise their contributionsand promoting its profile and identity withstakeholders.

Work to address some of these areas hadalready begun before Tribal’s final reporthowever, the external assessment has actedas a catalyst to accelerate this.

In terms of ensuring our systems andprocesses can demonstrate return oninvestment, NHS Improvement hasdeveloped three key systems that make bestuse of its knowledge and information anddemonstrate the impact its making acrossthe full range of specialties – they are thewebsite, NHS Improvement System(available through the website), and newPerformance System.

The Performance System is central inevidencing the outcomes of its work,gathering information in a number of vitalareas such as patient experience,productivity and efficiency gains and theresources allocated. Using real-time datadashboards, it allows information to bequalified, quantified and aggregated inorder to demonstrate value for money,impact and return on investment againstQIPP. These data dashboards mean that NHSImprovement staff can even drill down toindividual project sites - who are contractedto provide baseline information, monthlymonitoring data and case studies - andevaluate performance against the projectmilestones and identify any risks.

Diagnostics work programmes. It alsoreviewed existing literature and empiricalevidence, conducting interviews with 26people and facilitating discussion workshopsbetween April and July 2010.

In summarising their findings, Tribal saidNHS Improvement had a “catalytic” role inbringing about improvements to outcomes.It recognised the organisation’s importancein disseminating best practice throughclinical networks and other stakeholders -using a range of channels such as itspublications, events and online support.Tribal further argued that NHS Improvementwas “well positioned” to provide acoordinated whole NHS system approach tohealthcare improvement.

According to Tribal: “Good value formoney can be demonstrated by therelationship between costs andbenefits. Our evaluation uncoveredsubstantial benefits from the work ofNHS Improvement, even if not all ofthese can be measured. There are someprojects which do have verymeasurable results, for example, thefaster access to diagnostics (cytology),saving bed days (23 hour breast cancermodel), and primary angioplasty unitadmission (PPCI roll out programme).”

The report concludes by saying: “...It is ourconsidered view that NHS Improvementdoes represent value for money,playing a critical role in thedevelopment, testing and roll-out ofclinical improvements. Due to the‘behind the scenes’ role that it oftentakes, especially when clinicalimprovements may have manystakeholders and participants, it is easyto underestimate the relative impactand importance of NHS Improvement.”

THE


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The great advantage of the PerformanceSystem is that it is integrated with the NHSImprovement System and website, providinga seamless flow of information.Stakeholders working with NHSImprovement will be able to access theImprovement System. This provides acomprehensive online resource developedto support every stage of an improvementinitiative, including initial scoping; projectmanagement; reporting; case studydevelopment and ultimately sharing theoutputs and outcomes with the wider NHS.

IDENTITYVisible leadership and a mentoringapproach were demonstrated byNHS Improvement in variousimplementation programmes.

NHS Improvement, to ourknowledge, is unique in employing(on a part-time basis) a variety ofclinicians (consultants, GPs, nurses,physiotherapists, ambulance staffetc) who are chosen because oftheir expertise and standing in theareas which the programmes areconcentrating... as a consequenceof this background, all of them havemajor national ‘street credibility’.

NHS Improvement staff appeared tohave a common set of beliefs andvalues and work towards acommon objective of sharinglearning, increasing impact andbringing tangible improvements inthe delivery of NHS services.

VALUE CREATIONIts ability to engage with keystakeholders, the strength andvalue of NHS Improvement’sconnections, an ability to bringpeople together around a commonagenda of improvement, andworking in partnership withcharities and voluntaryorganisations, as well as the NHS.

BUSINESS APPROACHNHS Improvement has a strongfocus on aligning its planning tothe strategic priorities of theDepartment of Health... at theorganisational level, measures toevaluate the performance of theorganisation and individualprojects have been introducedand aligned to QIPP. ”

“


NHS Improvement’s knowledge andunderstanding of the NHS contextwas seen as a major asset.Respondents noted that thisincluded both practical andtheoretical knowledge – of keyclinical areas, of the health servicesystem and of the challenges facedby NHS staff.

NHS Improvement is a learning andteaching organisation with strongcommitment to improvement. It issuccessful in terms of helping theNHS to focus on meeting thenational priorities, sharingknowledge and developingnetworks and relationships.

As a result of Tribal’s review, NHSImprovement intends to re-affirm itscommitment to supporting staff in anumber of areas including:

• Sharing and learning betweenworkstreams

• Increasing use of IT solutions to supportvirtual working

• Ensuring a healthy work/life balance• Introducing an anonymous questionsand answers facility to pose questionsto the national director as well as anonline forum

• Maintaining the programme of monthlyNational Team meetings to allowcontributions to future planning,knowledge sharing and networking

A member of NHS Improvement’s executiveteam is leading this work. Planning includesa funded training and developmentprogramme which will encompass specificskills, training opportunities and a broaderfocus on career development in thechanging health landscape. A two dayworkshop will be held in September 2011with a focus on preparing for the future.

Promoting its profile and identity withstakeholders

The Tribal report stated that NHSImprovement: “In common with similarbodies has been formed from theamalgamation of previous programmes,following a review. As such, the exactnature of NHS Improvement is notalways immediately apparent to theoutside, and an improved marketprofile is one of the recommendedoutcomes of this evaluation.”

In response, it has revamped itscommunications strategy in order to bettermanage its brand and raise its positiveprofile so key stakeholders are better placedto know who NHS Improvement is, what itstands for and how it can help them. It willencourage feedback from its wide range ofstakeholders to ensure what it offers andhow it is communicated is well-timed andwell-targeted.

In the last year around 75,000 uniquevisitors from 140 countries visited NHSImprovement’s website and there weremore than 350,000 page visits. Ourwebsite was refreshed to include a newQIPP section featuring more than 200 casestudies from across both our specialtyprogrammes and all parts of the patientpathway. The site also links to our highlycommended case study examples on theNHS Evidence website.

Nearly 9,000 people have subscribed toNHS Improvement’s range of e-bulletins toreceive news about best practice in theirparticular field of interest as well as nationalguidance, latest news and informationabout learning events and workshops. Theorganisation also showcased its services andachievements over the past year, reachingthousands of people from across the healthsector and beyond through appearing atover 100 events and producing over 25publications which help to further share andembed best practice.

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How NHS Improvement hasresponded to the Tribal report

Supporting and developing its staff sothey can maximise their contributionsNHS Improvement has run its ‘Valuing Staff’initiative for three years and conducted twostaff surveys during that period to assesshow well it is doing. ‘Valuing Staff’ aims tomake sure that it provides personaldevelopment opportunities, improvesworking between programmes, developsmore effective team working, and creates amore supportive/ listening environment. Aspart of the initiative, 10 working principleshave been agreed to ensure that staff arevalued and developed and a trainingprogramme supporting business prioritiesfunded. This has included:

• Statutory/mandatory training from theNHS Core Learning Unit

• A programme of service improvementtraining days/events for all staff

• Development days focused on teamdevelopment

• Attendance at courses and conferencesand ad hoc events

Other means of supporting staff to fulfiltheir demanding national roles haveincluded a practical focus on using new andemerging technologies to enhancecommunication and reduce avoidabletravelling. Notable examples include theincreased use of teleconferencing and webconferencing. The results of the latest staffsurvey are shown in the following section‘How our staff see us’.

STAFFPERSPECTIVETHE

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In 2008, an initial staff survey was carriedout to assess their views on life in theworkplace, what support they required toperform more effectively, where progresswas being made and to identify potentialfuture improvements. This was repeated in2010, with some identical questions forcomparison but also additional questions,reflecting the new world and its challenges,to establish what it was like.

The 2010 survey was completed by 51 staff(a response rate of 74%). In summary, thefeedback was very encouraging, despite theclimate of uncertainty within the NHS andwider public sector.

More than 80% of staff agreed or stronglyagreed that they understood the scope anddirection of work covered by theirworkstream and NHS Improvement as awhole. A total of 84% of staff said they feltsupported in forging strong workingrelationships with their team and linemanager – a 22% increase on the previoussurvey findings. More staff were receivinginductions than in 2008 and these werehelping to provide reassurance of expectedperformance.

Staff indicated they have freedom to actwith 80% saying ‘I have an opportunity todo what I do best as part of my job’ – asimilar result to 2008. While staff generallyacknowledged that the pace and volume ofwork has increased, 84% also recognisedthat support was provided to maintain anappropriate work/life balance.

More than 72% of staff wished to takeadvantage of additional training anddevelopment in order to fulfil their roleswhile 86% of staff said their line managerwas genuinely concerned about their well-being – a similar result to 2008.

A total of 72% of staff also felt there wereopportunities to discuss work issues withcolleagues in other workstreams. Staff saidin general they felt empowered tocontribute to discussions regarding thefuture of their workstream (90% agreed orstrongly agreed) and NHS Improvement as awhole (64%).

The survey revealed positive themesaround opportunities, relationships,communication, organisation andleadership, induction, training anddevelopment, and work/life balance. Thiswill be used to further develop the role ofline managers, explore trainingopportunities and build staff views intofuture corporate plans.

Direct comparisons between NHSImprovement’s survey and the annualnational NHS survey are slightly difficult dueto different methodologies, however thegeneral comparison is favourable.


22

According to a review of staff survey resultsacross the NHS for 2009 produced by theCare Quality Commission (CQC) , 58% ofstaff felt that they had adequate materials,supplies and equipment to do their work,whereas the figure was 90% for NHSImprovement.

In the national NHS survey (which coveredall 388 NHS trusts in England), just overtwo-thirds of respondents said they hadclear objectives, but in answer to a similarthemed question, 84% of NHSImprovement staff said ‘I know exactly whatis expected of me in my work in NHSImprovement’.

The national picture is that more than halfof all staff (57%) said they knew how theirrole contributes to what their trust wastrying to achieve. The NHS Improvementposition is that 64% agreed or stronglyagreed that ‘I feel empowered to contributeto discussions regarding the future directionof NHS Improvement’.

The national NHS survey found 63% of stafffelt they had frequent opportunities toshow initiative in their role, whereas 92% ofcolleagues in NHS Improvement said ‘I havesome say over the way that I work’.

The passion, energy andmotivation of NHSImprovement’s staff werecommented on. Employees aredrawn from a range ofbackgrounds and professions;however they appear united intheir passion for improving thehealth service. This was seen asan important asset, both toinspire and energise the NHSorganisations they work withand to sustain NHS Improvementstaff in what can often bechallenging work.

Tribal Report, September 2010

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STAKEHOLDERPERSPECTIVENHS Improvement’s work can only besuccessfully progressed in partnership withvaried interest groups (clinicians, front linestaff, managers, policy-makers, charities,professional associations, carers andpatients).

In order to better understand how NHSImprovement is viewed by its stakeholders,to improve its working relationships andenhance its communication channels,research was conducted at a number ofevents between November 2010 and June2011 which involved nearly 500participants.

The overwhelming majority of surveyrespondents viewed NHS Improvement’scontribution as positive – with 56% sayingits work was ‘good’ and a further 29%saying it was ‘very good’. A similar responsewas received in judging how effectivepeople saw NHS Improvement as anorganisation with 51% saying good and26% saying very good.

The stakeholder research did indicate thatits reputation was seen as overwhelminglypositive – 24% said it was ‘very good’, 48%said was ‘good’, 26% were ‘not sure’ and2% said ‘poor’.

These results were broadly in line with otherpieces of research carried out on a nationalscale which involved consideration of NHSImprovement. A primary care trust censuscarried out by the National Audit Office in2010 showed 69% of respondents were‘aware of’ and ‘had used’ NHSImprovement as an information source.

Nearly a quarter of those polled were awareof but had ‘not used’ the organisation while8% were ‘not aware’ of NHS Improvement.Their census found 52% of respondentshad found NHS Improvement ‘very useful’as an information source (only topped byHospital Episode Statistics and ImprovingOutcomes guidance results) and 42% said itwas a ‘useful’ source.

In a census of cancer networks carried outby the National Audit Office in 2010, 89%of respondents were ‘aware of’ and ‘hadused’ NHS Improvement as an informationsource whereas 11% were ‘aware’ but had‘not used’ it. These figures comparefavourably with other national programmesand centres within the NHS. The censusrevealed that 15% had found NHSImprovement ‘very useful’ as an informationsource, in this case we were behind the topthree of NICE guidance, ImprovingOutcomes guidance and the NationalCancer Intelligence Network. A further 69%in their census stated they had found us‘fairly useful’.

THE

Elsewhere, there has been support for NHSImprovement’s work in an Ipsos MORIreview of the Coronary Heart DiseaseNational Service Framework. Their reportsaid national improvement teams/improvement agencies “played afundamental role in supporting servicedesign and developing networks but weremuch less at the forefront of most people’sminds.”

NHS Improvement - Stroke worked with theNational Audit Office during production ofthe 2010 report ‘Progress in ImprovingStroke Care’ and also cooperated with theNAO to create an addendum to ‘Progress InImproving Stroke Care: A Good PracticeGuide’. Similarly, the Care QualityCommission 2010 report ‘Stroke services:National report’ highlights the work of NHSImprovement and directs those seekingadvice and information on improvingservices to our resources.

The National Audit Office also in its recentreport ‘Managing high value capitalequipment in the NHS in England’ drew ongood practice identified by NHSImprovement including case study evidenceand recommended that Trusts make use ofits work to improve their management ofhigh value equipment (MRIs, CT scannersand linac machines for cancer treatment).

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Helping youngsterscope with cancer

Strategic overviewToday more than 1.6 million people living inEngland have had a diagnosis of cancer4

and with an ageing population this is likelyto increase significantly in future years. TheImproving Outcomes - A Strategy forCancer publication5 (January 2011) sets outplans to drive up England's cancer survivalrates so that they match the best in Europe,saving an extra 5,000 lives every year by2014-15. But as Professor Sir Mike Richards,England’s clinical director for cancer, says:"... improving outcomes for people withcancer isn’t just about improving survivalrates. It is also about improving patients’experience of care and the quality of life forcancer survivors and our strategy also setsout how that will be tackled."

An important population within thesefigures are children and young peopleaffected with cancer.

There are approximately 40,000 survivors ofchild or young person cancer in Englandwho will need some level of care and longterm follow up as they live into adulthood,perhaps 50+ years after their cancerdiagnosis.

4www.improvement.nhs.uk/cancer/documents/NCSI_Vision.pdf5www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371

IMPROVEMENTCANCER

26


Providing long term follow-up for allchildhood cancer survivors in a hospitalsetting is not viable or appropriate in thefuture given the exponential increase in thenumber of cancer survivors.

The Children and Young People (CYP)workstream, working with clinicians,commissioners, patients and local teams,has developed national safe risk stratifiedpathways that identify how follow up forchildren and young people can be deliveredin line with current pressures andaspirations.

The pathways form the basis of themodels of care now being tested by thefour prototype sites. The principlesemerging from the testing emphasise theimportance of:• Patient choice and being responsive toindividual, clinical, psychosocial andpractical needs

• Providing patients with treatmentsummary and care plan

• Stratify risk and signposting patients tothese appropriate and tailored pathways

• Providing differing levels of care andsupport based on risk assessment

• Effective coordinated supported care• Effective automated surveillance / remotemonitoring systems to remind patients /healthcare professionals when specificscreening/investigations are required

• Fully supporting primary care within anyshared care arrangements

• Managing transition between paediatric,young adult and adult services

• All after care services need to be costeffective and delivered by the appropriatehealth care professional to ensure thebest use of skill mix and resources

Patients have been involved in shaping anddeveloping these pathways of care with anemphasis on actual / practical improvementsfor all cancer patients.

The following case study is one aspect ofthe important issues identified for CYPcancer survivors.

All children and young people who are cancer survivors shouldexpect to receive the same, high quality standard of individualisedcare irrespective of where and when they are treated.

Alex Brownsdon, Patient Representative NCSI CYP Steering Group

“”

The Survivorship Programme aims toprovide relevant, sufficient and timelyinformation that informs, supports andempowers survivors in relation to manyaspects of their lives that have beenaffected by treatment for cancer.

Through three education coursescompleted in 2010, the programmeseeks to improve the quality of patientcare and self-management. Sessionsfocused on a range of topics includingrelationships and body image, anxiety,coping strategies and risky behaviours,late effects of treatment, fertility,finances, education, employment andlife skills. The programme is part of theNational Cancer Survivorship Initiative(NCSI6) and The Christie is one of thetest sites for the children and youngpeople workstream.

The pilot courses were held inManchester with patients from theTrust’s Young Oncology Unit. A total of56 patients enrolled on the courses withattendances varying between sessions.Attendees were aged between 16 and32, with the average age being 22. Themajority of people on the courses werefrom the Greater Manchester area.

The Christie Survivorship Programme

Questionnaire feedback was completedas part of the programme with furtherfollow-up evaluation to come. This workhelped measure the value of theintervention, ensuring continuousassessment and on-going refinement.Participants were asked whether thecourse met expectations and 12 sessionsout of 24 received 100% feedback ofeither ‘agree’ or ‘strongly agree’. Theyalso gave 100% backing to eight out of24 sessions that had motivated them tolearn more.

CANCER

“

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“

”6www.ncsi.org.uk

CASE STUDY

A cancer diagnosis in childrenand young people is rare.However, when this occurs asa child or young person this isat a time in their lives whenthey need to meet manychallenges. Physical and socialdevelopment, education,and the learning to takeresponsibility to move on intothe adult arena for exampleThe diagnosis, treatmentand later consequences oftreatment puts this normaldevelopment into jeopardy.Longer term support is vitalto assist survivors to achievemaximal quality of life.

Dr Gill Levitt, Great Ormond Street Hospitalfor Children NHS Trust, National Clinical Leadfor Children and Young People Survivorship

The survivorship programmehelped me in many ways.Primarily it gave me a betterunderstanding of what helpwas available after havingcancer, as well as being ableto use the folder as ahandbook to refer to in theshort and long term. It alsogave me vital contacts to getin touch with which reallyhelped a lot and on thewhole I think it’s a brilliantidea!

Patient who took parton the programme

DOMAIN 5:Treating and caringfor people in a safeenvironment andprotecting themfrom avoidable

harm

DOMAIN 1:Preventing people

from dyingprematurely

DOMAIN 2:Enhancing qualityof life for peoplewith long-termconditions

DOMAIN 3:Helping people to

recover fromepisodes of illhealth or

following injury

DOMAIN 4:Ensuring thatpeople have a

positiveexperienceof care

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IMPROVEMENTTransforming Inpatient Care: Driving improvements inquality that values patients’ time and increases efficiency

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The improvement programme promotesinnovation and new models of care delivery:• Day case/one night stay for breastsurgery and other procedures

• Enhanced recovery approaches forelective care (colorectal, gynaecological,urological and musculoskeletal)

• Approaches to reduce avoidableemergency admissions and readmissions

• Reducing unnecessary lengths of stay forthose who need to be admitted asemergencies and elective

Strategic overviewThe Cancer Reform Strategy (2007)highlighted the need to focus attention oninpatient care for cancer patients. TheTransforming Inpatient Care Programmewas established to take this forward led byNHS Improvement.

The National Audit Office (2010) reportedgood progress has been made in reducingthe number of inpatient days per year forcancer patient’s, however, there is scope togo much further and to make a significantcontribution to the efficiency savings thatthe NHS needs to make.

The Transforming Inpatient CareProgramme continues to be a cancerpriority and this is reflected within theImproving Cancer Outcomes Strategy(2011) supporting the QIPP agenda andOutcomes Framework.

The lessons learned from testing prototypesand new models is disseminated across theNHS in order to improve the quality of careand experience for patients and to maximisethe potential scope of savings.

The Transforming Inpatient Programme isunderpinned by four ‘Quality WinningPrinciples’.

The Quality Winning PrinciplesWinning Principle 1Unscheduled (emergency) patientsshould be assessed prior to the decisionto admit. Emergency admission shouldbe the exception not the norm.

Winning Principle 2All patients should be on definedinpatient pathways based on theirtumour type and reasons for admission.

Winning Principle 3Clinical decisions should be made on adaily basis to promote proactive casemanagement.

Winning Principle 4Patient and carers need to know abouttheir condition and symptoms toencourage self-management and to knowwho to contact when needed.

CANCER

Patient feedback tells us that beingdiagnosed with cancer can be a difficulttransition to make. Patients undergoingsurgery for both cancer and non cancerexpressed they wanted to be in hospitalsfor as short a time as possible. Throughpatient forums, diaries and interviews,people have talked about how unnecessarywaits and procedures increased anxiety.Patients have stressed the importance ofgetting back to normal as soon as possibleand valuing their time.

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Getting breast surgery patientsbetter soonerThe ‘Quality Winning Principles’ wereapplied to the redesign and streamlining ofthe breast surgery pathway for all patientsundergoing major breast surgery (withoutreconstruction).

The working hypothesis was that thestreamlining of the breast surgical pathwaycould reduce length of stay by 50% andpotentially release 25% of bed days andmanaging patient expectations the patientsexperience could be improved.

Why breast surgery?Baseline data drawn from local and nationalsources indicated:

• Variation in clinical practice andconflicting clinical evidence surroundingthe use and effectiveness of wounddrains, drainage of seromas, anaestheticsand pain control

• Breast cancer is one of the mostcommonly diagnosed cancers in the UK.In England, female breast cancer equatesto approximately 34,000 new cancercases registered per annum andapproximately an additional 20,000patients undergo breast surgery forbenign conditions. (Cancer Registrationin England 2000)

• Breast cancer is one of the areas whichappears to perform worst – survival rates

• Significant geographical variation inlength of stay

• All admissions for mastectomy areelective but only a quarter of patients(27%) were treated as day cases

• In 2007-2008, there was 54,115 electiveadmissions form breast surgery thatoccupied 305,061 bed days (HES)

• The mean range of length of staybetween acute providers ranged from0-7 days for mastectomy procedures.Prompting the question. Why shouldmastectomy be an inpatient procedure?It is a:• Relatively short operation• Low post operative pain• Patient can mobilisation early• No high risks as with other majorsurgery such as retention/ileus

• Rare significant post op events

Enhanced Recovery PartnershipThe principles of enhanced recovery in elective surgery are currently beingimplemented across the NHS nationwide and, as a result, transforming the approachto care before, during and after surgery. This innovative, evidenced-based practice hasalready resulted in dramatically improving the recovery times for patients acrosscolorectal, gynaecology, urology and musculo skeletal care pathways.

It has so far been recognised that implementing enhanced recovery pathways insteadof using traditional models actual improves efficiency as it is helps patients to getbetter sooner after surgery - it also has improved their experienced due to shorterstays in hospital and a more rapid return to normal living as they are encouraged tocontribute to their own recovery. The hospital itself benefits in stable or reducedreadmissions rates, with lower complications and better bed utilisation as reductionshave also been witnessed in the amount of high dependency and intensive bedswhich are normally required.

Enhanced recovery entails a multidisciplinary team and healthcare communityapproach as they are actively involved in the patients care before, during and aftersurgery. This means the patient is well informed and prepared pre-operatively, whichhelps to reduce anxiety or stress levels prior to surgery and results in the patientmaking the correct decisions about their treatment and recovery pathway.

The Enhanced Recovery Partnership led by NHS Improvement working in partnershipwith National Cancer Action Team, SHA Enhanced Recovery Leads, Cancer Networksand National Clinical Leads supports the NHS to implement and realise the benefitsof enhanced recovery.


The breast surgery improvement workwas undertaken in four phases. Thegovernance of the programme of workwas through the Cancer TransformingInpatient Care Programme steeringgroup which reported to Mike RichardsCancer Programme Board.

Phase 1: 2006-2007Baseline and scoping year exploringcurrent practice gathering informationand evidence from a variety of sourcesrelating to bed days, lengths of stay,patient experience and evidence of bestclinical practice.

Phase 2. 2007-20081. Testing the idea and providingProof of Principle. Two NHS Trusts:Kings College NHS Foundation Trust andSandwell and West BirminghamHospitals NHS Trust - City Hospitaldesigned and tested a pathway forpatients undergoing mastectomies as aday case/one night stay. This involvedreviewing clinical procedures, listeningto patients’ views and integrating thepathway between acute hospitals andthe community. It challengedpreconceptions surrounding clinicalpractice in breast cancer surgery andsuccessfully tested mastectomies(without reconstruction) using a daycase/one night stay model.

Phase 3 2008-20092. Prototyping. Tested thetransferability of the improvement,and how different models could beadopted in different settings. The PanBirmingham Cancer Network serviceimprovement team tested the model inday case units, treatment centres andinpatient wards.

The Pan Birmingham Cancer Networkcovers a population of 1.8 million. Theteam identified a potential saving of £1million across the network. The pathwayhas spread across the West Midlandswhere 15 PCTs out of 17 are in the bestquartile (short length of stay, CancerReform Strategy second annual report20098). Sandwell and West Birminghamnow provide 94% of all breast surgery(excluding reconstruction) within oneday (NHS Consolidation report July2010)9.

The prototyping indicated the potentialbenefits of the improvement andconfirmed the working hypothesis. Thelearning has been widely disseminatedacross the country to accelerate thepace of change to benefit morepatients.

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Phase 4; 2009-2011Spread and Adoption - focused onspreading the model across England,involving 13 clinical networks covering,77 hospitals sites (55 NHS Trusts);36%coverage of providers.

8www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_1093389http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Cancer%2fNational%2fWebsite%2fTransforming%20Inpatient%20Care%2fConsolidation_Report.pdf

The day case/one night stay breast surgicalcare pathway: From Testing to Spread.

CANCERCASE STUDY


harm






following injury



I went down to surgery at about 8.45am and by 11.30amI was sitting up in bed and by 3.30pm I was having tea andbiscuits. My recovery has been remarkable, within a couple ofdays, I had forgotten about the surgery and I would highlyrecommend day surgery to others.

Patient, Kings College Hospital NHS Foundation Trust

“”

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More patients are now benefiting fromthe new pathway and over 2,000patients have evaluated it as a positiveexperience. Patients’ experience has alsobeen captured on video and throughfocus groups. King’s College conducteda postal questionnaire and feedbackthrough focus groups, supported byBreast Cancer Care. Patient support forday surgery was unanimous - all same-day discharge patients said they wouldchoose the approach again and thatsame-day discharge provided an earlypsychological boost.

Progress to dateGood progress has been made provingthe working hypothesis of streamliningthe breast surgical pathway couldreduce length of stay by 50% andpotentially release 25% of bed days.

Clinical engagement has been strongand the pathway has receivedendorsement by the British Associationof Day Surgery (BADS).

Mastectomies and wide local excisions(without reconstruction) National meanLength of stay reduced from baseline2.4 (2006/7) to 1.4 (10/11 provisional)There has been a reduction in 30% ofbed days from the 2006/7 baselinepotentially saving £7.89 million ifreleased locally.

There has been no significant increase inre admissions related to reducing lengthof stay.

The biggest shift in practice has beenseen around drains patients are nowhaving no drains, drains removed priorto discharge, or being discharged withdrains in situ rather than remaining inhospital.

Mean LoE

5

4

3

2

1

02006-07 2007-08 2008-09

2006/07 Baseline to 2010/11 (7 months provisional)

2009-10 2010-11 v7

Mea

nle

ngth

ofst

ay(d

ays)

Figure 1: Progress form baseline to spread

Patient’s expectations are managed atthe beginning of the pathway with theemphasis on a good pre-operativeassessment.

The breast surgical day case/one nightstay pathway has been acknowledgedas best practice by NHS Evidence,

Sum of bed days

140,000

120,000

100,000

80,000

60,000

40,000

20,000

02006-07 2007-08 2008-09

2006/07 Baseline to 2010/11 (7 months provisional data)

2009-10 2010-11 v7

Num

ber

ofpr

oced

ures

&be

dda

ys

Number of procedures

Figure 2: Progress form baseline to spread: 2006 - 2010potentially 39,483 beds saved

CQuins and the best practice tariff. Thepathway has been presented nationallyand internationally. It has also beenpublished in professional journals.

(HES data)

(HES data)

IMPROVEMENTAdult cancer survivorship: living with and beyond cancer

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NHS Improvement has been working,through the adult cancer survivorship team,to support the NCSI, helping clinical teamsand patients to better understand thecurrent service and potential for the future.

An evaluation of the NCSI test communityprojects through a patient experiencesurvey10 was carried out in November 2009by the Picker Institute.

A total of 1,284 questionnaires werecompleted by patients receiving care at 17test community projects.

Among the many findings, the surveyreported that:

• 85% of patients said their follow upcare was ‘excellent’ or ‘very good’ andjust 5% said it was ‘poor’ or ‘fair’

• 74% of all respondents had a namedindividual they could contact if concernedbut 21% did not

• 69% of patients said they currentlyneeded no extra help with physical,clinical or medical concerns; just over aquarter (26%) of those who requiredadditional help needed help with fouror more different physical aspects ofliving after cancer

• Almost all patients reported positiveexperiences of the care provided bydifferent health professionals involvedand few reported any problems. Patientswere able to ask the questions theywanted, receive answers they couldunderstand and felt health professionalslistened to them; 86% felt they had beengiven consistent advice all or most of timeand 96% said they had been treatedwith dignity and respect by healthprofessionals all (or most of) the time

Strategic overviewThe Cancer Reform Strategy (2007) statedthat: “Every person affected by cancershould receive world class services at eachstage of their cancer journey” andhighlighted the need to focus attention onliving with and beyond cancer. The NationalCancer Survivorship Initiative (NCSI) was setup as a partnership between policy(Department of Health), voluntary sector(Macmillan Cancer Support) and serviceimprovement (NHS Improvement) toimprove the quality and effectiveness ofservices delivered to those living with aprevious cancer diagnosis. There are 1.7million people living after a cancer diagnosis(2008) and this is projected to rise by atleast 3.2% a year.

The test communities within this NHSImprovement programme are testing anumber of approaches that reflect the NCSIand its five key shifts.

Traditionally, cancer services have focusedon cancer as an acute illness with theemphasis post-treatment on surveillanceand monitoring for further disease orrecurrence for a period, usually up to fiveyears. The cancer story is changing. Asindividuals live longer following a diagnosisit is not just the impact of acute effects thatare problematic, but also the chronic effectsof those living with cancer and the effectsover time their treatment for cancer mayhave on their lives and health. There is asuggestion that 50% of people living withand beyond cancer could self manage withsupport, remote monitoring, informationand access back in to the ‘system’ shouldthey need it.

• 62% of patients had most of theirfollow up care at their local hospital, 16%at another hospital, 10% at their GPsurgery and 6% elsewhere; 14% saidthey had not had any follow up care

Improvement work in two test communitiesin England and Wales is highlighted in thisdocument. These case studies are takenfrom the publication ‘The improvementstory so far’11, which contains many moreexamples of progress in developing newmodels of care and improving the patientexperience.

11www.improvement.nhs.uk/cancer/survivorship/documents/nhsi/improvement_story_so_far.pdf

10www.improvement.nhs.uk/cancer/LinkClick.aspx?fileticket=T7F7QDka6xY%3d&tabid=214

CANCER


At the start of the programme, lungcancer care in Sussex faced a number ofissues, many of which related to thenumber of sites offering care andtreatment and coordination betweenthese sites. There was inadequate timefor patient assessments and a lack ofaccess to other support services.

A process mapping exercise highlightedareas for improvement in the care ofpatients with lung cancer and led to anewly-designed pathway. A weeklymultidisciplinary Combined CancerClinic (CCC) within the Sussex CancerCentre at Brighton and Sussex UniversityHospitals NHS Trust has beenestablished where patients at any stagein their treatment pathway post-diagnosis have an holistic assessmentcarried out. The clinic has been designedto be more flexible to suit patients’needs, allowing them to trigger anappointment or cancel if not requiredand rebook for a later date.

During the consultation a treatmentrecord summary (TRS) is produced whichis given to the patient either at the clinicor sent to them and their GP within 24hours. The patient also has a detailedassessment and care plan (ACP)completed by the specialist nurses. Alldocuments are given to the patient tobe kept in their own patient-heldrecord. Initial feedback from bothpatients and staff has been very positive.

Improving quality for patients with lung cancer in Sussex

Non elective emergencies appear to bereducing compared to data in previousyears. Of those patients admittedbetween February and May 2010 nonewere patients who had received carethrough the new service.

Due to the setting of the clinic and theincreased time allotted to each patient,the local team has been able to carryout certain procedures in the cancercentre, avoiding the need for emergencyadmission or re-attendance at a laterdate for an outpatient procedure.

Huge advances have beenmade in cancer treatmentover past years, andsurvivorship rates areincreasing all the time.However, a by-product of thissuccess is that cancer patientstypically need supporting formany years beyond the end oftheir primary treatment. Thecare planning needs includenot only monitoring forpossible recurrence of theoriginal illness but also awhole range of unrelatedconditions that can arisebecause of the long termeffects of the original cancertreatment. As a patient whohas lived with the effects ofcancer over many years, I amhugely encouraged to see theprogress being made.

CANCER

The cancer landscape haschanged but the public andprofessional view is laggingbehind. Cancer is seen insimple terms - completelycured and ‘back to normal’ orincurable disease and‘terminal’. Reality is different.Some still die within a year ofdiagnosis. Others withincurable cancers live yearswith their illness or experiencetreatment consequencesdirectly after cancer treatmentor years later, with similarillness patterns to a long termcondition.

“

” ”Professor Jane Maher, National ClinicalLead for NHS Improvement

“

Michael Prior, Cancer survivor

CASE STUDY

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IMPROVEMENT

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Achieving a sevenday turnaround inhistopathology

Strategic overviewApproximately 800 million pathology testsare performed annually in England. TheReview of Pathology Services in England in2006 by Lord Carter estimated that 70-80%of all health care decisions affectingdiagnosis or treatment involve a pathologyinvestigation. Pathology employs 25,000staff nationally and costs the NHS in theorder of £2.5 billion a year, representingnearly 4% of total NHS expenditure.

In 2006, Lord Carter endorsed the work ofNHS Improvement’s Diagnostics team andLean as the methodology to deliver a seven-day service (from the time the patient hasthe specimen taken to the result beingavailable to their clinician) and makeimprovements in quality, safety andproductivity.

The recently-published ImprovingOutcomes: a Strategy for Cancer confirmscurrent cancer waiting time standardscontinue to be justified and should beretained. Histopathology services are animportant element in delivering the 31-dayand 62-day cancer wait standards forpatients. Improvements within the servicedeliver tangible results in measuring thepatient experience.

DIAGNOSTICS


When the situation became very difficult in terms of resistance tochange, NHS Improvement were unfailingly supportive. There isno doubt in my mind that external, impartial training and supportis critical to the success of any profoundly transformationalproject, particularly when it involves doctors.

Dr Patricia Harnden,Clinical Director, The Leeds Teaching Hospital NHS Trust

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Whipps Cross Hospital - Turnaround Times - % of workload in 3 and 7 days

Historically there were lengthy delays inhistopathology reporting at WhippsCross University Hospital NHS Trustresulting in a risk of breach of cancerdiagnosis targets. With the support ofNHS Improvement, the service has beentransformed and their success is nowbeing celebrated with awards. Byeliminating a number of bottlenecks,the overall turnaround time has reducedfrom 11 to four days, with 95% ofresults available in seven days, givingpatients and clinical teams a guaranteedand predictable service.

As well as allowing earlier managementand treatment of patients, time andefficiency savings have been made bothwithin and outside histopathology asevidenced by the feedback from theservice users.

In January 2011, the histopathologyteam presented their ‘extra requestsdatabase’ to the Trust’s Dragons’ Den-style competition, attended by NHSInnovations. From 28 applications, theywon first prize and a £2,000 educationalbursary.

How has this change happened?Prior to this initiative, there were anumber of problems affecting theservice. Histopathology results weredelayed and issued in batches,particularly for ‘routine’ cases. Thedepartment was regularly receivingtelephone and fax requests for resultsfrom clinical teams and multidisciplinaryteam coordinators - 10% of which weremade whilst the patient was in clinicbeing seen by a clinician.

Whipps Cross University Hospital NHS Trust

Six hours of resource within pathologywas wasted on a weekly basis dealingwith requests and prioritising cases. Inother departments, resource wasrequired to keep track of outstandingcases and chase results. The overallmean turnaround time was 11 days withsome cases taking up to 40 days.

Analysis of specimen pathway datausing statistical process charts (SPC)highlighted the points of greatest delayand inefficiency. These were targetedusing a series of of ‘plan, do, study, act’problem solving cycles, which led toimprovements across the pathway andconsistent reductions in turnaroundtime. The average turnaround time isnow four days and the degree ofvariation markedly reduced so that 95%of results are available with sevencalendar days.

The impact has been felt by clinical usersof the service:• Dermatology patients are now giventheir histopathology results anddischarged when they return to havetheir sutures removed a week post-biopsy. This has eliminated the needfor a further follow-up appointment,saving on average 25 appointmentslots every month with annual costsavings of £30,000

Changes made in histopathology have changed the servicebeyond recognition. My patients are getting reassurance earlier.Firm management plans are being made much earlier. Timeand money are being saved by potentially reducing the needfor follow up clinic slots.

Consultant Gastroenterologist

DIAGNOSTICS

• Faster histopathology results haveenabled colposcopy to increase thenumber of results letters dispatchedwithin two weeks

• Nurse-led telephone clinics operatemore smoothly as 100% of results(previously just 75%) are available atthe outset

• In urology, patients are discussed atthe multidisciplinary meeting andgiven management plans within fourworking days of the biopsy beingtaken

• The referral of patients withgynaecological malignancy to theregional cancer centre has beenstreamlined with the elimination ofbatching

• Unexpected malignancies are reportedpromptly as prioritisation of casesaccording to clinical need has beenabolished and all samples are dealtwith on a first-in-first-out basis

• Throughout the units, unnecessarytelephone calls and waste ofadministrative resource have beeneliminated

As a result of these changes, cliniciansreceive histopathology results faster, in apredictable and guaranteed fashion.This improves the overall patientexperience.

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CASE STUDY

35


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IMPROVEMENTDIAGNOSTICSUsing Lean processesto support delivery ofthe new CervicalScreening Vital Sign

Strategic overviewImproving Outcomes: A Strategy forCancer12 (January 2011) confirmed that“commissioners should ensure thatcervical screening results continue to bereceived within 14 days. As at November2010, 81% of women were receivingtheir results within 14 days. Asrecommended by the AdvisoryCommittee on Cervical Screening, thethreshold for achieving this has been setat 98%... By taking a complete screeningpathway approach, achieving a 14-dayturnaround time has also been shown tobe cost saving, with an average £100,000saved per unit per year. Some cancernetworks are using this in their localQuality, Innovation, ProductivityPrevention (QIPP) programmes.”

Following the initial success of phase oneCytology, the 10 pilot sites havecontinued to embed their improvementsacross the whole end to end pathway,developing a culture of continuousimprovement in their daily work.Sustainability is the greatest challengefollowing any improvement effort and theteams continued to monitor their datavery closely for a further 12 months.

In phase two, six sites were challengedto take the learning from phase one anduse this to accelerate the pace ofimplementation.

12www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371

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Your work is on target with its focus on quality, prevention,and safety along with an improvement in productivity.Specifically, your work in the histopathology services valuestream is creating a predictable process as seen in your 36%reduction in turnaround times while reducing errors in samplelabelling and requisitions. You should be proud of your success todate, while taking your approach to other processes within theorganisations you are working with.

Charles Hagood,President – Healthcare Performance Partners, Inc. USA

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NHS Improvement has gainedinternational recognition and been askedto present its Lean work at conferences inDenver, Seattle and Copenghagen.

Sample taken to received in lab - Baseline data

The Somerset and West Dorset multi-agency programme spans more than 50general practices, two call-recallagencies, three acute trusts and twocommissioners - providing a cervicalscreening service for up to 45,000women a year. It was a phase onenational pilot site, working with NHSImprovement in 2008-09. At the start ofthe programme, the average time for awoman to get her result was 22 days.Despite a massive surge in demand half-way through the project, by the end ofthe programme all results were beingreturned within 14 calendar days. Thislevel of service has been maintained,month on month, for over a yearfollowing sign-off, with parallelimprovements in patient safety andproductivity.

The project has been successful inachieving the 14-day turnaround timedespite a 30% increase in demandduring this time, following coverage ofthe illness of Big Brother celebrity JadeGoody.

It has been made possible due to anumber of changes in the process.Samples are stockpiled at the point ofreceipt and handled on a ‘first in, firstout’ basis while cases identified asurgent are prioritised and processed thesame day. The project has benefittedfrom good and regular communicationacross all aspects of the pathway. Strongsponsorship from the chief executivehelped to accelerate improvements in ITservices and elsewhere that might havebeen difficult to negotiate without heractive support.

Somerset and West Dorset Cervical Screening Service:Managing demand and building long term sustainability

In addition to meeting the 14-dayturnaround time, 95% of results arereturned to women within seven days oftheir smear being taken, there has beena 90% fall in major and minor errors inrequest details and a 90% fall in clinicalincident reports across the wholeprocess. Analysis has shown a return ofbetween £85,000 and £100,000 a yearbased on an initial investment of£30,000.

I got my result back so quicklythat I nearly phoned the lab tocheck that they had actuallydone the test.

Patient

DIAGNOSTICS

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”

“I was absolutely amazed bythe results you have allachieved - you must be veryproud. I know you areexperiencing great increasesin demand...with my thanksand much appreciation: welldone all of you.

Jo CubbonChief Executive, Musgrove Park NHS Hospital

CASE STUDYDOMAIN 5:

Treating and caringfor people in a safeenvironment andprotecting themfrom avoidable

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IMPROVEMENTImproving access andquality of care

Strategic overviewNHS Improvement has worked inpartnership with the Department of HealthNational Audiology Programme since July2008, to support 18 NHS providers inpiloting innovative ways to redesignhearing, balance and tinnitus, complexneeds and children’s pathways of care.

During the first year, 12 ‘challenged’audiology services needing urgent helpwere assisted to reduce their waiting timesand streamline their ‘testing and fitting’services to attain maximum efficiency withintheir systems.

Following publication of four good practiceguides: incorporating care pathways foradult hearing impairment; paediatrics;tinnitus; and complex hearing and balance,the programme set out to improve thequality of the patient experience, increaseproductivity and sustain the improvementsmade. Learning from this initial pilot phaseis shared in the national publication,Pushing the Boundaries: evidence tosupport the delivery of good practice inaudiology (NHS Improvement, July 2010).

Six out of the 18 sites have been involved inthe subsequent prototype phase to furthertest the following four key principlesestablished in the pilot phase, whichunderpin an effective service:• Direct access to audiology services• Implementing one-stop clinics –encouraging adoption of the ‘assess andfit’ procedure

• Access to care in the community• Developing standardised specificationsand pathways for those identified withcomplex hearing problems anddeveloping communities of practice tosupport delivery of these services

The focus of this concluding work was onquality and innovation. However, additionalproductivity and prevention benefits wererealised as a direct result of theimprovement work:• Early indications show that byimplementing the model of direct accessto a tinnitus audiologist for the 65,761tinnitus patients seen nationally each year,a potential saving of £5.9m per annumcould be made

• For the 205,000 re-assessmentsundertaken annually, work with oneprototype site demonstrates thatproviding access in the community byan associate practitioner, a potentialsaving of £5.3m per annum could besaved nationally

The learning from this work has beencaptured, evidenced and disseminatedacross the NHS in: Shaping the Future:Strengthening the Evidence to TransformAudiology Services (NHS Improvement,March 2011).

AUDIOLOGY

39

www.improvement.nhs.uk/audiology

DIAGNOSTICS -

Mapping work has begun in testing howthese ‘winning principles’ from audiologycan be applied to other physiologicaldiagnostic services with early scoping workacross seven disciplines: cardiac physiology,urodynamics, vascular ultrasound,ophthalmology, gastro intestinal physiology,lung physiology and neurophysiologyalready indicating where the key challengesand issues are and where significantimprovements can be made.

CASE STUDY

The audiology teams at UniversityHospitals Birmingham NHS FoundationTrust and Sherwood Forest HospitalsNHS Foundation Trust identified that upto 73% of GP referrals to ENT (ear, noseand throat) outpatient clinics met thedirect access audiology service criteriafor tinnitus management. Patientsreported that delays in access to servicesadded to the emotional impact oftinnitus and that professionals wereproviding inconsistent information.

New guidelines were therefore drawnup to allow GPs to refer directly toaudiology clinics or via an agreedpathway to ENT. These services areprovided by audiologists and hearingtherapists who have access to ENTconsultants with the ability to requestMRI scans if required.

Core measures were identified atSherwood Forest as key to establishingwhether any implemented changeswere a true improvement – or justadded more variation into the patientpathway.

These were agreed with patient focusgroups. To demonstrate quality andproductivity benefits, the measuresincluded:

Clinical outcome measures – numberof patients red flagged to ENT,treatment modalities, severity scores oftinnitus at presentation and six weeks.

Process measures – number ofreferrals , referral source, referral toaccess times, number of DNAs, numberof follow ups per patient, quality ofclinical records/individual managementplans.

Measuring the impact of a direct access audiologytinnitus management clinic

Defect measures – proportion ofreferrals that met red flag criteria onreferral letter, proportion of referralsthat on clinical assessment patients metred flag criteria.

Patient satisfaction measures – asatisfaction survey was given to allpatients attending clinic. A patientfocus group was used to evaluate thepatient experience.

Staff satisfaction surveys – staff weregiven a questionnaire to determine thelevel of involvement and awareness ofpathway redesign to help identifytraining needs of staff

The graph above shows reducedvariation and turnaround times forpatients following the direct accesspathway.

Measurable changes,outcomes and impactVariation in the referral to assessmenttimes were identified by use of statisticalprocess control (SPC) charts – seediagram above. Root cause analysis onthe outliers from mean identified: delaysin redirection of referral from ENT,DNAs; variation in capacity due tostaffing leave.

Activities that delayed the consultationprocess (i.e. clinic room stock levels lownecessitating the audiologist to leavethe room) were identified andovercome. Some tasks were simplifiedand combined – e.g. patients able toagree a follow up appointment on theday of clinic. Telephone follow up andpartial booking were implemented toreduce DNAs.

Waiting times have been reduced fromup to 28 weeks to less than four weeks,with less follow-up appointmentsrequired.

AUDIOLOGY40

Referral to access time


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Like many people I put offseeing my GP for a long time,therefore I found the veryshort wait to see someone inthe tinnitus clinic verybeneficial. My visit to thisclinic was very reassuring; theaudiologist was friendly, clearand concise and discussed myoptions with me as regardsboth my hearing and mytinnitus as well as confirmingthat I was not imagining whatI am going through... Thisclinic gave me the reassuranceof further help andencouragement to deal withmy tinnitus in the future.

Audiology tinnitusmanagement clinic patient

I was relieved when I went formy appointment at thetinnitus clinic. After weeks ofunhelpful appointments withdoctors, particularly the ENTconsultant, I was feeling veryfrightened. I didn’t think thatanyone could help me. I feelit would have been better tobe referred straight to thetinnitus clinic.

ENT referred patient

This new pathway enablesmore effective access forother patients that require anENT opinion. Only a smallvolume of patients withtinnitus need a medicalopinion, for example,objective tinnitus – these arepulsatile tinnitus or complexpatients for which tinnitus is asymptom with multiplemedical issues.

Andrew Reid, ENT Consultant Surgeon,University Hospitals Birmingham NHSFoundation Trust

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CASE STUDY

Patients need to be able to access thereassessment service when they feeltheir hearing has changed. NottinghamUniversity Hospitals NHS Trust wished tore-design the support provided forpatients who routinely require hearingaid assessments and simple repairs. Thenew pathway had to be more efficientthan the existing reassessment service,more cost effective and also offer carecloser to home for their patients,therefore improving accessibility, whilstmaintaining or improving quality.

With the acceptance that an ageingpopulation will inevitably lead to asignificant increase in demand, thefuture provision of services by a welltrained workforce was also tested in thismodel. The aim was to provideevidence that the service can bedelivered safely and effectively usingassociate practitioners was tested andmeasured by comparing clinical andpatient outcomes between the existingand new pathways.

Measurable changes,outcomes and impactWith direct input, patients,commissioners, managers and clinicians(all grades) agreed to pilot andprototype care closer to home so thatpatients would have more accessibleservices, with fewer and shorterjourneys, thus valuing their time.

By introducing a ‘screening’appointment, they reduced the time inclinic for most patients and improvedthe department’s ability to manage

Improving access to patient care in the community

capacity. The work has improvedaccessibility with services increasinglyprovided in a community location oftheir choice, reducing patient travelwhile maintaining clinical quality.Evaluation has shown a 46% reductionin patient visits was required and a 43%reduction of time spent in clinicsmeaning that a greater number ofpatients can be seen within existingresources. (see old and new pathwaydiagram above).

This site demonstrated that:• Clinical quality is maintained inthis model

• 97% of patients preferred a localservice with a survey showingincreased patient satisfaction

• There is no detrimental impact onpatient care

• Patients do not return more oftenfor reassessment at a local service

• A greater number of patients can bemanaged within existing resources

This audiology team were short listedfor their Trust’s annual awards forinnovation.

AUDIOLOGY42

Old Pathway New Pathway

Referral Telephonetriage andreferral

Repairwith triage(15 mins)

Reassess(45 mins)

Discharge

Min-maxtime (60-120mins)

Fitting(60 mins)

Newreassess(30 mins)

DischargeFurtherreassess(60 mins)

Fitting(45 mins)

Min-maxtime (30-90mins)

25% 50% 25%


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The pilot has developedindividual staff members intoteam players with the skillsto drive and implementchange and innovation inthe future.

Project Lead, Nottingham UniversityHospitals NHS Trust

We have shown that greatthings can be achieved ifchange is embraced notfeared.

Clinical Lead, Nottingham UniversityHospital NHS Trust

This project has been thebest thing I’ve done in 10years.

Long-serving junior audiologist,Nottingham University Hospital NHS Trust

It gives me more variety andresponsibility.

Associate Audiologist, NottinghamUniversity Hospital NHS Trust

Huge thanks to NHSimprovement for their supportwith our project, putting onsome really useful away days,their continued motivationand leaving us withtransferable skills. We were allapprehensive in the earlystages. Don’t be put off.

Richard Nicholson, Clinical and Professional;Lead, Audiology, Nottingham UniversityHospital NHS Trust

At the very start of the projectwe were asked our thoughtson what we wanted on howthe service could beimproved…I now have thereassurance that my hearinghas not deteriorated which isgreat as you get a lot of stickat home!

Brian Thacker, Audiology patient

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IMPROVEMENTFocusing onprevention and bestpractice to save livesand save money

Strategic overviewAtrial fibrillation (AF), an abnormal heartrhythm, is a major cause of stroke,accounting for 14% of all strokes. Strokemanagement and prevention, as set out inthe National Stroke Strategy (December2007), are major priority areas for the NHS.AF increases the risk and overall severity ofstroke and therefore improved recognitionand management of AF is important – a keyarea within the NHS where preventionshould be encouraged as both a cost-savingmeasure and an approach which willimprove people’s lives. The cost to the NHSand social services of the first year of carefor the 12,500 patients whose strokes areattributed to AF is estimated at £148million.

NHS Improvement has been involved in anational programme to reduce the numberof strokes caused by AF. The work aligns tothe national QIPP agenda throughimproving the quality of care, preventingthe risk of stroke, and increasingproductivity via reducing the costsassociated with stroke.

HEART

The programme has a number of aimsincluding achieving greater use of a riskmanagement tool called Guidance on RiskAssessment for Stroke Prevention in AtrialFibrillation (GRASP-AF) in primary care tohelp reduce the number of preventablestrokes (the tool was originally developed inthe West Yorkshire Cardiac Network).GRASP-AF identifies all patients on theexisting GP AF register and performs a riskassessment using CHADS2 to identifywhether they are on the correct treatmentand support the use of anticoagulant drugssuch as warfarin. Ultimately the programmewas initiated to reduce overall strokemortality.

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Fifteen cardiac and stroke networksparticipated in the first round ofnational priority projects to address thedetection and promote optimalmanagement of atrial fibrillation (AF) inprimary care and a further round of 10projects were supported by NHSImprovement in 2009-2010.

A number of the second round projectshave used the GRASP-AF tool (availablefrom NHS Improvement ) to facilitatethe detection of AF and improve itsmanagement.

In NHS County Durham and Darlington,31 practices have used the GRASP-AFtool. Their data indicated that AFprevalence was 1.75% (compared witha nationally reported figure of around1.2%) and that use of warfarin waslower than expected.

Avon, Gloucestershire, Wiltshire andSomerset Cardiac and Stroke Networkhas been working with seven primarycare trusts on use of the GRASP-AF tooland optimising the use of appropriateanticoagulation for high risk patients.Funding linked in with the programmehelped PCTs to run local events andshare the learning, review baseline dataand develop action plans. Interim datain December 2010 showed 107 GPpractices involved, more than 17,500patients with AF identified andconsequent big opportunities for strokereduction from optimal treatment. TheNetwork's atrial fibrillation programmeis geared towards demonstrableimprovements in the percentage ofpatients who receive appropriateanticoagulation.

In a similar pilot project in West Kent,the use of GRASP-AF in eight GPpractices also resulted in an increase inthe percentage of over 65s on AFregisters prescribed warfarin.

Other work under this programme hasseen a Colchester practice basedcommissioning group incentivise 86%of practices to undertake pulse checksat flu clinics. This allowed 34,201patients to be screened in six weeks ofwhich 189 were found to have AF.

This represented an estimated costsaving of £220,000 return oninvestment in addition to the improvedquality outcomes for these patients.

Throughout our involvement in thiswork we often see clear variations in AFprevalence rates across England andthat opportunistic screening increasesthe recorded prevalence. We have seenthat many individuals who have alreadybeen identified with AF and with knownrisk factors putting them at high risk ofstroke, are not being treated withanticoagulants. We believe that themanagement of AF in primary care ispractical, feasible and can be improvedby the use of the GRASP-AF tool.

HEART

NHS Improvement is committed toworking with cardiac and strokenetworks, charities, policy officials,universities and industry to raiseawareness, improve detection andmanagement of AF through a numberof approaches. As we take this workforward, we will be looking to increasethe use of GRASP-AF from the currentfigure of 830 to 2,000 GP practices byApril 2012.

Other important work on improvinganti-coagulation services has begun withthe publication of a resource to helpcommissioners. Anticoagulation forAtrial Fibrillation: A simple overview tosupport the commissioning of qualityservices, sets out to help commissionersdevelop quality anticoagulation servicesby emphasising evidence based practiceand measureable outcomes. This workaims to further reduce the number ofstrokes resulting from atrial fibrillationand poorly managed anticoagulation.

Nationwide stroke prevention in atrial fibrillation

CASE STUDY

The identification of those at risk and appropriatetreatment offers a real opportunity for cost effective, highquality care, with the goal of preventing avoidable mortalityand morbidity.

Dr Matt Fay, GP with a special interest in stroke and NHS Improvement Clinical Lead

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The introduction and dissemination ofprimary angioplasty (PPCI) in England,provides a good example of how anationalised healthcare system can workat its very best. After randomisedclinical trials had established thepotential superiority of PPCI overthrombolysis for ST segment elevationmyocardial infarction (STEMI), theDepartment of Health with the nationalsocieties British Cardiac Society andBritish Cardiovascular InterventionalSociety (BCIS) conducted a feasibilitystudy (the National Infarct AngioplastyProject, NIAP). The final report inOctober 2008 concluded that thenational implementation of PPCI wasdesirable, feasible and cost effective.

Taking account of geographicalconsiderations it was estimated thatPPCI could be offered as the treatmentof choice to 95% of the STEMIpopulation.

Concerted implementation work beganand was spearheaded by the CardiacNetworks, with the support forimplementation assigned to NHSImprovement, via a NationalImprovement Lead and Clinical Lead forreperfusion supported by a Director.

The work of NHS Improvement broughttogether interested parties including theDH vascular programme, BCIS, CardiacNetworks and Strategic HealthAuthorities to share and implementlearning from the growth of PPCI andearly thrombolysis when timely PCI isnot a feasible option.

The advisory role of NHS Improvement inimplementing primary angioplasty

Through its role NHS Improvement has:

• Increased awareness of theimplementation within the networks,capturing learning from early sites andsharing with the wider communityusing a dedicated web page,reperfusion newsletter, bespokemeetings and presentations atconferences

• Provided guidance to SHA,commissioners and any otherinterested parties on commissioningof PPCI services including ambulanceservices and cardiac rehabilitation. Ithas also published a commissioningguide for PPCI

• Given bespoke support toorganisations

• Co-produced the publication “Healthinformation provision post primary PCI– an overview for health careprofessionals

• Acted as an independent expert(honest broker) to arbitrate whensites have disagreement about thebest model for their area

• Developed a clinical advisory groupwith clinical and managerial/commissioning representation fromthe 28 Cardiac Networks

The publication of an interim report inOctober 2010 showed that 18 monthsinto the project more than 70% ofSTEMI’s are now being treated by PPCI(an increase from 10% when NIAPstarted) with all networks having robustplans to achieve 100% coverage foreligible patients by Dec 2011. At thestart of the project 27% of thepopulation had access to primaryangioplasty in 2008, increasing to 88%by February 2011 working to a goal of97% by October 2011.

HEART

The East Midlands Cardiac NetworkIn 2009, within East Midlands, only onehospital Trust offered a 24 hour PPCIservice, seven days a week. Following aregional reconfiguration project led bythe SHA working with the cardiacnetwork, which included serviceassessment site visits to inform theaccreditation process, five hospital trustswere accredited to perform PPCI withinthe East Midlands. This would ensureequity of access of the service within 60minutes for the population it serves.

In January 2011, four out of the fivehospital trusts were providing a 24/7PPCI service across the region with fullcoverage expected in November 2011.Throughout the whole process the EastMidlands region has been supported bycolleagues at NHS Improvement throughdeveloping a clinical summit early in theprocess and securing a national clinicallead to help gain project buy-in;facilitating at clinical advisory groups;attended site visits and led on peerreviews; identified independent patientrepresentatives and provided advice andsupport throughout.

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NHS Improvement has beeninstrumental in enablingprogress with PPCI across theEast Midlands. Both ProfessorRoger Boyle and Dr JimMcLenachan provided clinicaladvice and steer throughoutthe project which helped ourrecommendations beingacceptable to all.

Dr Doug Skehan, Consultant Cardiologist,University Hospitals Leicester NHS Trust,Cardiac Network Clinical Lead

NHS Improvement helpedwith a range of people andin a variety of ways – fromattending regional PPCImeetings and providing anational perspective, sharingbest practice with expertsupport and facilitation andeven providing cardiac nurseexpertise and representationduring the individual trustsite service assessmentsvisits.

Rebecca Larder, East MidlandsCardiac Network Director

Early in 2010, I was fortunateto be asked to sit on theaccreditation team for PPCI toprovide a patient/carer focus.I had the benefit of seeingboth a localised view and anational insight into howlearning from existing goodpractice can overcome themany challenges faced. Mycontribution was both valuedand inclusive, providing mewith confidence andreassurance that this was atruly patient-centredapproach, most definitelyproviding a benefit for all inthe long term.

Pauline Mountain, patient/carerrepresentative on the accreditation team forPPCI

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IMPROVEMENTStrategic overviewSubstantial progress in cardiac surgery hasbeen made over the last 10 years. Surgeonsare operating in a more timely fashion onmore people with higher levels of risk andco-morbidity, yet they are delivering betteroutcomes with mortality following a fall incoronary artery bypass graft surgery from1.9% in 2004 to 1.5% in 2008.

In 2008, one in four patients undergoingcoronary artery bypass surgery were over 75years of age, an increase from one in 10 in1999. The changes in cardiac care set out inthe National Service Framework have alsohad a marked effect on the way patients aretreated - operating on many more patientson an urgent basis as appropriatetreatments are now available much earlier inthe time course of the patients’ disease.Despite such progress there have been longdelays in both the elective (planned) andnon-elective pathways that lead to heartsurgery.

Eight NHS Trusts, supported by their localcardiac networks, participated in a nationalproject as demonstration sites from 2008 to2010 testing out new approaches to careand improvement to frontline patientservices. The work with the project sitesaddressed key efficiency measures seen asconstraining the management of smoothpatient flows, including pre-admissionprovision, referral management services,scheduling and discharge and post-operative care management.

HEART

13www.improvement.nhs.uk/heart/Portals/0/documents2010/Cardiac_Surgery_Commissioning_Guide.pdf

Lessons drawn from this work suggest thatquality improvement to cardiac surgeryservices requires smarter working, a datadriven approach to understandingprocesses, the enhancement of staff rolesand a shared overview of the patients’experience across referring providers andthe tertiary centre.

NHS Improvement’s A Guide toCommissioning Cardiac Surgical Services13

published in February 2010 aims to sharethe successes of the participatingdemonstration sites, showcasing examplesof innovation and improved efficiency.

Following completion of the nationalproject, work in 2011 has focused on thedevelopment of a resource (based onhospital episode statistics) linking the non-elective cardiac patient journey by

procedure across the shared pathway ofcare. This will help us define the QIPP,benchmarking and service improvementopportunities for improving the patientexperience through shorter length of stays.

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In one area of the country, patients stayed in hospital for an averageof 33 days from the time of their coronary event to being dischargedfollowing urgent surgery. An ideal path length would be more like12-14 days. Not only does this represent an unsatisfactory experiencefrom the patient’s point of view, it is a huge waste of resource.

The projects the eight centres worked on with the help of NHSImprovement focussed on the issues at the heart of these excessivelylong waits which lead to real improvements for patients and helpeddeliver more cost-effective care.

Steven Livesey, National Clinical Lead and Consultant Cardiac Surgeon

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Driving up quality and productivity in cardiac surgery

St George’s cardiac surgery team tookthe opportunity to become involved inthe national project to address some oftheir longstanding problems. Both theelective and non-elective adult cardiacsurgical pathways had room forimprovement. In pre-assessment in2007-08, fewer than 60% of electivecardiac surgery patients attended thepre-assessment clinic. Theatrescheduling was an issue with theatreoverruns and lack of beds. Electronicreferral was not being utilised and paperreferrals were frequently being mislaid.In the third quarter of 2008-09, only10% of elective cases were admitted onthe day and there was a need to reducelength of stay.

A project team was established, chairedby the unit’s general manager andbaseline data was collected to identifyareas for improvement across five keyworkstreams. A set of key valuesreflecting the Trust’s own strategic visionwere agreed and integrated within theteam’s vision established to deliver theimprovement work across the patientpathway. Highlight reports helpedmonitor each workstream against keygoals, actions, risks and progress. Datawas analysed to evidence improvementsand the work was informed by the useof patient and carer diaries.

Team members attended the nationalcardiac surgery priority project peersupport meetings which inspiredmembers to share good practice withinthe unit and to develop solutions tochallenges across the peer group.

St George’s Healthcare NHS Trust, London, and the SouthLondon Cardiac and Stroke Network

A new pathway for cardiac surgery wasdeveloped that featured:• Pre-assessment of all elective cardiacsurgery patients by September 2009

• A theatre scheduling policyintroduced in October 2009 whichincluded improving notice to patientsof their date for surgery

• Regular monitoring of theatrecancellations to reduce non-clinicalcancellations

• Implementation of the use ofelectronic referrals for non-electivecases by January 2010

• Implementation of admission on theday as normal practice

• Recruiting two additional staff - apre-assessment nurse and acardiothoracic nurse practitioner.While these new posts required

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funding, the project overall was costneutral due to the savings gained byeach workstream

• Implementation of new dischargeplanning for patients from Jerseywho previously had a long length ofstay due to flight restrictions imposedby the airline

The improvements have seen an overallboost to productivity – theatrescheduling, increased pre-assessmentand admission on the day, and reducedcancellations and length of stay have allcontributed towards an increase inactivity by £103,000 to date.

CASE STUDY

The national work will support the North East LondonCardiovascular and Stroke Network with ongoing local analysisof performance, particularly in relation to QIPP.

Margaret Ancobiah, Network Project Lead for Cardiac Surgery, North East LondonCardiovascular and Stroke Network ”“

Working on this project with the network and NHSImprovement has encouraged us to start a similar projectaddressing issues in cardiology - we’re now looking forward toa similar success story!

Jane Fisher, General Manager, Cardiovascular, St George’s Healthcare NHS Trust

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IMPROVEMENTEarly diagnosis ofheart failure

Strategic overviewThe increasingly successful management ofheart disease, particularly intervention forheart attacks, has greatly improved survivalrates but has left a burgeoning populationliving with left ventricular dysfunction. Heartfailure is now the only cardiovasculardisease increasing in prevalence. In the UK,heart failure affects about 900,000 peoplewith 60,000 new cases annually, and ispredominantly a disease of older people.

NHS Improvement has worked across thewhole heart failure pathway, working toimprove diagnosis, treatment and end of lifecare. More recently this involves working incollaboration with NICE as a publicationpartner for the Quality Standards forChronic Heart Failure and publication of aweb based resource to support theimplementation of these standards.

Early, accurate diagnosis of heart failure inthe community allows for earlier treatment,symptom relief, and offers patients a moreconvenient solution closer to home, butdiagnosis is not simple and heart failurereferrals to outpatients currently cost theNHS £51 million per year.

A simple blood test (serum natriureticpeptide or NP), costing £15-25, can rule outheart failure and reduce the need forfurther investigations by 30-40%. A surveyof cardiac networks by NHS Improvement inAug 2009 showed that only 46% ofprimary care trusts (PCTs) provided this testin primary care.

Computer simulations of the differentscenarios and pathways (using ScenarioGenerator from Simul8) before and afterthe introduction of the blood test shows

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potential cost savings of 25-40%, and ifused as an average potential saving per PCTyet to implement the test, the total nationalsavings would be £13.7 million.

In all areas where NHS Improvement haveundertaken projects to introduce serum NP,implementation has been achieved within6-12 months, and cost savings havebeen realised within six months ofimplementation. A total of 34 PCTs (todate) have requested NHS Improvementassistance with scenario simulation to helpput together business cases for introducing

this test, 23 have had their modellingcompleted showing total predicted annualsavings of £2.8 million.

In addition to the cost savings the serum NPtest also improves clinical effectiveness andspeeds up diagnosis of heart failure, byhighlighting the patients who need urgentreferral and so reducing the likelihood of anacute admission, whilst also ruling outheart failure in those without the disease,reducing the number of patients who haveto go through unnecessary tests andanxiety.

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Measured in terms of both processes and outcomes, the care of patientswith heart disease has improved beyond recognition in the past 10years, NHS Improvement - Heart and associated Cardiac Networks havebeen major drivers in this transformation. As heart disease is the mostexpensive sector of health spending, the new emphasis on preventionand productivity is clearly appropriate and NHS Improvement has amajor contribution to make in the future.

Mark Dancy, Consultant Cardiologist and National Clinical Lead for NHS Improvement - Heart

“”

Patients with heart failure requirecomplex therapy but a lack ofprospective case management oftenleads to disorganised care withinappropriate intervention or avoidableadmission as the disease progresses tothe end of life. Patients and theirfamilies are consequently moredistressed than they need to be. Bettertreatments for cardiac disease anddevelopments in heart failure care haveresulted in improved survivorship buthave not changed the nature of thischronic progressive condition which isultimately fatal.

NHS Improvement is dedicated toenhancing the implementation ofnational strategies for cardiac careacross England. For several years wehave been in the vanguard of thepromotion of end of life care foradvanced heart failure, and for the lasttwo years have supported a number ofprojects on the best ways ofimplementing an end of life service forheart failure patients. In 2009 we wereapproached by the National End of LifeCare team to help develop a frameworkfor implementing end of life services inheart failure.

Clinicians responsible for both heartfailure care and end of life care as wellas commissioners, providers, social careorganisations, charities and patient andcarer groups were invited to submit theirviews on the optimal structure of carepathways and service delivery for thesepatients. Formal meetings and otherforums took place during autumn 2009.

End of life care for heart failure: a framework for implementation

Treatment protocols, patient needs andthe challenges to co-ordinated carewere collated and then themed in thecontext of the recently implementedNational End of Life Care Strategy.

We published our framework documentin June 2010 and distributed itnationally to key stakeholders. Thepublication - End of life care in heartfailure - a framework forimplementation - sets out to raiseawareness of the supportive andpalliative care needs of people living ordying with progressive heart failure, andto facilitate the commissioning ofservices specifically tailored to meetthose needs. It does so in the context ofthe national End of Life Strategy.

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Integrating end of life care in a strategyfor advanced disease managementrelevant to all care settings ischallenging but care coordination ispivotal to the success of services. Wealso believe the template developed forheart failure in this initiative will providea useful model transferable to otherdisease states.

An e-seminar on the document toprovide healthcare staff with theopportunity to question the author hasproved an overwhelming success, anddue the great demand, more areplanned.

CASE STUDY

Praise for NHS Improvement’sheart failure frameworkpublication:

I am always on the lookoutfor this type of publication asI find it is such a powerfultool in helping GPs identifyend of life in conditions otherthan cancer. It would be aboost if we had similarpublications for other longterm condition such as COPDand stroke.

End of Life Care Facilitator

“

”

I have found the documentuseful as it covers many of theissues we highlighted duringour project... in particularrepeating some of the keycomponents that arenecessary for the process tocome together and besustained, for example,multidisciplinary teams,linking across care boundariesand end of life tools.

Service Improvement Manager”

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The team supports clinical teams,commissioners, service managers and otherkey stakeholders to deliver effective clinicalpractice through process improvement andre-design. It provides a wide range ofexpertise on how to begin, manage andsustain improvements that benefit patientsand staff. Working closely with theDepartment of Health and otherorganisations involved in this area, it alsoworks in partnership with strategic healthauthorities and the clinical leads forrespiratory care to co-ordinate thedevelopment of national improvementprojects using robust evidence, informationmanagement and service improvement andre-design methodologies.

Improving respiratorycare

Strategic overview

Why chronic obstructive pulmonarydisease (COPD)?• Awareness and diagnosis is low: only44% of smokers have heard of chronicobstructive pulmonary disease (COPD)when prompted and approximately 33%diagnosed ( plus 20-30% misdiagnosis).It is estimated that there is approximatelytwo million undiagnosed people with thislife limiting disease

• The death toll is high: Respiratorydisease (including COPD) is the secondbiggest killer in the UK. One person diesin England and Wales from COPD every20 minutes – a loss of about 25,000 livesevery year

• It’s expensive: Annual patient costs forCOPD are around £801-930 million; andthe disease leads to 24 million workingdays lost each year (9% of certifiedsickness absence)

• It is a burden on the NHS: One in eightemergency admissions to hospital arefor COPD (second biggest cause ofemergency admissions)

• The burden is avoidable: Followinghospital admission for an exacerbation,30% of people with COPD are likely tobe readmitted within a three-monthperiod

NHS Improvement - Lung provides nationalsupport for the local improvement ofrespiratory services. This covers COPD,asthma and home oxygen services. It is aninitiative to support the implementation ofrecommendations in the consultation onthe National Strategy for COPD Services inEngland.

A fresh approach to oxygen servicesNHS Improvement - Lung is working with anumber of project teams around thecountry via the Improving Home OxygenServices workstream, part of the NationalCOPD Projects.

While NHS Improvement - Lung is stillwithin the initial project cycle, early findingshave already become known and it islearning a great deal about how to improvethe delivery of services and how best toengage a range of stakeholders in makingthese improvements.


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A fresh approach to oxygen services

The rationale for the work of the projectteams is provided by recommendation 14 ofthe COPD Strategy Consultation14, whichstates: “All people with COPD andhypoxaemia should be clinically assessed forlong-term oxygen therapy and reviewed atregular intervals, and existing home oxygenregisters should be reviewed.”

The consultation document also highlightedthe need for respiratory services to meet thechallenge of achieving both quality andproductivity and makes the case for costefficiencies within home oxygen services.The Impact Assessment15 whichaccompanied the consultation stated thatan estimated 30% of people prescribedoxygen either derive no clinical benefit fromit or do not use their oxygen. Quality andproductivity in the home oxygen service canbe improved significantly. Gross savings ofup to 40% - equivalent nationally to £45million a year, or £300,000 per PCT canpotentially be achieved according to recentanalysis carried out by the Department ofHealth through the established of homeoxygen services and oxygen register reviewand formal clinical assessment16.

The project teams have made extensive useof British Thoracic Society Home OxygenServices Standards, early drafts of the 2010Department of Health Good Practice Guide,and NICE and IMPRESS guidance to informtheir thinking.

All the teams involved in this work havebeen supported and encouraged, throughtraining and resources made available byNHS Improvement – Lung, to seek solutionswith a premium placed upon problemdefinition through the use of ‘diagnostic’tools such as process mapping and ‘demandand capacity’ analysis.

14Department of Health. Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease(COPD) in England. Department of Health, 2010.

15Department of Health. Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease(COPD) in England: Consultation Impact Assessment. Department of Health, 2010.

16Department of Health. Home Oxygen Service - Assessment and Review: Good Practice Guide.Final version (November 2010)


Collaboration with NHSImprovement has providedgreater clarity, structure andfocus via project planning aswell as motivationalinteraction with peers. Wehave also benefitted from theexpansion of the future workplan to include demand andcapacity analysis and thedevelopment of a prescribingcosts ‘dashboard’.

Toni YellCommissioning development managerwith NHS Hull

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Historically, NHS Hull did not have anoxygen service, with patients beingpredominantly prescribed long-termoxygen on discharge from hospitalwithout review. In addition, GPs issuedoxygen therapy to patients on a wantrather than needs basis without formalassessment. From April 2010, NHS Hullcommissioned a new home oxygenassessment and follow up service,provided by City Health CarePartnership.

In June 2010, the project was acceptedonto NHS Improvement - Lung’sprogramme and a multidisciplinaryproject team was established includingrespiratory nurses, a smoking cessationspecialist, commissioners, oxygenprovider, a patient and the fire service.The project team work was integratedwithin the wider COPD pathway servicedevelopment work being undertaken bythe PCT.

The project aim is to contribute to a30% reduction in unscheduled hospitaladmissions and the optimisation ofCOPD patient care. This is beingapproached through the delivery ofappropriate and cost-effective oxygentherapy to adult COPD patientsidentified as being in clinical needdetermined through assessment by atrained healthcare professional.

Home oxygen service improvement project in Hull

Data metrics have been agreed by theproject team and data collectionprocesses established and informationprovision responsibilities assigned.Since July 2010, 428 patients have beenassessed or reviewed - prior toassessment these patients had acombination of 601 oxygen therapies inplace. After the assessments thecombination of therapies was reducedto 433 and there were 145 removalsand 44 decreases in oxygen flow rate.This has reduced monthly invoices by£11,378.

A local risk assessment pro-forma iscompleted by the clinical team at everyreview and which has strong links withboth the local oxygen provider and thefire service, enabling issues andconcerns to be highlighted andaddressed.

In addition, 24 patients on oxygen havestopped smoking, due to COPDsmoking cessation specialists and thehome oxygen service now has 404patients on their caseload and in thecycle of review.

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NHS Improvement has been working witha team in West Sussex to improve thepatient pathway for people with acuteexacerbation of COPD by reducing thenumber of avoidable hospital admissionsand streamlining the in-patient pathwaywhere admission is required.

The project is a joint venture betweenWorthing Hospital and NHS West SussexPCT. The team wanted to improve COPDcare across primary, secondary andcommunity care and provide a moreintegrated approach to patient care. Theyalso wanted to ensure high quality,respiratory specialist care was providedwhere this was necessary. For patientsadmitted to Worthing Hospital with acuteexacerbation of COPD there was a meanlength of stay of 6.1 days and 38% ofpeople’s care was managed by arespiratory consultant. Readmission ratesat 30 days were 15% and at 90 days were20%. It was felt that improving careacross the patient pathway woulddecrease admissions and readmissions andreduce unnecessary hospital utilisation.

The team convened a large group ofprofessionals from across primary,secondary and community care andpatients to evaluate the COPD patientpathway and identify the key areas forimprovement work. This process was alsocarried out within Worthing Hospital toidentify areas for improvement specific tothe inpatient stay.

The team identified a need to improvecommunication and the quality ofinformation about the patient’s admissionthat is passed between secondary andprimary care at the point of discharge.

Improving acute care in West Sussex

They have developed a discharge summarythat is being tested to allow timely,concise and accurate information to beshared.

There was a lack of a clear pathway forpatient follow up after admission for acuteexacerbation of COPD. The teamidentified several options for follow updepending on the patient’s clinical needand mechanisms to ensure it happens. Thedischarge summary has been instrumentalin this, and a COPD checklist has alsobeen developed for use by the communitymatrons to ensure follow up is high qualityand comprehensive, wherever it takesplace.

A monthly COPD multidisciplinary meetinghas been instigated which allows thesystematic discussion of patients who havehad more than one admission with theaim of avoiding future unnecessaryhospital admissions. It also allows thecommunity teams to access specialistsupport to effectively manage patients inthe community and reduce the need forformal out-patient consultations.

The team identified that there was limitedCOPD Respiratory Specialist Nurseavailability for patients admitted with an

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acute exacerbation, and that patients whowere admitted at weekends or when theCOPD RNS was on leave were less likely toreceive specialist in-put. The team isworking to develop a network of‘respiratory lead nurses’ with one on eachward to ensure specialist advice is alwaysavailable, and this will be supported by thewider team of respiratory specialist nurses.

The team is now identifying ways tofurther streamline and improve the carereceived during the in-patient stay and areconsidering the use of a care bundle. Inprimary care the team are exploring waysto improve the longer-term follow up ofthese patients and also to improvemedicines management in this group.

Through the work the project team havelearnt a number of lessons including theimportance of good communication at allstages of the patient pathway, particularlywhere care passes between departmentsand particularly across organisations.

The project has been closely aligned toQIPP and the new approach to workinghas the potential to demonstrate qualityimprovements as well as productivity gainsin admissions, readmissions and numberof hospital bed days used.

CASE STUDY

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We feel that our project support team really benefitted fromthe added value that NHS Improvement was able to bring. Notonly did it coordinate additional master classes, which haveenhanced our skills in how to run a project and on the toolsand techniques required such as process mapping and dataanalysis, it also provided key learning from other sites.

Jo Congleton, Respiratory Consultant, Worthing Hospital

“”

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Imperial College Healthcare NHS Trust(ICHT) and Fulham Primary Care Trust(H&F) recognised that there was a needto improve the services and outcomesfor patients with chronic obstructivepulmonary disease (COPD) and otherchronic respiratory diseases. In a jointventure with NHS Improvement they setout on the improvement journey toimprove the outcomes for patients andthe patient’s experience.

After an initial gap analysis revealedthere was over 5,000 undiagnosedCOPD patients within the geographicalregion of care and the cost of COPDadmissions resulted in an estimated costof over £1 million per year there was agenuine need and commitment toimprove the patient services within thisarea.

The initial analysis also highlighted thatimprovements could be made across theentire patient pathway from improvingthe quality of diagnosis, introducing asystem to enable patients to self-manage, facilities within generalpractices (GP) to record exacerbationnumbers and prioritise patients forreview. Within the geographical area itwas also observed that there was asignificantly higher death rates due toCOPD in H&F (standardised mortalityrate 31.5) than in neighbouring PCTs(K&C 18.7; W 21.4; Ealing 21.4); inLondon (27.2); and in England overall(26.8) which required addressing.

Integrated respiratory service to improve outcomes for patientswith long term respiratory conditions in West London

After the analysis was complete therewas an increasing amount of evidencethat application and implementation ofthe chronic care model to the care ofpatients with COPD can deliverimproved measurable outcomes.Previously, there was limited jointworking between the hospital,community and primary care but a multidisciplinary team (MDT) approach wasestablished which emphasisedengagement and enhancedcoordination between all organisations.An integrated COPD patient pathwaywas agreed and a respiratory redesigngroup was convened which was chairedby a local GP which also hadrepresentation from primary and

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secondary care, public health,commissioning, finance, communityproviders, community pharmacy, localsmoking cessation, the British LungFoundation and patients.

An innovative integrated servicesupported by improvementmethodology has improved and willcontinue to improve the quality ofpatient care which will result in deliverybetter patient outcomes and value formoney. Shared aims and joint workingacross primary, secondary andcommunity care, with the engagementand support of the commissionerswithin the region have been critical tothis process.

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Number of COPD acute spells per month for patients who are/arenot on the GP disease register

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Number of COPD hospital outpatient visits permonth (first and follow up)

Since the establishment of the newintegrated pathway, community basedrespiratory consultant clinics in primarycare were introduced along withconsultant led open access respiratoryMDT. Other improvement successincludes the introduction of pulmonaryrehabilitation, early supported dischargeand a rapid response telephone servicefor patients was introduced along withan electronic patient record forcommunity and hospital teams.

Other initiatives include specialistrespiratory nurse-led support to reviewdisease registers, provide workplacebased training and education, supportself management and case finding inprimary care.

These improvements to the service haveshown a reduction in acute admissionsby 19% and readmissions by 66%(2010/11 compared with 2009/10),along with a reduction in first andfollow up outpatient appointmentswhich equates to approximately £170k.There has also been a dramaticreduction in number of patientssurfacing without a previous COPD orasthma diagnosis and on GP diseaseregister.

IMPROVEMENTImplementing bestpractice in stroke care

Strategic overviewA stroke is a sudden interruption in bloodsupply to the brain caused by a blood clotor bleed in the brain . This can causepermanent damage, with a potential impacton the person’s ability to function includingeffects on movement, feeling, balance,vision, cognition, continence andcommunication. It is this country’s third-biggest killer, killing more women thanbreast cancer (National Stroke Strategy17

2007). It is the main cause of adultdisability, with a devastating impact onhundreds of thousands of people of allages. The National Stroke Strategyhighlights the preventable and treatablenature of stroke and the need for rapidresponse to the early warning signs.

NHS Improvement - Stroke was set up toprovide national support for localimprovement of stroke and transientischaemic attacks (or ‘mini-stroke’) services,through the stroke care networks. It takesboth a strategic and local approach workingclosely with national organisations includingthe Department of Health, the major strokecharities, Royal Colleges and statutorybodies. Local improvement is mediatedthrough the stroke networks and nationalimprovement projects with providers ofhealth and social care. It provides regulareducational national learning events andconferences to share good practice andlearning. The team has also published arange of web-based and paper resources toprovide a wide range of expertise on howto begin, manage and sustain stroke serviceimprovements that benefit patients andstaff.

Case studies – improving stroke careacross EnglandNHS Improvement has worked with anumber of national projects looking at howto improve patient care in acute settings,the transfer of care and rehabilitation, andpatient and public involvement. Three casestudies are shown here illustrating thosethemes and providing insights into how ourvaried activities support local teams acrossEngland. Additional case studies areavailable on the NHS Improvementwebsite18.

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17www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_08106218www.improvement.nhs.uk/stroke/CaseStudies/tabid/60/Default.aspx

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The ‘direct access into the stroke hyperacute unit’ (DASH) project atNottingham University Hospitals NHSTrust aimed to provide rapid andequitable access to the service. Thisincluded admission directly into the unitwhen arriving at the hospital, asopposed to admission through A&E. Theaim was for patients to be admitted,assessed and, where appropriate,treated with thrombolysis within threehours of the onset of symptoms.

At the start of the project there werepatients being admitted directly ontothe stroke unit, but lower in numbercompared with those being transferredfrom A&E situated on a campus fivemiles across the city, and from theemergency admissions unit which wason the same site as the stroke unit.Patients began to arrive on the strokeunit from A&E without a call beingmade to advise staff in advance.Telephone calls and triage of the callswere not reliably recorded.

The project saw close working with EastMidlands Ambulance Service,encouraging greater awareness andadherence to the agreed strokepathway. Communications focusedupon publicising the direct phone onthe stroke unit, which became known asthe ‘bat phone’ (with a new ring toneand flashing light fitted). The phonealerts staff on the ward immediatelywhen a patient is to be transferred,giving them the opportunity to triageand provide advice to the crew onwhere to take the patient.

Information was sent to all GPs askingthem to contact the stroke unit if theyassessed a patient with strokesymptoms. ‘Walking the patientpathway’ was carried out by bothclinical and non-clinical members of theteam to highlight any problems.

The project has successfully produced adirect access route into the hyper acutestroke unit. All suspected stroke patientsare now referred directly to the strokeunit. There has been a reduction indelays in transfer and a decrease inthe number of patients being admittedvia A&E.

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Speeding up Nottingham referrals via the ‘bat phone’

The NHS Improvement -Stroke team were key to thesuccess of the acute strokeproject, they providedongoing support and ensuredthat the project teamremained focussed on deliveryon improving outcomes forpatients. Peer support daysenabled the team to meetwith other teams undertakingdifferent projects and shareexperiences away from theclinical environment. Theprofile of being involved in anational project raisedawareness of the direct accessproject within the acute trustand the community –ensuring engagement ofexecutive teams andcommissioners.

Dawn Good, Head of Stroke Services,Nottingham University Hospitals NHS Trust

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In this project, colleagues across healthand social care in South East Londonworked together to improve the servicefor stroke patients on transition fromhospital to home and after they had lefthospital. At the project outset, a typicalLewisham stroke patient would need topass through up to seven differentteams, with variations in the quality ofservice throughout. The average lengthof hospital stay was 22.5 days, whichimpacted on the number of acute strokepatients who could be admitted to theward. Only 41% of stroke patientsspent more than 90% of their stay onthe stroke ward and the wait for genericcommunity rehabilitation after hospitaldischarge was often greater than 12weeks.

Through engagement with seniormanagement and clinical staff andconsultation with service users,bottlenecks in the transfer of care andrehabilitation process were identifiedand a collaborative approach acrosshealth, social care and voluntaryorganisations used to aspire to bestpractice. The pathway was re-designed,there was a focus on joint working andsystems of communication and areconfiguration of the workforce toinclude some new therapy posts andnew ways of working and to integrateprovision of stroke rehabilitation fromseveral teams into a single integratedteam.

A number of key improvements weremade at ward level, includingsimplifying the discharge process,addressing inaccuracies of coding andimplementing a key worker system. Apilot neuro-rehabilitation team wasformed as part of the new integratedcare team to address the lack of strokespecific community rehabilitation.

Service level agreements were re-negotiated with the third sector forfamily support at home and there wasimproved integration with social carestaff and processes.

As a result, there is now a re-designed,more efficient, simplified stroke pathwayin place and enhanced joint workingwith social care. Coordination of carehas been improved with a morepersonalised holistic service. The lengthof stay has decreased to 19 days (March2010) which has had an impact on thestroke Vital Sign with more than 80% ofstroke patients spending 90% of theirtime on the stroke unit. Theimprovements made a significant impacton access to community waiting timesfor therapy falling by 10 days or morefor some therapies, even before theplanned early supported discharge teamwas in place.

Better patient outcomes and value formoney will be realised through theintegrated team through sharedresources such as administration, sharedassessments and reduction in hand-offsand duplication.

Service users have given high praise forthe rapid response, motivating andcaring manner of the staff, and thereassurance of having rapid access toequipment and adaptations enablingthem to manage independently athome.

Lewisham integrated stroke project

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The Dorset Cardiac and Stroke Networkbelieves that patients, their families andcarers should be at the very heart oftheir NHS. This philosophy is in line withnational involvement requirements, theQIPP approach to service transition andthe 2011 Health Bill – all of whichsupport the need for true and ongoinginvolvement.

The network’s approach is reflected intheir patient and public involvementstrategies and plans – which highlightthe importance of ensuring effectiveand supported patient/carerrepresentation and also of activelyseeking people’s views so that they canbe used to inform service development.

It is aware that different people want tobe involved in different ways at differenttimes. They therefore developed anumber of different opportunities forinvolvement. These are called‘involvement levels’ and in the literaturehave been colour coded (to help peopledistinguish between them) andnumbered from one to five. The levelsare:

• Level one: home basedinvolvement

• Level two: discussion groups• Level three: involvement forums• Level four: local representation• Level five: network, regional

and/or national representation

The network currently has 155 localpeople signed up to 308 types ofinvolvement and works closely with localproviders and purchasers, third sectororganisations such as the StrokeAssociation and Connect, theambulance service, adult social care andtheir Local Involvement Networks.

They employ a variety of approaches toactively seek people’s views to influencecare – including focus groups, DiscoveryInterviews™, view seeking forums andeasy-read feedback forms.

Involving stroke patients in Dorset

There are a number ofingredients that haveunderpinned our model ofinvolvement – recognition ofthe importance of effectiveinvolvement from the networkboard and all of its sub-groups, commitment toprovide time and financialsupport to enable our modelto be developed andimplemented, truecollaborative working fromthe outset from everyoneinvolved - including ourpatients and carers andenthusiasm which has beenalmost palpable!

“

”Frances Aviss,Patient and Public Involvement Lead,Dorset Cardiac and Stroke Network

It is a pleasure that I look forward to, the involvement meetingscan be considered a therapy in their own right... they are wellorganised, focused and productive.

“”Derek Hurrell, Dorset Cardiac and Stroke Network patient representative

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Heart• Anticoagulation for Atrial Fibrillation• End of life care in heart failure: a frameworkfor implementation

• Atrial Fibrillation in Primary Care - Making animpact on stroke prevention

• Heart Failure - Quick guide to qualitycommissioning

• A guide to commissioning cardiac surgicalservices

• Guide to implementing primary angioplasty• Continuous improvement to cardiac services2009/10

• Improving patient experience - developingsolutions to deliver sustainable pathways incardiac surgery

• Pathways for heart failure care: makingimprovements in heart failure services

• Transforming Cardiac Rehabilitation -celebrating achievements and sharing thelearning from the national projects

Cancer• Effective follow up: Testing risk stratifiedpathways

• Risk Stratified Breast Cancer Pathway• Risk Stratified Lung Cancer Pathway• Risk Stratified Breast Cancer Pathway• Risk Stratified Prostate Cancer Pathway• Models of care to achieve better outcomes forchildren and young people living with andbeyond cancer

• Teenage and young adult aftercare pathways• Building the evidence - Developing WinningPrinciples for children and young people

• Providing evidence to achieve improvementsfor patients: children and young people livingwith and beyond cancer

• The improvement story so far: living with andbeyond cancer

• An integrated approach: the transferability ofthe Winning Principles - sharing the learning

• Consolidation report: From testing to spread• From testing to spread: sharing the knowledgeand learning from organisations spreading theWinning Principles - case studies

Diagnostics• First steps in improving phlebotomy: Thechallenge to improve quality, productivity andpatient experience

• Continuous improvement in cytology:sustaining and accelerating improvement

• Cytology improvement guide: achieving aseven day turnaround time in cytology

PUBLICATIONSLIST 2010-11

• Learning how to achieve a seven dayturnaround in histopathology

• What a difference a day makes

Audiology• Shaping the Future: Strengthening the evidenceto transform audiology services

• Pushing the Boundaries: Evidence to supportthe delivery of good practice in audiology

Stroke• Commissioning for stroke prevention in primarycare: the role of atrial fibrillation

• Why treat stroke & TIA's as emergencies?• Going up a gear: practical steps to improvestroke care

• Going up a gear: joining up prevention• Going up a gear: implementing best practicein acute care

• Going up a gear: improving post hospital andlong term care

Lung• Improving home oxygen services: emerginglearning from the national project sites

• Chronic and self management services:emerging learning from the national projectsites (Summer 2011)

• Transforming acute care in COPD: emerginglearning from the national project sites(Summer 2011)

• Driving up quality diagnosis: emerging learningfrom the national project sites (Summer 2011)

• Improving end of life care services: emerginglearning from the national project sites(Summer 2011)

General• Bringing Lean to life: making processesflow in healthcare

• Demonstrating how to deliver the QIPPchallenge - pocket guide

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101


NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

partners, professional bodies and charities, over the past year it has tested, implemented,

sustained and spread quantifiable improvements with over 250 sites across the country as

well as providing an improvement tool to over 800 GP practices.’

Delivering tomorrow’simprovement agendafor the NHS

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the best of clinical pathway redesign - practical examples of delivering benefits to patients

Health & Medicine

nhs improvement framework

nhs medicalnice

practical service improvement

nhs evidence website

clinical networks

best practice examples

service improvements

best outcomes