The NHS “landscape” & The NHS “landscape” & implications to MSSN implications to MSSN

specialist servicesspecialist services

Or “Does anybody have any idea Or “Does anybody have any idea of what is going on?”of what is going on?”

What do we know for certain ?What do we know for certain ?

“The future will be more like today …….

…. and less like today, than you can ever imagine”

What do we know for certain ?What do we know for certain ? The NHS is no longer an institution but an The NHS is no longer an institution but an

overarching labeloverarching label Population, politics & Post code lotteryPopulation, politics & Post code lottery Evolution of MS care is fastEvolution of MS care is fast Patients will always need nursesPatients will always need nurses People with MS will always need specialist People with MS will always need specialist

nurses until the cure is foundnurses until the cure is found

What else is pretty certain?What else is pretty certain?

Strong evidence from surveys and case studies Strong evidence from surveys and case studies of the value that MS nurses bring to patientsof the value that MS nurses bring to patients

Neurologists unanimous valuing the roleNeurologists unanimous valuing the role GPs are likely to want to maintain and even GPs are likely to want to maintain and even

expand services provided they:expand services provided they: Are rapidly accessible Are rapidly accessible Integrate well with other community servicesIntegrate well with other community services Decrease, rather than increase, their Decrease, rather than increase, their

workloadworkload Don’t add cost, and ideally release cashDon’t add cost, and ideally release cash

The economic arguments for MS The economic arguments for MS nurses are strongnurses are strong

Cash releasing Cash releasing savingssavings

Non-cash releasing Non-cash releasing savingssavings

• Reduction in emergency Reduction in emergency admissions / readmissionsadmissions / readmissions

• Reduction in consultant Reduction in consultant neurology appointmentsneurology appointments

• Reduction in A&E Reduction in A&E attendancesattendances

• Reduction in GP Reduction in GP appointmentsappointments

• More effective use of More effective use of medicationmedication

• Lower hospital length of Lower hospital length of staystay

… and supported by economic research on specialist nurses in other specialties

Political imperativesPolitical imperatives

QIPP here to stay QIPP here to stay Finite budgetsFinite budgets No clear tariffsNo clear tariffs Minimal data and lack of understanding of valueMinimal data and lack of understanding of value

Remember:Remember: Neurology remains under resourcedNeurology remains under resourced

Defining the MS Specialist role - Defining the MS Specialist role - resourcesresources

MS Specialists and the QIPP agenda

The economic worth of the MS Specialist

Caseload and activity

Presenting the role to others

Quality Innovation Productivity Quality Innovation Productivity PreventionPrevention

MS Specialist Nurses & QIPPMS Specialist Nurses & QIPP

The complexity and unpredictability of MS and the rapidly evolving treatment options require highly

specialist care for successful long term management.

Poorly managed MS carries a significant socio-economic and emotional burden for all those involved.

MS Specialist Nurses utilise their specialist knowledge and skills to deliver safe, effective, evidence based

quality care

Quality Innovation Productivity Quality Innovation Productivity PreventionPrevention

QualityExpert specialist care responsive to varied and unpredictable clinical

need.Management of complex and hidden disability, with an emphasis on

partnership and self-management.Skilled family and psychological support tailored to particular issues

encountered in MS.Up to date guidance and support to gain the best outcomes from

treatment programmes.Specialist skills and education guided by

comprehensive, nationally recognised competenciesHigh-level telephone & e-mail

consultation skills.

Quality Innovation Productivity Quality Innovation Productivity PreventionPrevention

Innovation

Innovative use of local resources through collaborative working such as sports facilities, community centres.

Bringing new skills in the care of people with MS.Initiation of strategies for self managing MS in

community and home settings.Development of care pathways for rapid relapse

management avoiding hospital admission.Safe virtual care and support

Quality Innovation Productivity Quality Innovation Productivity PreventionPrevention

ProductivityNon medical prescribingHigh quality professional consultations which reduce/prevent

unnecessary GP appointments and increase Neurologist capacity.

Cost effective case management of whole episodes of care.Skilling of other Health and Social care professionals in

managing MS care effectively in hospitals and the community.

Fast-track specialist support/advice for GPs in urgent situations.

Supporting knowledgeable self-management for people with MS and their carers.

Facilitation of early return to work/remaining in work.

The economic arguments for MS The economic arguments for MS nurses are strongnurses are strong

The quality arguments for MS The quality arguments for MS nurses are strongnurses are strong

Quotes from service users are a very powerful support to the economic argument when it is a “cost neutral”, “cost saving” or “cost benefit” outcome. Brokerage and rescuer roles are important aspects of quality.

The quality arguments for MS The quality arguments for MS nurses are strongnurses are strong

Autonomous 360˚ highly complex range of interventions, skills and clinical expertise

Broker

Rescuer

Facilitative expert

Cross boundary working

Pivot for cohesive coordinated care

Good return for the investment

Leadership, Innovation and new boundaries

Stratifying your caseloadStratifying your caseload

Numbers from research Numbers from research are at diagnosis, time is are at diagnosis, time is relevant for caseloadrelevant for caseload

15 years from diagnosis 15 years from diagnosis 58% have reached EDSS 58% have reached EDSS 44

7% of your caseload will 7% of your caseload will be benign MSbe benign MS

25% R/R on DMTs 25% R/R on DMTs ↑ = 40↑ = 40 28% R/R no treatment28% R/R no treatment

Caseload Caseload analysisanalysis

Total Total populationpopulation

212,121212,121

Prevalence of Prevalence of MSMS

165:100,000165:100,000

CaseloadCaseload 350350

45% R/R45% R/R 158158

35% S/P35% S/P 122122

13% P/P13% P/P 4545

Your serviceYour service What is your caseload in relation to the population? What is your caseload in relation to the population? What actions / interventions are necessary at each stage of the What actions / interventions are necessary at each stage of the

patient’s disease journey?patient’s disease journey? What % of your time is clinical?What % of your time is clinical? New to follow up ratios?New to follow up ratios? What tariff prices are paid or affected by your activities? What tariff prices are paid or affected by your activities? What evidence do you hold from your patient’s about what they What evidence do you hold from your patient’s about what they

value?value?

What can we offer the neurologist?What can we offer the neurologist?

We can reach beyond the medical diagnosis of MS and enable neurologists to transfer the health implications of that diagnosis, and the management of them, to the nurse.

We can work with a “life model” that enhances the “medical model”.

We can ensure successful implementation of treatment decisions, and refer back when they are not working well

We can translate those “medical” decisions for people with MS into something meaningful to their everyday lives

We can make nursing treatment decisions that will support medical treatment decisions

What can we offer the neurologist?What can we offer the neurologist?

We can inform and enlighten neurologists on the (existential) challenges their patients face in living with MS

We can ensure safe and skilled care in a smooth transition from the point of diagnosis and also ensure a smooth and safe transfer back when further neurologist intervention is needed

We can give neurologists increased capacity and efficiency to see more patients with MS knowing that others are safely monitored and cared for.

We can take responsibility with additional skills and knowledge that assures good and safe health outcomes without direct supervision from the neurologist

What can we offer the provider?What can we offer the provider?

Key areas to consider are risk (safety), productivity and quality.

What would happen if you were not in post?

1. Evidence the risk and get sign up to that risk if they want to cut services

2. Evidence the productivity and get acknowledgement of discrete complex outcomes

3. Evidence the high quality of your service

What can we offer the provider?What can we offer the provider?Lets take risk………..

There is a safety risk to patients who are on current treatments if they have no correct surveillance and financial risk to this

There is an unscheduled care and re admission risk, and a financial risk to this

There is a safety risk in that this group is vulnerable to unpredictable serious events such as relapse, undetected depression, atypical infection, pressures sores (litigious territory) without expert monitoring

There is a social/economic risk without your expert intervention so prolonged periods out of work, family risk, inappropriate access to resources  

There is a protracted length of hospital stay risk if your support is not available

What can we offer the provider?What can we offer the provider?

……….now take productivity

The capacity for your neurologist to sustain a healthy new to follow ratio and ensure safe care will be significantly compromised

Your GP’s will have a substantial rise in consultations and re referrals back to the neurologist if you are not there (has the governance process ensured they are fully informed of this risk?)

Your planned admissions (income generating) will be under threat as who will manage that service

Your patients are likely to be out of work or unable to return to work as efficiently without you in post to manage relapses or prevent secondary complications  

What can we offer the provider?What can we offer the provider? 

……….finally quality Complaints will increase

The current service will drop into the poor performers (the MS Trust new map may help with this)

People with MS risk experiencing poor care outcomes and lack of access to treatments that will enable them to remain active, employed etc

People with MS risk developing complications and further health problems

Generalist health and social care providers will lack necessary expertise to manage complex aspects of MS

Generalist health and social care professionals will be unable to identify the entry and exit criteria for the new treatments in MS so patients will have a poor choice

Commissioning pathway for MSCommissioning pathway for MS

Patient outcomes pathway for MSPatient outcomes pathway for MS