Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Right person, right place, first time Transforming elective care services neurology Learning from the Elective Care Development Collaborative
NHS England INFORMATION READER BOX Equality and health inequalities
Directorate Promoting equality and addressing health inequalities are
Medical Operations and Information Specialised Commissioning at the heart of NHS England’s values. Throughout the
Nursing Trans. & Corp. Ops. Strategy & Innovation development of the policies and processes cited in this
Finance document, we have:
• Given due regard to the need to eliminate
Publications Gateway Reference: 000735
discrimination, harassment and victimisation, to
Document Purpose Resources
advance equality of opportunity, and to foster good
Document Name Transforming elective care services: General medicine relations between people who share a relevant
Author Elective Care Transformation Programme protected characteristic (as cited under the Equality
Publication Date 17th July 2019 Act 2010) and those who do not share it; and
Target Audience CCG Clinical Leaders, Care Trust CEs, Foundation Trust CEs, Medical Directors, NHS • Given regard to the need to reduce inequalities between
Trust Board Chairs, NHS England Regional Directors, NHS England Directors of patients in access to, and outcomes from, healthcare
Commissioning Operations, Allied Health Professionals, GPs, Emergency Care Leads
services and to ensure services are provided in an integrated
Additional CCG Accountable Officers, CSU Managing Directors, Directors of PH, Directors of way where this might reduce health inequalities.
Circulation List Nursing, Communications Leads
Description Information Governance Statement
Cross Reference N/A Organisations need to be mindful of the need to comply
(if applicable) with the Data Protection Act 2018, the EU General Data
Superseded Docs N/A Protection Regulation (GDPR), the Common Law Duty
Action Required N/A of Confidence and Human Rights Act 1998 (particularly
(if applicable) Article 8 – right to family life and privacy).
Timing/Deadlines N/A
(if applicable)
Contact details for Linda Charles-Ozuzu This information can be made available in
further information Director - National Elective Care Transformation Programme alternative formats, such as easy read or large print,
Email: england.electivecare@nhs.net and may be available in alternative languages,
upon request. Please contact 0300 311 22 33 or
Document Status
email: england.contactus@nhs.net stating that this
This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet document is owned by Elective Care Transformation
is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this Team, Operations and Information, NHS England.
document should not be saved onto local or network drives but should always be accessed from the intranet.
Right person, right place, first time
Introduction
The national context and
Contents click to return to this page
challenges facing elective
care services in England
The national general surgery Introduction 4
challenge
he Elective Care
T The national context and challenges facing elective care services in England 5
Development Collaborative
Overview of ideas being tested The national neurology challenge 6
and described in this guide
Essential actions for
successful transformation
The Elective Care Development Collaborative 8
1. Rethinking referrals:
Overview of ideas being tested and described in this guide 9
a. Standardised referral
pathways and
structured templates Essential actions for successful transformation 10
b. Shared learning
opportunities 1. Rethinking referrals:
c. Increasing use of
Advice and Guidance a. Standardised referral pathways and structured templates 12
2. Shared decision
making and self-
management support:
b. Shared learning opportunities 17
a.
Self-management
education and support
c. Increasing use of Advice and Guidance 22
for headache and
migraine 2. Shared decision making and self-management support
3. Transforming
Outpatients: a. Self-management education and support for headache and migraine 27
a. Community migraine
clinics 3. Transforming outpatients:
b. Community MDT clinics
aking transformation
T a. Community migraine clinic 31
forward
b. Community MDT clinic 36
Taking transformation forward 40
3 Right person, right place, first time
Introduction
The national context and
Introduction
challenges facing elective
care services in England
The national general surgery This handbook is for commissioners, providers and those leading the local transformation
challenge
of neurology elective care services. It describes what local health and care systems can do to
he Elective Care
T
Development Collaborative transform neurology elective care services at pace, why this is necessary and how the impact
Overview of ideas being tested of this transformation can be measured. It contains practical guidance for implementing and
and described in this guide
Essential actions for
adopting a range of interventions to ensure patients see the right person, in the right place,
successful transformation first time.
1. Rethinking referrals:
a. Standardised referral The list of interventions is not exhaustive and reflects
pathways and those tested in the fifth wave of the Elective Care
structured templates Development Collaborative using the 100 Day Challenge
b. Shared learning methodology. General medicine, neurology and radiology
opportunities
were the specialties in this wave and this handbook is
c. Increasing use of
Advice and Guidance just one of the resources produced to share learning.
2. Shared decision Further handbooks, case studies, resources, discussion
making and self- and methodology can be found on the Elective Care
management support:
Community of Practice pages.
a. Self-management
education and support Interventions are grouped by theme within this handbook
for headache and
migraine and include ‘how-to’ guides. The success of interventions
3. Transforming designed to transform local elective care services should
Outpatients: be measured by changes in local activity following
a. Community migraine implementation of the intervention and performance
clinics against the Referral to Treatment (RTT) standard. Patient
b. Community MDT clinics and professional outcomes and satisfaction should also be
aking transformation
T measured (NHS Improvement, 2018).
forward
You can learn about the interventions tested in previous
waves (MSK, gastroenterology, diabetes, dermatology,
ophthalmology, cardiology, urology, ENT, respiratory,
gynaecology and general surgery) and find all the
handbooks and some of the many case studies on our
webpages.
4 Right person, right place, first time
Introduction
The national context and
The national context and challenges facing
challenges facing elective
care services in England elective care services in England
The national general surgery
challenge
he Elective Care
T The NHS is experiencing significant pressure and Timely access to high-quality elective care is a key
Development Collaborative
Overview of ideas being tested
unprecedented levels of demand for elective care. priority under the NHS Constitution.
and described in this guide Around 1.7 million patients are referred for elective consultant- The NHS Long Term Plan sets out the ambition to provide
Essential actions for led treatment each month. Between 2011/12 and 2016/17, alternative models of care to avoid up to a third of face-to-face
successful transformation
referrals rose annually by an average of 3.7% per year. outpatient appointments. In 2017/18 there were 119.4 million
1. Rethinking referrals: outpatient appointments, almost 80% more than in 2007/08.
a. Standardised referral Over the 12 months to December 2018, growth in GP referrals The rate of patient attendance at these appointments decreased
pathways and decreased by 0.4%. Total referral growth in 2018/19 was 1.6% from 81.6% in 2007/08 to 78.4% in 2017/18. There has been an
structured templates increase in occasions where the patient ‘Did Not Attend’ (DNA),
at December 2018, against planned growth of 2.4%. Keeping
b. Shared learning
the GP referral growth rate below plan represents a significant but a more marked increase in hospital and patient
opportunities cancellations.
c. Increasing use of
achievement in redesigning pathways across primary and
Advice and Guidance secondary care and implementing interventions across the This makes the redesign of elective care services a must-do for
2. Shared decision elective pathway, to reduce avoidable demand and ensure that every local system, to achieve better demand management that
making and self- patients are referred to the most appropriate healthcare setting, improves patient care (clinically and from a quality of experience
management support:
first time. perspective) while also improving efficiency. It is essential to
a. Self-management understand the drivers of demand and what can be done to
education and support At the end of March 2019, the number of people waiting over improve upstream prevention of avoidable illness and its
for headache and exacerbations, including more accurate assessment of health
migraine 52 weeks had halved since the year before, and the number
of people waiting less than 18 weeks had increased. However, inequalities and unmet need. This includes addressing the needs
3. Transforming
Outpatients: growing demand means that the proportion within 18 weeks of local populations and targeting interventions for those
people who are most vulnerable and at risk (NHS Long Term
a. Community migraine is below the constitutional standard for referral to treatment
clinics Plan, 2019). Technology offers digitally-enabled possibilities in
target of 92%. primary and outpatient care to support this transformation.
b. Community MDT clinics
aking transformation
T The Friends and Family Test (FFT) results for March 2019 showed
forward that overall satisfaction with outpatient services remained high,
with 94% of 1,391,002 respondents saying that they would
recommend the service to a friend or family member; 3% saying
they would not recommend the service, and the remaining 3%
saying either ‘neither’ or ‘don’t know’. It is important to take
steps to ensure that patient satisfaction remains high.
5 Right person, right place, first timeIntroduction
The national context and
The national neurology challenge
challenges facing elective
care services in England
The national general surgery Neurology covers many different conditions from working in small and medium acute trusts (Royal
challenge migraine to motor neurone disease and management College of Physicians, 2011) with some hospitals having
he Elective Care
T of chronic pain. The number of people living with no acute neurology service at all (The Neurological
Development Collaborative neurological conditions in England is rising (currently Alliance, 2018). Annual reviews of neurological patients
Overview of ideas being tested 12.5 million) and will continue to increase. The current by a specialist such as a nurse is a measure included
and described in this guide
service provision cannot meet the needs of patients. in many of the National Institute of Health and Care
Essential actions for
successful transformation One in 10 GP consultations related to neurology in Excellence (NICE) guidelines relating to neurological
1. Rethinking referrals: 2011 (The Neurological Alliance, 2018). From 2012/14 to conditions. In practice these rarely happen (The
a. Standardised referral 2015/16 there was a 14% increase in hospital admissions Neurological Alliance, 2018).
pathways and for people with a primary diagnosis of a neurological • Commissioning is fragmented. CCG engagement with
structured templates
condition, and a 10% increase in emergency hospital neurology is poor, compared to other conditions and
b. Shared learning
opportunities
admissions (The Neurological Alliance, 2018). The actual care pathways are fragmented and poorly co-ordinated.
c. Increasing use of
number of first outpatient appointments decreased In some cases, not recognising and treating a comorbid
Advice and Guidance year on year by 5.0% in 2017/18 and 2.5% in 2018/19. mental health condition can lead to inpatient admissions.
2. Shared decision However, waiting times have continued to rise with the Optimising care pathways and specially designed services
making and self- proportion of patients waiting less than six weeks for to bring together neurology and mental health will
management support:
a first outpatient appointment falling from 35.8% in result in system savings and better patient outcomes (The
a. Self-management
education and support 2016/17 to 32.4% in 2018/19 and the waiting list growing Neurological Alliance, 2018).
for headache and by 17% from March 2017 to February 2019. This suggests
migraine a lack of secondary care capacity in neurology rather • A national shortage of neurology consultants. The
3. Transforming than a reduction in demand. Current challenges and shortage of neurologists in small and medium acute
Outpatients:
opportunities in neurology include: trusts means that often those presenting with a
a. Community migraine
clinics
neurological condition are unnecessarily admitted
• Unwarranted and unnecessary variation in service because specialist opinion is not available at the
b. Community MDT clinics provision. People with long term neurological
aking transformation
T
front door, or have a longer length of stay because
conditions benefit from a multidisciplinary approach their condition is not initially accurately diagnosed
forward
involving not only neurology consultants but specialist (Royal College of Physicians, 2011). Better provision of
nurses, GPs with extended roles (GPwERs) and allied community specialist services would help prevent crises
health professionals (AHPs). However, there is variation and unplanned admissions, and also facilitate better
in availability and provision of this type of support discharge (The Neurological Alliance, 2018).
(Royal College of Physicians, 2011). Patient access is also
affected by variation in the number of neurologists
6 Right person, right place, first timeIntroduction
The national context and
The national neurology challenge
challenges facing elective
care services in England
The national general surgery • Poor communication between primary, community, • Managing expectations of patients and carers. Self-
challenge secondary and social care. Integration of health management is a key element for many neurological
he Elective Care
T and social care (and access to both) is a key part of conditions. Shared development of patient management
Development Collaborative maximising patient experience and outcomes. Increasing plans can empower patients to self-manage (Royal
Overview of ideas being tested demand for neurological services needs to be supported College of Physicians, 2011), however only 15% of
and described in this guide
by better communication between care settings. neurology patients currently have care plans, with 82%
Essential actions for
successful transformation There is significant concern among GPs about the time of neurology patients saying they have never been
1. Rethinking referrals: taken from referral for patients to see a consultant offered a care plan (The Neurological Alliance, 2018).
a. Standardised referral neurologist. Referral triage and access to specialist As with all long-term conditions, the mental health
pathways and Advice and Guidance could be used to filter referrals, needs of people with neurological conditions need
structured templates
reduce unnecessary referrals and free up secondary care to be considered. Integrated psychological support
b. Shared learning
opportunities
capacity. (The Neurological Alliance, 2018). Greater use and social prescribing can better meet the needs of
c. Increasing use of
could be made of GPs to manage headache and follow neurological patients without placing further demand
Advice and Guidance up conditions in remission, potentially with practices on the stretched specialist neurology workforce (The
2. Shared decision working in a networked manner to manage these Neurological Alliance, 2018).
making and self- patients with support from the local neurologist (Royal
management support: Not all of the challenges and opportunities above could
College of Physicians, 2011).
a. Self-management be tackled by the teams during their 100 Day Challenge.
education and support • Maximising the role of community nurse specialists. However, input from key stakeholders helped to
for headache and
migraine Due to the shortage of neurology consultants, the develop the challenge framework for Wave 5 and the
3. Transforming specialist nurse role and particularly a community nurse ideas tested.
Outpatients: role is a valuable resource for increasing patient access to
a. Community migraine treatment. Access to a well co-ordinated multidisciplinary
clinics team is key to the provision of good care and maximising
b. Community MDT clinics patient outcomes, particularly in a community setting
aking transformation
T (The Neurological Alliance, 2018). GPwERs and specialist
forward
nurses have the potential to improve care, reduce follow-
up requirements and (re)admission rates (Royal College
of Physicians, 2011).
7 Right person, right place, first timeIntroduction
The national context and
The Elective Care Development Collaborative
challenges facing elective
care services in England
The national general surgery NHS England’s Elective Care Transformation Programme supports local health and care systems to work together to:
challenge
Better manage rising demand for elective care services.
he Elective Care
T
Development Collaborative Improve patient experience and access to care.
Overview of ideas being tested
and described in this guide Provide more integrated, person-centred care.
Essential actions for As part of this programme, the Elective Care Development Collaborative has been established to support rapid change led
successful transformation
by frontline teams. In Wave 5 of the Elective Care Development Collaborative, local health and care systems in south west
1. Rethinking referrals:
Hampshire, Liverpool, north east Essex and Salford formed teams to develop, test and spread innovation in delivering
a. Standardised referral
pathways and elective care services in just 100 days (the 100 Day Challenge). You can find more about the methodology used here.
structured templates
b. Shared learning
The teams used an intervention framework to structure their ideas around three strategic themes:
opportunities
c. Increasing use of
Advice and Guidance
Rethinking Shared decision making and Transforming
2. Shared decision
referrals self-management support outpatients
making and self-
management support: Rethinking referral Taking a universal personalised care approach means that: Transforming
a. Self-management processes to ensure • People are supported to stay well and are enabled to make outpatients means
education and support they are as efficient considering how patient
for headache and informed decisions and choices when their health changes.
migraine and effective as pathways and clinic
3. Transforming possible means that • People with long term physical and mental health conditions arrangements (including
Outpatients: from the first time are supported to build knowledge, skills and confidence and processes) ensure that
a. Community migraine a patient presents to live well with their health conditions. patients always receive
clinics in primary care, • People with complex needs are empowered to manage their assessment, treatment
b. Community MDT clinics patients should own condition and the services they use. and care from the right
aking transformation
T always receive person, in the right
forward
the assessment, Shared decision making is a collaborative process through which a place, first time. This
treatment and care clinician supports a patient to make decisions about their treatment may not be in secondary
they need from the and care that are right for them. This should be considered at every care. Virtual clinics,
right person, in the stage of the patient pathway and can incorporate digital health technological solutions
right place, first time. tools, personalised care and support planning, social prescribing, and treatment closer to
patient choice, patient activation and personal health budgets. home are all possibilities.
8 Right person, right place, first timeIntroduction
The national context and
Overview of ideas being tested and described in this guide
challenges facing elective
care services in England
The national general surgery Intervention The opportunity
challenge
If a standard neurology pathway is used practitioners should have access to relevant
he Elective Care
T
Development Collaborative guidance and information when making or receiving referrals. Referral quality should be
Overview of ideas being tested Standardised referral more consistent and the number of unnecessary referrals should reduce. This should mean
and described in this guide pathways patients are seen as soon as possible by the right clinician.
Essential actions for
successful transformation If learning and knowledge about neurology conditions is shared between practitioners,
1. Rethinking referrals: patients should receive effective treatment and advice earlier. Primary care practitioners
a. Standardised referral Shared learning should build their knowledge, confidence and expertise reducing the number of referrals
pathways and into secondary care and improving the quality of referrals made.
structured templates
opportunities
b. Shared learning
opportunities If GPs can access specialist advice it helps them to manage patients more effectively in
c. Increasing use of primary care and avoid unnecessary referrals into secondary care. This should also improve
Advice and Guidance Increasing the use of the quality of referral information that accompanies the patient.
2. Shared decision Advice and Guidance
making and self-
management support:
a. Self-management If patients have high quality information about their condition and multi-channel self-
education and support Self-management management education and support, they will be able to better manage their own
for headache and
migraine
support for headache symptoms which will improve patient outcomes and experience.
3. Transforming
and migraine
Outpatients:
Patients benefit from an extended appointment with a specialist, where they can discuss
a. Community migraine
clinics their headaches and receive support with putting together an initial management plan. A
b. Community MDT clinics
Community community migraine clinic means that patients receive in-depth specialist support earlier
aking transformation
T
migraine clinic and closer to home and demand for acute neurology outpatient services is reduced.
forward
Management of certain conditions, such as multiple sclerosis (MS) or chronic pain, requires
specialist doctors, nurses and allied health professionals to work together as a
multidisciplinary team (MDT). If MDT reviews are provided in the community patients can
receive the right management and access to specialist opinion earlier, GPs can receive advice
Community MDT clinic
and guidance on management and more patients can continue to be managed in primary
care, reducing demand on outpatient services.
9 Right person, right place, first timeIntroduction
The national context and
Essential actions for successful transformation
challenges facing elective
care services in England
The national general surgery The actions below are essential for creating the culture of change necessary to transform
challenge
elective care services and are relevant to the interventions described in this handbook.
he Elective Care
T
Development Collaborative
Establish a whole system team the system. Involving senior clinicians as early as possible is
Overview of ideas being tested crucial to reaching agreement and implementing changes
and described in this guide Consider who needs to be involved to give you the widest effectively across organisational boundaries.
Essential actions for possible range of perspectives and engage the right
successful transformation stakeholders from across the system as early as possible. The 100 Day Challenge methodology facilitates cross-
1. Rethinking referrals: It is essential to include patients and the public in your system working. Working across multiple organisations
a. Standardised referral work. Find top tips for engaging patients and the public in this way is essential to establishing effective Integrated
pathways and on the Elective Care Community of Practice. Care Systems, which need to be created everywhere by
structured templates
April 2021 (NHS Long Term Plan, 2019).
b. Shared learning Secure support from executive level leaders
opportunities
Ensure frontline staff have permission to innovate, help
c. Increasing use of
Advice and Guidance unblock problems and feed learning and insight back into People to involve from the start:
2. Shared decision • People with lived experience of Throughout the
making and self- using the service handbook you
management support: will find useful
Useful resources: Allied health professions supporting • Patient organisations and
a. Self-management
patient flow: a quick guide (NHS representatives (including the tips on who else to involve
education and support Public Health England website voluntary sector) for specific interventions. It
for headache and
Leading Large Scale Change (NHS Improvement and NHS England, 2018)
migraine • GPs and primary care clinical is important to consider how
England, 2018) Guidance for NHS commissioners on and nursing staff you are addressing the needs
3. Transforming
Facing the Facts, Shaping the Future equality and health inequalities legal of your local population and
Outpatients: • Radiology consultants
(Health Education England 2018) duties (NHS England, 2015) how interventions can benefit:
a. Community migraine • Service managers
clinics Equality and health inequality NHS people living in the most
Useful publications and resources • Radiographers deprived areas; inclusion health
b. Community MDT clinics
on quality improvement (The Health RightCare Packs (NHS England, • Sonographers
aking transformation
T 2017) groups (including homeless
forward
Foundation, 2018) • Business information analysts people and rough sleepers);
100 Day Challenge methodology NHS England response to the • Administrative team support Gypsy, Roma, Traveller groups;
(Nesta, 2017) specific duties of the Equality Act: • Physiotherapists vulnerable migrants and sex
Equality information relating to • Commissioners workers; and people with
Principles for putting evidence-based public facing functions
guidance into practice (NICE, 2018) • Appointment booking staff characteristics protected under
• IT team. the Equality Act 2010.
10 Right person, right place, first timeIntroduction
The national context and
Essential actions for successful transformation
challenges facing elective
care services in England
The national general surgery Ensure the success of your transformation activity can
challenge be demonstrated Indicators and metrics that may be useful for specific
interventions are included in the relevant sections
he Elective Care
T
Development Collaborative
SMART (specific, measurable, attainable, realistic, time throughout the handbook.
related) goals and clear metrics that are linked to the
Overview of ideas being tested Some suggested indicators that are relevant to most
and described in this guide intended benefits of your interventions need to be
interventions in this handbook are described below:
Essential actions for defined right at the start of your transformation work.
successful transformation
Key questions include:
1. Rethinking referrals:
• What are you aiming to change? Benefits Suggested indicators
a. Standardised referral
pathways and
structured templates
• How will you know you have achieved success? Improved • Friends and family test score (FTT)
patient • Patient reported experience measures (PREMs)
b. Shared learning You may wish to use a structured approach such as logic
opportunities and staff scores (where available)
modelling. Consider how you are going to include both experience
c. Increasing use of qualitative and quantitative data in your evaluation. • Qualitative data focused on your overall aims
Advice and Guidance
(through surveys, interviews and focus groups)
2. Shared decision
making and self- Questionnaires can be extremely useful to obtain • Number of complaints
management support: patient and staff feedback. Resources and top tips Improved • Referral to treatment time
a. Self-management from the Patient Experience Network can be found efficiency
education and support on the Elective Care Community of Practice. • Waiting time for follow-up appointments
for headache and
migraine • Overall number of referrals
3. Transforming • Rate of referrals made to the right place, first time
Outpatients: Useful resources for evaluation:
• Cost per referral
a. Community migraine Making data count (NHS Improvement, 2018)
clinics Improved • Patient Reported Outcome Measures (PROMs)
How to understand and measure impact (NHS England, 2015)
b. Community MDT clinics clinical scores (where available)
aking transformation
T Seven steps to measurement for improvement (NHS quality • Feedback from receiving clinicians
forward Improvement, 2018)
• Commissioning for Quality and Innovation (CQUIN)
Patient experience improvement framework (NHS Improvement, 2018) indicators
Evaluation: what to consider (The Health Foundation, 2015) • Quality and Outcomes Framework (QoF) indicators
Measuring patient experience (The Health Foundation, 2013)
Improved • Ease and equity of access to care
Guidance for NHS commissioners on equality and health patient safety • Rate of serious incidents.
inequalities legal duties (NHS England, 2015)
11 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England a. Standardised referral pathways and structured templates
The national general surgery
challenge
he Elective Care
T What is the idea? Primary care clinicians have easy access to the
Development Collaborative information they need when making referrals. This means
Overview of ideas being tested Standard neurology referral pathways are informed by they have increased understanding of which cases to refer
and described in this guide best practice and ensure that patients see the right and the correct information to include in these referrals.
Essential actions for person, in the right place, first time. Structured templates
successful transformation
Clinicians also have more information about best practice
that are available on primary care IT systems can support in prescribing which helps them make better decisions
1. Rethinking referrals:
the use of standard referral pathways, ensuring that with patients and reduces variability in medicines use and
a. Standardised referral
pathways and referrers understand where to direct patients and what prescribing costs.
structured templates information needs to accompany them.
b. Shared learning
Secondary care clinicians receive the necessary clinical
opportunities and administrative referral details straight away and are
Why implement the idea? more likely to accept referrals first time. They may see
c. Increasing use of
Advice and Guidance
Many patients with common neurological conditions, fewer patients because more are managed in primary
2. Shared decision
such as headache, can be managed in primary care with care and/or the community.
making and self-
management support: some guidance. For those with more complex conditions,
a. Self-management diagnosis can be difficult and it can take several
education and support appointments for patients to see the most appropriate
for headache and
migraine specialist. This contributes to increased demand for
3. Transforming neurology services that often have a relatively small
Outpatients: number of consultants. As a result, patients can wait a
a. Community migraine very long time to access treatment.
clinics
b. Community MDT clinics Structured referral templates that include referral criteria
aking transformation
T and guidance can reduce the number of inappropriate
forward referrals and improve the quality of referral information
that accompanies the patient, avoiding unnecessary delay.
This helps to ensure that patients who need to be
assessed and treated by specialists receive appropriate
care as quickly as possible and management options
available in the community are started straightaway.
12 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England a. Standardised referral pathways and structured templates
The national general surgery
challenge
he Elective Care
T
Development Collaborative We know it works
Overview of ideas being tested
and described in this guide A pilot pathway and guidelines to assist primary care full roll-out this would reduce the cost of headache
Essential actions for practitioners to manage patients with headache was from £410,000 to £142,000, and create an increase in
successful transformation introduced by West Norfolk Clinical Commissioning capacity of 979 first appointments per annum. (NICE
1. Rethinking referrals: Group (CCG) after GPs expressed a wish for greater shared learning database, 2018)
a. Standardised referral access to imaging. The pilot was preceded by a well
pathways and As part of the 100 Day Challenge:
structured templates received educational programme provided by the
b. Shared learning authors of the pathway. Twelve months after GPs were Pre-referral guidance was implemented for headache
opportunities able to refer patients direct for MRIs there was a 29% patients in north east Essex to advise GPs on when to
c. Increasing use of reduction in headache referrals to the neurology refer to secondary or community headache clinic and to
Advice and Guidance
department. (Redhead et al, 2015). manage in primary care. During the 100 days 13
2. Shared decision
referrals were redirected from secondary care to the
making and self- An evaluation of GP direct-access CT concluded this
management support: community clinic. Overall waiting times for the
pathway was the preferred choice of GPs for management
a. Self-management neurology service reduced from 28 weeks to 25 weeks.
education and support of patients with chronic daily headache. This study also
for headache and suggested that 86% did not require further specialist In Liverpool, a pilot primary care multidisciplinary team
migraine referral suggesting an approximate cost-saving across (MDT) for chronic pain identified that 27% of patients
3. Transforming the study group (4,404 scans) of at least £86,000 waiting for a specialist appointment could be managed
Outpatients:
(Simpson et al, 2010). Similar results were also shown in by their own GP with guidance. New primary care
a. Community migraine
clinics an evaluation of primary care access to CT for headache guidance for chronic pain was drafted and agreed by
b. Community MDT clinics in Tayside and North-East Fife (Thomas et al, 2010). the MDT for launch across Liverpool. A supporting
aking transformation
T digital template was also produced to automatically
In the first three months of a new headache pathway in
forward prompt referrers to use the guidance.
Oxfordshire, 89% of all headache referrals were
directed away from general neurology outpatients. At
13 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England a. Standardised referral pathways and structured templates
The national general surgery
challenge
he Elective Care
T How to achieve success
Development Collaborative
Overview of ideas being tested The sections below include learning from sites in Wave 5 of the Elective Care Development Collaborative:
and described in this guide
Essential actions for Work with stakeholders from across the local system to • Ensure that referral forms can integrate with
successful transformation develop the pathways local Advice and Guidance systems and patient
1. Rethinking referrals:
• Review existing pathways and referral forms. Map the management systems. Seek IT expertise from the start
a. Standardised referral
patient journey for common pathways such as headache to ensure that forms can be uploaded and adjustments
pathways and
structured templates and seek input from stakeholders to understand what can be made to improve usability (such as automatic
b. Shared learning is working well and what needs to change. Consider pop-ups and pre-population of patient details).
opportunities the needs of your local population, particularly those • Communicate plans to referrers. Use a variety of
c. Increasing use of that may be outliers in terms of GP referral rates or methods, such as letters, posters and education sessions,
Advice and Guidance
unplanned hospitalisations. Explore the reasons behind to communicate changes to the pathway and why they
2. Shared decision
making and self- any variation, considering equality of access to services. are needed.
management support: In particular, consider people living in the most deprived • Agree key outcome measures and establish a
a. Self-management areas; inclusion health groups (including homeless baseline to measure progress against. Seek input
education and support
for headache and people and rough sleepers); Gypsy, Roma, Traveller from stakeholders on the key metrics necessary to
migraine groups; vulnerable migrants and sex workers; and demonstrate impact of your intervention.
3. Transforming people with characteristics protected under the Equality
Outpatients: Act 2010.
a. Community migraine Ensure you have considered the
clinics • Review pathways and templates from elsewhere.
Understand what could work well locally and develop a perspective of everyone who will be
b. Community MDT clinics
version relevant to your local context. making and receiving referrals. Patient
aking transformation
T
forward insight is key to pathway redesign.
• Develop a smart template on the primary care patient Ensure you consider equality and health inequality,
record system that includes explicit referral criteria. along with your legal duties to make reasonable
This should prompt the referrer to access relevant adjustments for disabled people.
guidance when making a referral, thereby optimising
opportunities for shared learning. However, try to
keep the referral template and questions as simple and
relevant as possible.
14 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England a. Standardised referral pathways and structured templates
The national general surgery
challenge
he Elective Care
T Implement the pathways and templates • Ensure all materials you produce are as accessible as
Development Collaborative
• Develop, test and refine on a small scale to possible. Work with your communications team to
Overview of ideas being tested
demonstrate early impact. This makes attempting to ensure that materials are available in a variety of
and described in this guide
scale across multiple clinical commissioning group (CCG) languages and formats, depending on the needs of your
Essential actions for
successful transformation or sustainability and transformation partnership (STP) local population. For example, this may include
1. Rethinking referrals: areas much easier. producing ‘easy read’, large print or audio versions for
a. Standardised referral
disabled people or translations into the languages
pathways and • Ensure that the success is measured. In the early stages of spoken most frequently in your area.
structured templates implementation, feedback is key to future refinement.
b. Shared learning We are working with NHS Digital to identify any
opportunities underutilised neurology codes which could be used to Metrics to consider for
c. Increasing use of capture data for improvement and audit purposes,
Advice and Guidance measuring success:
including the possibility of proposing a new clinical code
2. Shared decision
making and self- for headaches. In addition to the suggested overall impact
management support: metrics on page 11, you may wish to
a. Self-management
NHS England and NHS Improvement are consider the following metrics for this
education and support
for headache and working with NHS Digital to improve intervention:
migraine coding of neurology activity to capture • Awareness and uptake (e.g. percentage of referrers
3. Transforming data for improvement and audit purposes. using the referral form).
Outpatients:
a. Community migraine In the interim speak with your Data Analyst Lead to • Effectiveness (e.g. time spent completing the
clinics identify suitable codes that can be used for tracking referral by the referrer, feedback on ease of use).
b. Community MDT clinics activities along the pathway.
aking transformation
T
• Quality of referrals made (e.g. time spent reviewing
forward each referral once received, feedback from
Provide useful information for patients receiving clinicians on the quality of referrals and
• Consider the needs of patients using your service and accompanying information, number of referrals
provide appropriate information to help them make shared returned to referrer).
decisions about their treatment. It may be useful to refer
to NHS England’s guidance on shared decision making.
15 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England a. Standardised referral pathways and structured templates
The national general surgery
challenge
he Elective Care
T
Development Collaborative The following standards and guidance may be useful:
Overview of ideas being tested
and described in this guide
Chronic pain: assessment and management (NICE, Headache Pathway Case for Change (Cader & Wood, 2017)
expected publication in 2020)
Essential actions for Medicines optimisation in long-term pain (NICE, 2017)
successful transformation
Commissioning better headache services (Bateman, 2015)
1. Rethinking referrals: Migraine prophylaxis: flunarizine (NICE, 2014)
a. Standardised referral Guideline scope Chronic pain: assessment and
Motor neurone disease: a guide for GPs and primary
pathways and management (NICE, 2018)
structured templates care teams (Motor Neurone Disease Association and
b. Shared learning Guidelines for All Healthcare Professionals in the RCGP, 2015)
opportunities Diagnosis and Management of Migraine, Tension-Type,
Suspected neurological conditions: recognition and
c. Increasing use of Cluster and Medication-Overuse Headache (British
Advice and Guidance referral [NG127] (NICE, 2019)
Association for the Study of Headache, 2010)
2. Shared decision
making and self- Quick Reference Guide for Healthcare Professionals:
Headaches overview (NICE, 2018)
management support: Conditions for which over the counter items should not
a. Self-management Headaches in over 12s: diagnosis and management: routinely be prescribed in primary care (NHS England)
education and support Surveillance report 2016 [CG150] (NICE, 2016)
for headache and
migraine
3. Transforming
Outpatients:
a. Community migraine
clinics
b. Community MDT clinics
aking transformation
T
forward
16 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England b. Shared learning opportunities
The national general surgery
challenge
he Elective Care
T What is the idea? Why implement the idea?
Development Collaborative
Overview of ideas being tested Shared learning opportunities give practitioners and Shared learning opportunities support management of
and described in this guide commissioners from across primary and secondary care the demand for neurology services. The implementation of
Essential actions for chance to improve their knowledge and understanding of shared learning opportunities may mean that:
successful transformation
current practice and outcomes for their patients.
1. Rethinking referrals: Patients benefit from support to manage their condition
a. Standardised referral There are many opportunities for shared learning, in primary care.
pathways and including formal training or peer mentoring; system-wide
structured templates Primary care clinicians gain a better understanding of
shared learning sessions or events; optimising feedback
b. Shared learning which cases to refer to neurology and the correct
opportunities from Advice and Guidance services or triage of referrals
information to include in these referrals. Their knowledge,
c. Increasing use of by specialists; multidisciplinary team case review meetings
confidence and expertise improve, meaning that referrals
Advice and Guidance and system wide audits.
are only made into secondary care when necessary.
2. Shared decision
making and self- For neurology, key learning can be shared around
As the quality of referrals improves, receiving clinicians
management support: management in primary care of common conditions, such
have the information they need to accept referrals.
a. Self-management as headache, or guidance on prescribing and medicines
education and support
for headache and optimisation. Local health inequalities can also be examined
migraine to best understand how to address these. Shared or
3. Transforming interprofessional learning is valued by clinicians and can
Outpatients: help improve understanding of professional roles and also
a. Community migraine enhance clinical learning (Pearson & Pandya, 2010).
clinics
b. Community MDT clinics
aking transformation
T
forward
17 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England b. Shared learning opportunities
The national general surgery
challenge
he Elective Care
T How to achieve success
Development Collaborative
Overview of ideas being tested The sections below include learning from sites in Wave 5 of the Elective Care Development Collaborative:
and described in this guide
Essential actions for Plan for learning opportunities across your local system by overthinking your offer. You may find that there
successful transformation is information available but people aren’t aware
• Establish where there are gaps in learning. Ask
1. Rethinking referrals: of how to access it, in which case you may wish to
primary care practitioners which areas they would like
a. Standardised referral focus on consolidating and promoting this material.
pathways and to explore and where there are areas for development.
Alternatively, you may find that the available resources
structured templates Ask secondary care clinicians and expert patients where
are not fit for purpose in your local context, so adapting
b. Shared learning they think learning should be directed. The wider the
opportunities these or designing your own may be a better option.
range of people involved in planning the learning
c. Increasing use of
Advice and Guidance
opportunities, the wider the range of perspectives.
2. Shared decision • Identify where there are skills and expertise that can Resources required
making and self-
management support:
be utilised. Think about who will be producing, giving • Information resources, • Visibility of
a. Self-management
and receiving the education and information materials. including patient consultant
education and support Engage clinicians from across primary and secondary testimony. and specialist nurse
for headache and care from the beginning and ensure the mutual benefits
migraine • Posters and leaflets to among GPs, e.g. leading
of shared learning are explained and understood so that workshops.
3. Transforming
people are willing to give of their time and knowledge. reinforce key learning
Outpatients:
points after an event. • Filming equipment
a. Community migraine • Keep key stakeholders involved. Organisational
clinics • A venue to hold the and editing support
support and local ownership are vital for engagement. for ongoing training
b. Community MDT clinics session, or via e-learning
Send full updates by email and take the opportunity package, e.g. video, FAQs.
aking transformation
T forum, e.g. video.
forward to present at any clinician meetings or events. Through
• Administrative support to • People with lived
engaging with people from across the system, you may
promote and co-ordinate experience who are
be able to start having different conversations, share
the event and pull willing to share their
learning and improve the care being delivered.
together the resources experience.
• Review existing resources to establish what is most developed by the team.
and least helpful. It is easy to get stuck and held back
18 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England b. Shared learning opportunities
The national general surgery
challenge
he Elective Care
T Decide upon the approach you will take
Development Collaborative Inviting patients to describe their
• Training and peer mentoring in primary care. experiences and insight can be a
Overview of ideas being tested
and described in this guide Specialists can deliver structured training and become powerful way to optimise learning.
Essential actions for peer mentors for clinicians who do not have the same
successful transformation level of specialist knowledge. Mentors can come
1. Rethinking referrals: from a range of disciplines including general surgery • Develop and share resources. These may include
a. Standardised referral consultants, specialist nurses and pharmacists. specific information such as algorithms, information
pathways and
structured templates • Shared learning events and forums. These can count packs or resources for patients. Such resources can be
b. Shared learning towards continuing professional development (CPD). invaluable when planning subsequent meetings and
opportunities They usually have a specific focus and bring together events and it is useful to plan an easy method by which
c. Increasing use of individuals with similar interests and learning needs. resources can be shared.
Advice and Guidance
2. Shared decision • Virtual multidisciplinary team review meetings. These • Identify suitable venues and dates. Ensure events are
making and self- allow a team of professionals from across primary and easily accessible and appealing to the intended attendees.
management support: Keep costs low or free for attendees wherever possible.
secondary care to gain holistic oversight of complex
a. Self-management Consider holding shared learning events during
education and support patients. They allow for learning and expertise to be
for headache and shared and are an opportunity to ensure that care scheduled CPD time and ensure an appropriate venue is
migraine pathways and treatment plans are integrated and available to keep travel time to a minimum and
3. Transforming aligned across the multidisciplinary team. maximise attendance. Remember to promote relevant
Outpatients:
resources developed at the event. It may be useful to
a. Community migraine Plan ahead for implementation identify administrative support to help coordinate
clinics
b. Community MDT clinics • Identify a specific focus and engage expert presenters. venues and invites for speakers and participants.
aking transformation
T A specific focus (such as a theme or patient cohort) for
forward an event or virtual review meeting ensures that attendees
Ensure you consider equality and health
know what to expect and can get the most out of the
inequality, along with your legal duties
opportunity. This needs to be communicated in good
to make reasonable adjustments for
time to enable cases to be prepared for discussion and
disabled people.
to ensure that all relevant clinicians can attend.
19 Right person, right place, first timeIntroduction 1. Rethinking referrals
The national context and
challenges facing elective
care services in England b. Shared learning opportunities
The national general surgery
challenge
he Elective Care
T • Promote shared learning opportunities to the intended
Development Collaborative audience. Approach your local communications team either The following standards and guidance may be useful:
Overview of ideas being tested in the CCG or local trusts to help you produce information Care of People with Neurological Problems (Royal
and described in this guide resources and market any events and materials. Work with College of General Practitioners, 2019)
Essential actions for local clinical networks to attract attendees and ensure the
successful transformation Commissioning better headache services (Bateman, 2015)
right people are involved. Get dates into diaries as far in
1. Rethinking referrals: advance as possible. Guidelines for All Healthcare Professionals in the
a. Standardised referral Diagnosis and Management of Migraine, Tension-Type,
pathways and • Optimise informal opportunities for shared learning. For Cluster and Medication-Overuse Headache (British
structured templates example, referral mechanisms may be a useful tool for Association for the Study of Headache, 2010)
b. Shared learning improving communication and sharing learning between
opportunities referrers and specialists across primary and secondary care. Headache Pathway Case for Change (Cader & Wood,
c. Increasing use of When consultants respond with feedback on the referral, 2017)
Advice and Guidance referrers can share this learning with colleagues for future Headaches overview (NICE, 2018)
2. Shared decision reference. Work across the system to enable shared learning Management of migraine (with or without aura) (NICE,
making and self-
management support:
to happen organically alongside developing formal learning 2015)
opportunities.
a. Self-management Motor neurone disease: a guide for GPs and primary care
education and support • Think about ways to be inclusive. Consider the timing and teams (Motor Neurone Disease Association and RCGP,
for headache and
migraine accessibility of sessions to increase attendance (for example, 2015)
for people with caring responsibilities outside of work).
3. Transforming
Ensure shared learning is delivered in a variety of formats. Quick Reference Guide for Healthcare Professionals:
Outpatients:
Conditions for which over the counter items should not
a. Community migraine • Share learning as widely as possible. If the speakers and routinely be prescribed in primary care (NHS England)
clinics
participants are happy to be filmed, it can be useful to share
b. Community MDT clinics Stroke rehabilitation in adults [CG162] (NICE, 2013)
education online to enable those who could not attend to
aking transformation
T benefit from the learning. Suspected neurological conditions: recognition and
forward referral [NG127] (NICE, 2019)
• Seek feedback and review your learning offer regularly.
Consider the best way to evaluate each shared learning The Long Term Plan for the NHS: Getting it right for
opportunity and ensure that they meet your key aims. neurology patients (The Neurological Alliance, 2018)
Further iterations and opportunities should be developed Equality and Health Inequality NHS RightCare Packs (NHS
based on the feedback received and impact achieved. England, 2017)
20 Right person, right place, first timeYou can also read
