East Midlands

From Evidence to Excellence - our clinical vision for patient care

Executive Summary

June 2008

1The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

Page

Foreword 2

Introduction 3

Improved care from birth to death 6

Making the vision a reality 11

Contents

2 From Evidence to Excellence - our clinical vision for patient care

Foreword

From Evidence to Excellence – our clinical vision for patient care provides a high level framework for the delivery of world class healthcare over the next 10 years for the people of the East Midlands.

As joint clinical leads for the review, our ambition is to create a stronger health system that is evidence based, patient centred, safe, high quality and championed by clinicians.

This document provides a summary of the vision developed by doctors, nurses and other health and social care professionals from around the East Midlands. A copy of the full document and more detailed information is available on our website.

In the autumn and winter of 2007 more than 500 doctors, nurses and other staff met to discuss the evidence for the best healthcare. They did this in eight workstream groups spanning from birth to death:

n Maternity and newborn caren Children’s healthn Planned caren Mental healthn Staying healthyn Long term conditionsn Acute caren End of life care.

A ninth regional workstream was set up in February covering learning disabilities.

We asked the workstreams:

n Looking at the evidence, what does good practice look like?

n What practice already exists which matches this?n What prevents us implementing good practice?n What changes would allow these barriers to

be overcome?n What needs to happen locally, regionally and

nationally to deliver best practice?

A further 1,400 members of staff took part in engagement events set up to gather views from people working in health and social care across the East Midlands region. During the same period, over 6,500 patients and members of the public were asked to tell us what matters to them. Their views were enormously helpful in writing our clinical vision and we are grateful to everyone who took part.

We should like to continue to receive comments on the vision after it has been published and you can do this in a number of ways which are outlined at the back of this document.

We believe the vision gives us a strong evidence based foundation on which to build a patient centred NHS in the East Midlands. The challenge for us all is to make the vision a reality.

by Joint Clinical Leads for Our NHS - our future, NHS East MidlandsDr Kathy McLean, Medical Director and Consultant Physician, Derby Hospitals NHS Foundation Trust and Professor Mayur Lakhani, CBE, GP and Medical Director, NHS East Midlands

3The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

Introduction

The background to this review began in July 2007 when the Prime Minister, Gordon Brown, and Health Secretary, Alan Johnson announced a major review of the NHS. Led by Parliamentary Under Secretary of State Lord Ara Darzi, Our NHS, our future – the Next Stage Review will identify the way forward for the NHS in the 21st century NHS.

We believe we need to change the way we provide care because:

We need to improve people’s health - more than one in four people in the region still smoke and more people are obese or overweight in the East Midlands compared to the national average.

Inequalities in health are growing - in 2003-2005, a baby born south of the River Trent in Rushcliffe would expect to live, on average, around five years longer than a baby born north of the river Trent in neighbouring Nottingham city.

We are not meeting the public’s expectations - people have told us they want the NHS to do more to prevent people from getting ill; want it to be easier to make appointments at their GPs; want better access to NHS dentistry; want a more personalised service and want shorter waiting times for hospital services.

Quality and safety need to improve – for example, people want cleaner hospitals and fewer infections.

Some of the ways we deliver care are not based on the best evidence – for example, we do not treat strokes and heart attacks as well as we could.

Doctors, nurses and healthcare professionals believe they can improve patient care - clinicians are often frustrated when they try and improve services for their patients.

The hospital is not always the answer - people have told us they want services to be easy to get to and convenient to use; be nearer to where they live or easily available in the areas they work. Medical advances can make this possible.

Better access to healthcare is needed - better access to services is vital if we are to give people more choice and convenience.

There is a need for more specialised care - evidence tells us that the most seriously ill need specialised care.

The population is becoming more elderly – we expect the number of over 85 year olds to increase by 37% in the next seven years, which is good news but older people tend to need the NHS more than younger people.

NHS East Midlands published its strategic plan in October 2007. Better Health, Better Care: Preparing for the Next Stage gave the public in the East Midlands five promises: 1. A positive experience for all our patients, where

everyone is treated with courtesy and respect, and personal dignity is a priority. A service which offers real choices where patients and their carers have influence and are involved in decisions about their care

2. Accessible, convenient and flexible services, available promptly and equally to everyone where proper consultation means real influence on how services are delivered

3. Safe, high quality, effective care delivered in modern clean hospitals and surgeries where clinical quality delivers excellent outcomes

Sir John Brigstocke, KCB ChairmanNHS East Midlands

Dr Barbara Hakin, OBEChief ExecutiveNHS East Midlands

From Evidence to Excellence - our clinical vision for patient care4

4. Well run, efficient services delivering best value for tax payers’ money where transparency allows proper scrutiny

5. A steady improvement in health and reduction in inequalities between the most and least deprived.

As a result of the Next Stage Review we have added a sixth promise to our list:

6. We will create a system where we involve, listen and are influenced by the views of our patients, the public and our clinicians.

The clinical vision summarises what our patients, the public, our clinicians and health service professionals have told us needs to change and how. More detailed information is available on our website www.eastmidlands.nhs.uk

We will now embark on a programme of major change to look in more detail at services and produce the final blueprint. However there are a number of areas where our early findings demonstrate the direction of travel and which identify the changes our patients and the public will see across the East Midlands.

From individual workstreams these include:

n Developing at least two specialist heart attack centres, saving more than 40 lives a year and preventing almost 90 further heart attacks and 22 strokes each year

n Developing at least four specialist centres for the treatment of stroke which would enable at least 87 stroke victims in the East Midlands to regain independence

n Establishing a full level 1 trauma centre in the East Midlands to give the most seriously injured patients the highest quality care

n An industrial scale approach to health promotion and prevention of ill health, working with our partners to persuade people to stop smoking, reduce harmful alcohol use, eat a healthy diet and take more exercise

n A commitment from all GP practices to implement annual health checks and health action plans for those patients with a learning disability, ensuring appropriate information is recorded on registers

n A year on year improvement in the numbers of patients registered with an NHS dentist

n Additional investment in midwives to guarantee one to one care for women during labour

n Aiming for 80% of all appropriate outpatient and diagnostic activity for children to be delivered in community health settings

n Expansion of screening programmes - including breast, bowel and cervical cancer - enabling early diagnosis and better outcomes for cancer patients

n Improved access to mental health services, including care closer to home with a single point of access and more people trained to deliver talking therapies

n All patients with a long term condition having their own personalised care plans by 2009, which will be owned by them and reviewed at least annually

n Exploring the potential for ‘virtual wards’, using the systems and staffing of a hospital ward but without the physical building, thus providing care for people in their own homes

n Tailored packages of care for those with long term illnesses such as diabetes, asthma or mental health problems.

There were also some themes which featured across more than one workstream. These include:

n Getting the basics right by ensuring hospitals and other healthcare settings are clean, and continuing to reduce infection rates

n A highly systemised quality and patient safety culture that routinely measures the outcomes of treatment

5The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

n Creation of a system where we involve, listen to and are influenced by the views of our patients, the public and our clinicians

n A new focus on improving the health of our patients through more treatment in general practice, reducing the chances of illness and premature death

n Promoting and extending choice for patients and their carers, including lifestyle choices to prevent future ill health, choice of different treatments, choosing not to have treatment and a choice of where to have treatment

n Closing the gap between the most healthy and the least healthy, giving priority to children to prevent lifelong deprivation

n A change in the way GP services are delivered to give patients additional opening times in the evenings, early mornings or Saturdays

n A broader range of service provision in patients’ homes, integrated with social services and helping patients to care for themselves

n Year on year improvements to be included in local plans for investment in diagnostics, extending access so that all GPs are able to utilise diagnostic tests, including imaging, seven days a week

n Introduction of a maximum 18 weeks wait for all therapies, child and adolescent mental health services and talking therapies

n Developing agreed clinical outcome measures, including patient reported outcomes

n A commitment to the continuous development of clinical leadership and clinical engagement at all levels.

From Evidence to Excellence - our clinical vision for patient care6

Improved care from birth to deathThis section outlines the vision for each workstream. The detailed reports, including the models of care are available in full on our website – www.eastmidlands.nhs.uk

Maternity and newborn care - women will be able to contact their midwife as soon as they suspect they are pregnant. They will already know from their education the importance of a healthy diet, taking exercise, not smoking and not misusing alcohol or drugs and can refresh their knowledge about maintaining a healthy lifestyle from a range of other places. Women will have the support of the same midwife throughout their pregnancy. The midwife will guide her through a comprehensive antenatal screening and diagnostic programme and will continually assess the woman’s needs and instigate the right care for her.

When the time is right for the expectant mother, the midwife will discuss with her the choices of where she can have her baby. All women will be offered this choice in future and all maternity facilities will promote a philosophy of normality, natural labour and childbirth.

The safety of mother and child will be paramount, so that all care will be provided within a network supported by strong neonatal services to ensure that, if complications occur, there is an easy transfer to an appropriate facility. Women will be given a further choice of the setting for post natal care. They will be encouraged to breastfeed their baby with support from trained practitioners and peer supporters. If their baby requires special or intensive care, this will be provided within a clinical network as near to the mother’s home as possible.

Children’s health - Prevention of ill health and promotion of good health will be improved. Identifying vulnerable children will happen as early as possible and everyone who comes into contact with the child and their family will be able to offer advice on healthy eating, exercise, smoking and alcohol and drug misuse. As children grow up, health education will be a vital part of their education.

Care for children will be provided as close to the home as possible within settings that are accessible to the child and their family, for example community health venues and children’s centres. Only acute care and highly specialized or technological care will be delivered from a hospital setting. Early intervention and treatment will be carried out locally, including tests and investigations, outreach specialist services and outpatient care for ill children and those with long term conditions and palliative care.

Parents will know how to access care simply and swiftly though single points of access. Once they have accessed care, the child and their parents will be able to move throughout the system seamlessly being seen by the right person at the right time in the most appropriate location.

Children with long term conditions will receive their care as locally as possible but in a system that is flexible enough to enable them to have direct access to a specialist when acutely unwell.

Acutely ill children who need urgent or emergency care in hospital will be assessed and treated in child-friendly facilities by staff experienced in the care of the acutely ill child, including where necessary, paediatric intensive care units.

Children who require surgery will have this carried out locally wherever it is clinically safe to do so. If children require complex surgery then this will be centralised where evidence shows this delivers a better outcome for the child.

Adolescents will receive care in facilities that are appropriate for their needs rather than in either children’s or adult facilities.

As adolescents move into adult services as they get older, they will be well-educated about their own healthcare needs and have a clear plan about how these needs will be met in adult services.

7The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

Children and adolescents who are terminally ill will have real choice about where they choose to die and parents will be given the right level of support to enable them to achieve this.

Planned care - Far more planned or pre-arranged care will be provided locally in the future.

Patients will be able to manage simple conditions themselves, getting advice when they need it from their local pharmacy or online or by phone from NHS Direct.

If they need to visit their GP practice, they will find it easier to book appointments that are convenient to them. In some cases, they may not need an appointment but can obtain advice from their GP by phone, thus saving them a journey. They may also find that another member of the primary care team is able to help them rather than the GP.

Patients often need a range of tests and investigations to enable a diagnosis to be made. GPs and other healthcare professionals will be able to request more tests and investigations in the future within a clear clinical governance framework. In addition, more of the tests will be available in local settings, including x-rays and some scans.

Patients who are referred to a specialist will be able to book their appointment on line through the Choose and Book system and will be able to choose an appointment convenient to them. They will be able to choose any hospital in the country and they will be able to access information to help them make their choice that will include much more information about, for example, infection rates.

Far more specialist outpatient clinics in the future will be held on an outreach basis in local facilities avoiding the need to travel to hospitals. Some treatment will be available at home in the future, such as chemotherapy.

If a patient requires surgery, this will increasingly be carried out on a day case basis which means that it can also be carried out safely in more local settings.

A section on cancer is included within the planned care chapter of the vision document because one in four deaths in the UK is caused by cancer. Included in the priorities for cancer care are a reduction in cancer mortality for people under 75 years of ages and expanding screening programmes, such as breast, bowel and cervical cancer.

Dentistry also has a section because access to NHS dentistry was raised as a specific concern by patients and the public. Priorities for change include consulting with the public on fluoridation, focusing on prevention and health promotion, addressing health inequalities and improving access to NHS dentistry.

Mental health – The importance of emotional wellbeing – how we feel, think, communicate and understand- will be better understood by the public so the artificial barrier between physical and mental health will be removed and the stigma attached to mental illness significantly reduced.

From Evidence to Excellence - our clinical vision for patient care8

Early identification of mental health problems and preventive measures will be supported. Literature and other health promotion resources will be made available in a wide number of settings.

Services will be easy to access with the early stages of the pathway open to self referral. Most care will be delivered in primary and community settings by an interagency partnership including primary care, secondary care, social care and the third sector.

A stepped care approach will be followed, with interventions at different levels available to the service user, starting with less intensive interventions. There will be clear monitoring of patients’ outcomes allowing treatment to be stepped up or stepped down as appropriate.

Learning disabilities - People with learning disabilities make up about 2% of the population, meaning there are about 86,000 in the East Midlands.

The needs of people with learning disabilities will be recognised, understood and met across public services.

Younger people with learning disabilities will make the transition into adulthood with proper planning, facilitated handover, and with the right support in place.

People with learning disabilities and their carers and advocates will have the main influence in determining the choice and quality of care they are offered.

Health and social care commissioners will develop an integrated, comprehensive approach to ensure the health care needs of people with learning disabilities are met, wherever they live.

All health care services, working closely with social care, the independent sector and the wider community, will be dedicated to promoting maximum independence and quality of life for people with learning disabilities.

Primary and secondary health services will understand the health vulnerabilities and risks of people with learning disabilities, offer effective health promotion advice, check their health regularly and offer care and treatment sensitively and effectively. They will collaborate with specialist services, including mental health, within a stepped care approach, building their own skills and working with specialist colleagues as partners in care pathways tailored to the needs of people with learning disabilities.

Specialist services will be offered in the community, as close to home as possible, to support people where they live. They will be able to intervene in emergency or crisis to help stabilise situations and offer increased support while it is needed. Services will offer intensive and continued support to the most vulnerable, and to those whose behaviour challenges carers, or the wider community. Specialist assessment and treatment services will offer focussed in-patient care, with clear arrangements to support people returning to life in the community.

Staying healthy - in the future, health promotion and the prevention of ill health will play a part in every pathway so that every contact with the NHS and our partners is seen as an opportunity to promote health.

This will begin before birth with advice to women before and during pregnancy. It will continue as children grow up with health visitors advising parents and through health education in schools. It will be a feature of the workplace, leisure centres, pubs and social clubs.

People will be able to access health promotion advice and support from a far greater number of providers in future, including local pharmacies, schools, and children’s centres.

9The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

Patients and the public will be offered programmes which we know work in enabling people to change behaviour. In particular we will focus on smoking, harmful alcohol use and obesity. The aim will be to get people to think differently about their behaviours so they begin to think about and make changes. For those who continue to drink or smoke, we will provide them with the skills that allow them to do so in a less dangerous way.

We will use marketing techniques such as advertising campaigns to help change people’s behaviour.

Long term conditions - care for people with long term conditions will be transformed. People will understand their condition and how to manage it. They will be empowered to access care by following their own care plan, ensuring the transition through the pathway is planned rather than reactive.

The service will be based around the needs of empowered and informed “expert” patients who have continuous support and resources for self care supported by a diverse workforce including GPs, specialists, social workers and educators.

Patients will receive integrated assessment and planning of their health and social care needs and will have access to information to help them make choices.

Services will be based on prompt health promotion, diagnosis and treatment as close to home as possible. Once diagnosed, patients will receive proactive, responsive and integrated care with direct access to specialists where appropriate. All clinicians will have access to centralised up to date information about the patients including a personalised care plan.

Patients who need rehabilitation will receive timely ongoing rehabilitation in a setting that best meets their needs. They will receive timely, appropriate assistive technology to help them maintain their independence.

Carers and families will not be forgotten and will have access to appropriate support and services.

Acute care - If patients need urgent or emergency treatment in the future, it will be much clearer how they can access such services. There will be a single point of access through a single telephone call so that patients will no longer worry over whether they ring NHS Direct, ring the out of hours service, go to a walk in centre or go straight to hospital. The NHS will stop complaining that patients ‘misuse’ the system by making it easier for them to use it correctly.

More care will be provided locally - either at home, at the scene or in primary care. Patients will have increased access to GPs and pharmacies and the ambulance service will play an increasingly important role through schemes like ‘hear and treat’ and ‘see and treat’. More services will be co-located, for example primary care and social care urgent services, so that delays are reduced.

More attention will be given to crisis aversion so that patients already in the system (for example, with a mental health problem or a long term condition) are able to avoid emergency admissions to hospitals.

From Evidence to Excellence - our clinical vision for patient care10

Patients suffering strokes, heart attacks or major trauma will be taken directly to the centre that can offer them the most up to date and effective treatment.

The aim in all cases, wherever care is given, will be to make an early correct diagnosis and give timely definitive treatment. Clinical teams who are the first responders to or the first receivers of all urgent calls or referrals will include or have access to a senior clinical decision maker 24/7.

End of life care - all NHS staff will be better trained in recognising and responding to signs that patients are entering the terminal phase of illness.

Patients will be allocated a key worker who will be their advocate, who will coordinate care and assess, support and review the needs of both patients and carers in the last months of life.

Patients will be given more choice in decisions about care and their preferred place of death. Their choices will be recorded in an advanced care plan that is available to all the team involved in their care and will take away the guess work for future caregivers.

Services will be in place, available 24/7, to respond to the changing needs of patients and carers including rapid response services, hospice at home, hospices.

Carers will have an assessment of their own needs and there will be systems in place to support them if they become unable to continue caring. Bereavement care and support will be available.

The public will become more open about death and dying and people will find it easier to talk about it.

11The full vision and its detailed appendices are available on www.eastmidlands.nhs.uk

Making the vision a realityThe models of care and care pathways are based on the evidence, so many of them are not new. What is new is the engagement of doctors, nurses and other clinical staff with patients and the public in analysing the barriers to delivering the models of care and identifying the enablers and underlying themes which will help us overcome the barriers.

Patients, the public and staff have been involved throughout this process. Overall there was a marked degree of synergy between what the workstreams have told us and what patients and the public felt. In particular we need to:

n Do more to prevent ill health and promote good health

n Make care individualised and personaln Speed up diagnosis and treatment, which is

important because it gives patients certaintyn Provide patients with better information all along the

care pathwayn Help patients navigate complex pathways and

ensure more coordinated care.

What is also new is the commitment to delivery – the agreement of chief executives to make the delivery of this vision through the development of World Class Commissioning their main objective and the focus of the Strategic Commissioning Board. They have also agreed that to deliver it more quickly, there will be an increased emphasis on collaboration between PCTs, with one PCT leading on a key area of work and sharing the output with others.

It is recognised that we need to move quickly and deliver some quick wins to retain clinical engagement and commitment. But it is also recognised that other key deliverables will take longer.

The workstreams looked at what prevents clinicians implementing good practice so that we could learn what has stopped us in the past. They also considered the enablers – the things that will allow clinicians to deliver the evidence-based models of care to provide the highest quality of service for their patients and achieve excellence. The findings of the workstreams can be found in full on our website – www.eastmidlands.nhs.uk

The NHS of the future will be seen to be more clinically led at all levels. It will also engage patients and the public continually, learning to listen to things it may not like to hear, finding a way through the different views that will be expressed and acting on the consensus.

PCTs will continue to engage with the public and patients, including using the membership lists of Foundation Trusts as a further opportunity to engage with interested parties.

The vision will be delivered by commissioning organisations that are world class with explicit and robust processes and skills. The outcome of this will be:

n Services based on clinical evidence and best practicen Demonstrable improvements to health outcomes n Reduction in health inequalitiesn Greater patient satisfactionn Increased public confidencen Greater NHS staff satisfaction.

Chief executives have agreed that this will be the main focus of the work of their organisations during 2008. By focusing on continuous quality improvement, underpinned by clinical and public involvement, we can ensure that our health system delivers our six promises: 1. A positive experience for all our patients,

where everyone is treated with courtesy and respect, and personal dignity is a priority. A service which offers real choices where patients and their carers have influence and are involved in decisions about their care

2. Accessible, convenient and flexible services, available promptly and equally to everyone where proper consultation means real influence on how services are delivered

3. Safe, high quality, effective care delivered in modern clean hospitals and surgeries where clinical quality delivers excellent outcomes

4. Well run, efficient services delivering best value for tax payers’ money where transparency allows proper scrutiny

5. A steady improvement in health and reduction in inequalities between the most and least deprived.

6. We will create a system where we involve, listen and are influenced by the views of our patients, the public and our clinicians.

Please let us know what you thinkWe want to continue to hear from individuals and groups on what you think about our vision. If you would like to comment, you can either:

n Complete this page and post it to:

Next Stage Review teamNHS East Midlands Octavia HouseInterchange Business ParkBostock’s LaneSandiacreNottinghamNG10 5QG

n or email your comments to ournhs@eastmidlands.nhs.uk

Name:

Address:

Email:

Comments:

From Evidence to Excellence - our clinical vision for patient care12

✂✂

Designed and published by Brainstorm Graphics, The Old Stables, rear of 8 Carlton Road, Worksop, Notts. S80 1PH. Tel: 01909 509105

East MidlandsStrategic Health Authority

Octavia HouseInterchange Business ParkBostock’s Lane, Sandiacre

NottinghamshireNG10 5QG

Tel: 0115 968 4444Fax: 0115 968 4400

Web: www.eastmidlands.nhs.uk

East Midlands