An integrated approach: the transferability of the winning principles: sharing the learning

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Transforming Inpatient Care Programme
An integrated approach:
The transferability of the Winning
Principles - Sharing the learning

An integrated approach: The transferability of the Winning Principles - Sharing the learning | 3

Contents
Foreword 4

Introduction 5

Transferring the Winning Principles through integrated working 6

Testing the transferability of the Winning Principles 8

Winning Principle 1 and 4 - Single point of access for cancer patients 9

Winning Principle 1 - How existing good practice in long term 14
conditions can benefit lung cancer patients

Winning Principle 1 - A primary and secondary care clinical 18
management pathway for all patients with acute urine retention

Winning Principle 4 - Self management programme 21
for cancer patients and carers

Lessons from other integrated working communities 24

A practical service improvement framework to support 25
integrated working

Challenges faced and overcome 26

Key learning - Patient and carer experience 27

Achieving integration - 12 recommendations 28

Conclusion 29

Appendices 30

Websites and useful reading 32

Acknowledgements 33

Further information 34

4 | An integrated approach: The transferability of the Winning Principles - Sharing the learning

Foreword
Every person affected by cancer should receive world class services at each stage of their cancer
journey. (The Cancer Reform Strategy, 2007).

A patients’ journey involves many stages, and they encounter a large range of staff from different
organisations providing services to them. The provision of integrated services that provide care in
the right place, at the right time and through the right person or team is paramount.

An integrated approach – The transferability of the Winning Principles shares the learning and
challenges drawn from the experiences of the integrated working communities involved in this
work. The integrated working communities involved a vast range of staff from Acute Care, Primary
Care, Social Care and the third sector communities. All of whom aim to improve services for their
patients, carers, service users and their families.

This improvement work is part of the Cancer Transforming Inpatient Care Programme and highlights
that although ‘integrated community working’ can be challenging the opportunities and benefits
are great for patients and their families.

Dr Janet Williamson
National Director
NHS Improvement


Introduction
NHS Improvement tested the transferability
of the four quality driven Winning
Principles (NHS Improvement 2008). The
aim was to explore if the spread of the
principles could be accelerated through
taking an ‘integrated’ working approach to
support the drive to enhance health and
social care integrated working.

The learning from this testing supports the
new governments ‘commitment to the
continuous improvement of the quality of
services to patients’ (The Coalition; Our
programme for the Government 2010)
and continues to support the delivery of the
Cancer Reform Strategy, Transforming
Inpatient Care Programme (2007).


Transferring the Winning Principles through
integrated working
Five integrated test communities
took on the challenge to spread.

The learning from the integrated test
sites demonstrated that the principles
are appropriate, relevant and Winning Principles
transferable across the health and Winning Principle 1
social care setting. Unscheduled (emergency) patients should be assessed prior to the decision
to admit. Emergency admission should be the exception not the norm.
There has been a decade of
publications and policies that indicate Winning Principle 2
the benefits of health and social care All patients should be on defined inpatient pathways based on their
integrated working. However the tumour type and reasons for admission.
case studies in this publication Winning Principle 3
indicate this is not easy to achieve and Clinical decisions should be made on a daily basis to promote proactive
involved significant challenges, case management.
learning , vast amounts of time and
they have had varying degrees of Winning Principle 4
success and shown that integrated Patient and carers need to know about their condition and symptoms to
working can be achieved, provided: encourage self-management and to know who to contact when needed.

• Relationships are built www.improvement.nhs.uk/cancer/inpatients
• Agreements are reached and
communicated, with services and
systems that are aligned
• Partnership working and decision
making is clearly understood, what
this means and the values that
underpin this
• Responsibility for the improvement
of services is shared.


The case studies, share the learning from
five ‘integrated’ working communities, Figure 1: Discipline of staff involved in integrated working
involving acute care, primary care, social
care, and tertiary services. Over 360
people, including patients, carer's and
staff were involved (Figure 1).
Staff disciplines

0 10 20 30 40 50
Number of staff involved

GP Practice Managers Ambulance Call Handlers
Training Co-ordinator End of Life Facilitators
NHS Direct Clinical Illustraion
PCT Commissioners Pharmacists
Clinical Governance Staff Service Improvement Staff
Information and Data Analysis All Managers Across All Organisations
Voluntary Organisation Staff Therapists
Benefits and Employment Specialist Nurses/Hospitals/Community
Hospice Staff Doctors/Consultants/GPs
Walk-in Centre Staff

‘There are many powerful examples of ways to improve
quality in the NHS while encouraging better productivity.
Together, we need to identify these examples of
excellence, understand why this kind of approach is
successful and actively diffuse this good practice across
the whole health service’
Jim Easton
NHS National Director for Improvement and Efficiency


Testing the transferability of the
Winning Principles
The integrated working communities
tested the transferability of the quality
Winning Principles, 1 and 4.

The following case studies share the
integrated working communities
learning and experiences.


Winning Winning
Principle 1 Principle 4

Integrated testing model: Single point
of access for cancer patients
Sherwood Forest Hospitals NHS Foundation Trust

Background
Trusts local baseline data (2008) on all Figure 2: Emergency referrals by type
cancer related admissions showed
that approximately 70% of cancer 120
inpatient admissions were non 100
Number of patients

elective. Average length of stay for
these patients was 6.5 days (April – 80
Dec 2009) and the majority of these 60
admissions came via A&E (Figure 2).
40
The most common reasons for 20
emergency admissions were:
• Shortness of breath 0
Accident Emergency Emergency Other
• Pain & Emergency Outpatient GP Immediate
• Collapse Referral type
• Diarrhoea, constipation,
dehydration, nausea and vomiting Source: SFHFT Health Informatics Department

As a testing community we agreed to
test the assumption that many of the
patients admitted as emergencies
could have been treated in alternative Integrated testing community -
care settings and admission into what was it?
hospital could have been averted. The testing community included
Bringing care closer to home and 22 organisations across the
valuing patients time. community (Figure 3).

Figure 3: Integrated working community

Sherwood Forest Hospitals NHS Foundation Trust Kirkby Walk in Centre
GP Practices Nottingham University Hospital NHS Trust
East Midlands Cancer Network Beaumond House Hospice
CNCS Crossroads
Social Services Lloyds Pharmacy
MacMillan Local independent pharmacy
Patients and carers Crossroads
Notts County Teaching PCT Department of Work and Pensions
NHS Direct Job Centre Plus
EMAS Nottinghamshire Community Health
Nottinghamshire Health Informatics Service John Eastwood Hospice


Key stakeholders from the What was tested?
organisations were identified early on To address the issues identified it was Included in the scope of testing was
in the work to assist in building agreed to test a single point of access the out of hours provision (OOH) and
momentum and planning for an (SPA) communication model. This the measures of impact were:
integrated cancer service. supported the testing of the • Valuing patient time reducing
transferability of Winning Principles 1 unnecessary waits and delays
Fact finding and visioning events were and 4 and built upon the concept of • % reduction of inappropriate
held during the first four months of Recurring Admission Patient Alerts admissions to hospital
2009 to establish areas of (RAPA) that had been successfully • % of appropriate care delivered
commonality, identify problems that implemented in the Trust. nearer to home.
needed to be investigated and
highlight where testing may be The single point of access was After considering several options the
needed. supported by patients and their carers most appropriate provider for testing
as during the visioning events they the model of a single point of access
Across the community the main stated that they: were Central Nottinghamshire Clinical
‘issues’ indentified were: Services (CNCS). They were able to
• Poor communication and integrated offer dedicated nurses to answer calls,
working between health and social and already had information sharing
care ‘Did not know who agreements with the trust and an
• Inappropriate and rigid systems of understanding of primary and
diagnostics and treatment within to contact and how secondary care. Therefore this was a
care pathways
• Lack of patient empowerment with
to access services use of resources already in place
rather than new financial investment.
care needs.
• Unclear management of emergency
after the end of the
admissions working day.’
• Lack of a clear clinical pathway
• Lack of development promoting Patient carers statement
patient self management support.

Figure 4: The Single Point of Access (SPA)

Patient makes call to
Single Point of Access (SPA)

SPA arranges for SPA SPA SPA SPA SPA SPA No immediate
admission to refers to refers refers to refers to refers to refers to care required
surgical & medical oncology clinical walk in GP for social crossroads for Advice given
assessment units. ward nurse centre assessment services independent or signposted
NOT A&E specialist and/or visit social care

Automated call outcome
sent via email to appropriate CNS


Figure 5: Amount of patients that called SPA (including multiple times)
Testing ran for 12 weeks (October
2009 – January 2010) and involved 82
Tumour site In hours Out of Calls (total)
cancer patients from four tumour
hours
sites: Gynaecology, Breast, Lower
Gastro Intestinal (LGI) and Urology. Breast 16 16 32
Lower GI 3 5 8
Calls were received by SPA call
handlers at CNCS, were dealt with Urology 13 4 17
and then an automated message sent Gynaecology 7 2 9
directly to both an email account and Total 39 27 66
the smart-phones held by the clinical
nurse specialists (CNS), which linked
to the existing successful RAPA
methodology of automated alerts this Figure 6: Calls to SPA who answered in and out of hours
aided clear communication channels
to the relevant clinicians.
5%
Of the 82 patients, 66 calls were
made: 24%
• 41% of the calls were made in the Central Nottinghamshire Clinical Services
out of hour’s period (5pm – 9am), a
Cancer Nurse Specialists
timeframe which currently provides
little support outside of emergency Both CNCS & CNS (separate occasions)
71%
care and can be confusing for
patients and carers to navigate
• 34% of calls resulted in a possible
or definite emergency averted
admission
• 9% of all calls resulted in a primary
care intervention and averted a non
elective admission
• 4% of patients had an expedited Figure 7: Distribution of calls by outcome
emergency admission, bypassing
A&E and resulting in a shorter bed 25
stay 22

• A further 5% of calls resulted in a 20
possible averted admission, all cases
Amount

being resolved in primary care. 15 13
11
10
The following tables and graphs 6 7
provide a detailed breakdown of the 5
5

activity involved. 1 1
0
Info 999 Doctors Tested at Home Nurse District Non CNCS
to key Emergency Advice Primary Visit Advice Nurse Calls
worker Care Centre (CNS &
Tech Faults)
Outcome


Averting emergency admissions Figure 8: Averted and possible averted non elective admissions
and A&E attendances definitions
Where we have confirmed that had
Tumour site Averted non-elective Possible averted
the patient not contacted the SPA and
admission non-elective admission
that 999 would have been called, we
have classified this as ‘averted’. Breast 5 4
Where we have not been able to Lower GI 0 0
directly confirm whether an
emergency admission was averted but Urology 2 0
that it was indeed possible we have Gynaecology 1 0
classified this as ‘possible’. Total 8 4

Benefits and impact
Potential cost savings/capacity Figure 9: Potential cost savings/capacity releasing
releasing
Based on local data from Sherwood Cash flow release Potential bed days released Potential
Forest Hospitals NHS Foundation Trust £ (A&E only based across four tumour groups inpatient bed day
health informatics department standard tariff of (using average LOS of 6.5 cash flow release
(February 2010) from January 2010 £80) days & average tariff of £340)
across the four tumour sites involved Test (3 months 6.5 days x 8 patients = 52 bed days x
£80 x 8 = £640
in testing, there are approximately and 82 patients) 52 released bed days £340 = £17,680
4,255 active cancer patients.

Averting eight A&E attendances
during testing resulted in a saving of
£640 (standard A&E tariff = £80). Valuing patients time • Patient safety, less exposure to risk
Adding the four possible averted A&E For those patients that were admitted of hospital acquired infection
attendances brings the total to £960. during the test, the average LOS was • Improved communication model
Based on eight definite A&E averted 1.5 days. This was five days less than meaning call handlers can
attendances out of 82 test patients the original average length of stay. communicate directly with all
(9.75%) over a 12 month period the This can potentially be attributed to integrated areas.
potential cash flow release at a using the special patient notes and
standard tariff for active cancer improved communication set up for Productivity
patients in the test tumour sites the integrated testing work. • Reduction in length of stay from 6.5
equates to approximately £33,200 a to 1.5 days for those patients
year. The benefits identified from needing a hospital admission
testing the SPA • Potentially released 52 bed days
Quality • Potential cash flow release of
• Delivers care in the most £17,680
appropriate setting
• Reduces pathway delays – three Valuing patients’ time and
patients admitted straight to ward experience
missing out A&E and EAU • Values patients’ time and addresses
• SPA standardises in hours and out of patient and stakeholders
hours care expectations
• Special patient notes aid clinical • Delivers care at home where
decision making as does oncological necessary and where appropriate
emergencies training for call
handlers


• Enables patients to access
information and guidance allowing
for increased ability to self manage
• Reassurance of speaking to a person
rather than being met by an
answering machine enhanced their
confidence and assisted in reducing
anxiety
• Reduction in numbers of delayed
transfers of care demonstrated by
patients going directly to the ward
where appropriate.


Winning
Principle 1

How existing good practice in long term
conditions can benefit lung cancer patients
NHS Coventry

Background Figure 10: Hospital Episodes statistics Data
Working in partnership NHS Coventry,
University Hospitals Coventry and Emergency Ended in death Ended in Ended in Ended in
Warwickshire (UHCW) and Coventry admissions on day of death by death by death by
City Council, had developed an (Lung) admission day one day five day seven
integrated model of care – Care
Outside of Hospital for Long Term 140 12% 24% 45% 50%
Conditions, (LTC).

The aim of the integrated testing was Testing approach: Getting Collating baseline information
to build on this existing infrastructure baseline information for better for better decisions
and test the transferability of the LTC decisions The learning from this process and the
model to improve services for lung A systematic service improvement reality of the experience is shared in
cancer patients. approach was used for testing, this figures 11 and 12 and shows the
included a baseline analysis, and a Acute and PCT process.
What was the issue for lung retrospective notes review on the
cancer patients? initial lung cancer patient cohort.
Coventry had the highest number of Many of these patients were deceased
emergency admissions for lung cancer and notes were held off the hospital
patients across the West Midlands site. Although a well established
Strategic Health Authority (SHA), and approach, the process of undertaking
of the patients admitted 50% died this initial review proved difficult and
within seven days, suggesting that affected the momentum and
they were in the end of life phase of engagement across the integrated
their illness. working community.

Figure 11: The Acute process

Replicated Safe guardian of Room identified Head of Info Notes again
process as per notes niminated - where notes requested to requested
PCT map Director of Nursing review needs to order patient (16 Feb 2009)
& Medical Director take place notes (9 Feb 2009)

Head of Info: Notes to be Head of Info: Acute Trust
delegated notes available by liaise with PCT Executive
retrieval end of week to order intervention
required


Figure 12: The PCT process

HES data Patient identifiers Caldicott Request sent Clarity required
obtained requested approval to audit if this is ‘audit’
(Nov 2008) from PCT data needed at PCT department or ‘research’
department

Request sent Caldicott Guardian PCT data Paperwork not Need to
back to service sign off request department received in request Caldicott
redesign quality given issue job no. 247 relevant Guardian sign
director for clarity (Jan 2009) department off again

All paperwork Caldicott Guardian PIDs identified Sent to acute
resent approval given from PCT Head of trust to order
(Feb 2009) Info (Feb 2009) notes

Finance Process

No budget Agreement from
available service redesign quality
within PCT director to pay for
notes request

Identifying the real problems, Figure 13: Main presenting symptoms The event included staff members
issues and areas for testing from the acute and community
Although the notes review was a Presenting Number of organisations, West Midlands
pains taking experience they did symptom patients Ambulance NHS Trust and staff from
identify that a high proportion of Shortness of breath 42 Coventry City Council.
patients were admitted from one
Pain 23 The pathway day was successful for
particular post code area, CV2.
communication and engagement and
Patients from this area presented as it was agreed that communication
emergencies with a number of and information would be the focus
Gaining Re-engagement across the
symptoms, with the highest number of testing. Two ideas were taken
community
being shortness of breath and pain as forward:
A pathway event was held April 2009,
the main reasons for admission. • Single point of contact for lung
to share the results of the baseline
cancer patients
and to jointly determine across the
• Community directory.
community new ways of working.


Single point of contact for lung
cancer patients
This involved GP practices and
community service providers for the
postal code area of CV2.
A key improvement was to gain
access to the ‘special notes facility’
available on Webaccess. Webaccess is
a system that was already available for
use in all GP practices across Coventry.
This was utilised to share information
regarding lung cancer patients
included in the test cohort. It was a
resource already available and
required no further investment.

Testing was due to commence in
October 2009. However, technical
difficulties delayed the start of the
testing until January 2010. This delay
affected the momentum and
engagement in the work. The testing
period was for six weeks and included
14 GP practices in the CV2 postcode
area of Coventry, which at the time
had 13 patients between them
registered with a diagnosis of lung
cancer.

During the testing period the special
notes facility was accessed for 31% of
patients, none of these patients were
admitted to hospital suggesting that
the enhanced communication and
knowledge of the patient, i.e. access
to the ‘special notes facility’ may have
averted the admission.

The testing of the Webaccess system
for lung cancer patients demonstrated
that it can be utilised successfully, and
does avert emergency admissions.


Community directory for staff • ’There were many issues to be This work fits with many national
A community directory was developed addressed, but the ability to agenda’s, QIPP, Care Closer to Home,
in partnership between primary and generate ideas and innovations for Encouraging Improvements in Medical
secondary health care, social care and testing were not forthcoming Care and Decision Making. Integrated
Coventry City Council to enhance everyone seemed to think it was working supports the message that
communication. Notification of this someone else’s problem’ patient care does involve the whole
was emailed to all staff and GPs • ’An improvement project like this community. A key lesson learned from
involved in the test site. relies on good baseline information, this work is that an important success
but the delays in getting this factor is the organisations involved
It is available to all with access to the information was not identified as a have the ability to relate to one
NHS Coventry website. The directory risk, but it had a significant impact another and have the capability and
provides a comprehensive list of on engagement’ willingness to partner and share.
services, there is a brief explanation of • ’Leadership has proven difficult as This small scale testing indicated the
each of these services with contact originally this area of work was potential, however to take this
details and what patients and carers initiated by only one of the forward and scale up the work,
can expect form the service. organisations involved, with a engagement of all the organisations
dedicated lead for the work, involved must be at the forefront.
Lessons learned and reflections however when the individual moved
This improvement work was based on job roles there was no-one
the understanding that there was an identified to take ‘ownership’ of the
existing successful integrated model of workstream, it therefore lost its
care for long term conditions, and momentum’
that the relationships already • ’During the lifetime of the project,
developed through this work would other events (swine flu, HPV
provide a platform for testing development) took over the time,
integrated working with cancer resources and the key players
patients. However this did not provide available’
the basis for testing with cancer • ’There was no strategic pressures on
patients as had been anticipated. The any of the organisations to fulfill this
question is why? The following are project’s potential’.
observations and experiences from
some of those involved that may help
others when embarking on similar
integrated working.

• ’It has proven difficult to identify a
sense of a shared test initiative in
spite of the involvement of different
organisations and multi-disciplinary
groups of staff’


Winning
Principle 1

A primary and secondary care clinical management
pathway for ALL patients with acute urinary retention
The Lincolnshire Experience

Starting position • 119 (98%) patients had urine Lincolnshire Hospital NHS Trust, ward
A baseline data analysis on 122 retention, some with additional representation, community nursing
urology patients presenting to Lincoln symptoms such as abdominal pain leads, incontinence lead from the PCT
County Hospital revealed: or haematuria, and three patients and director of provider services for
• The average length of stay was five were admitted with a blocked the PCT.
days with a maximum of 57 days catheter.
and minimum of 0 days. After review of the baseline data it
• The largest referral source was 45 A real time data collection confirmed appeared that a large number of
% from GPs followed by: that a disparity in pathways existed for patients were being inappropriately
• 15% GP out of hours patients with acute urinary retention. guided to acute hospital emergency
• 23% patient, self referral Using an integrated approach the aim departments. The group agreed to
• 8% unknown was to test Winning Principle 1 and plan a clinical management pathway
• 4% via the nurse practitioner, new ways of working for patients which, if successful through testing,
• 2% other A&Es, with acute urinary retention that would be a benefit to a large group of
• 2% via outpatient clinic would benefit ALL patients with no patients who would/may go on to
• 1% via nursing home carving out for cancer patients. have prostate cancer or not.
• 113 (93%) of the 122 patients were
admitted as emergencies and It was agreed, as numbers were
catheterised as an in-patient An integrated task with an expected to be small, to initially test
• These patients presented at three integrated team. all males in first time urine retention
entry points An integrated task and finish group presenting from North West and
• A&E 42% was established, the membership South Lincoln Practice Based
• Emergency assessment unit 39% consisted of GPs, consultant urologist, Commissioning Clusters. Although
• Straight to wards 19% clinical nurse specialist from United the group acknowledged co-morbidity

Figure 14: Proposed primary care pathway for male patients with acute urine retention

If TWOC unsuccessful Failed reinsertion
catheter reinserted Patient referred
directly to EAU at LCH

Admitted to Community nurse completes
follow proforma & faxes GP for
alternative referral to urology team in
District nurse to secondary care Minimum Symptoms
pathway make contact Discharge to GP
visit & liaise
with GP
District nurse
GP to review if performs TWOC
(Trial Without Successful Seen by GPSI Maximum Symptoms
Patient Patient sent Discharged for necessary
Catheter) TWOC GP in BPH clinic Referral to
presents to A&E for district nurse 14 days after referral to inc Prostate urology team in
to OOH catheterisation contact visit GP to prescribe
patient to GPSI Symptom Score secondary care
or GP within 48hrs Tamsulosin
commences Flow Rate Referral faxed to
(Alpha Blockers)
Tamsulosin Bladder Scan one number
as per proforma
from A&E
Intermediate
Care If abnormal
Copy of DRE
Intermediate pathway to
Care GP to see be given to
within 24hrs patient
PSA result to
GP to initiate
2WW referral


reasons for admissions it felt that The group compromised from moving The two patients who had their trial
there was a need to test a pathway in the pathway entirely into primary care without catheter in the community
order to: to having the first catheterisation in were seen by day 12 as per protocol
United Lincoln Hospital NHS Trust and patient did not have to return to
• Reduce inappropriate admissions to A&E department. Unfortunately, A&E acute trust for this procedure.
hospital staff felt they were unable to
• Provide an opportunity for accommodate the testing of the new The communication between all
managing acute urine retention in pathway at the time. The group parties in primary care worked very
primary care secured the Emergency Assessment efficiently. The patient who had a
• Promote different ways of working Unit (EAU) as the single point of failed trial without catheter was
and identifying opportunities for access for patients to have their referred to urology team in acute trust
making services available in an catheters inserted. via the GP and this cut the wait for
alternative setting. appointment from 42 days to 11 days.
• Reduce unnecessary lengths of stay Stage one - Acute urine retention
in acute hospitals and value patients pathway The task group felt reassured that
time. Initially testing commenced for a three although numbers were small the
month period. At the end of this principles of the pathway could work
A pathway was initially developed to period only three patients had been and that the original hypothesis had
enable the total management of acute through the pathway, these numbers not changed. The clinical
urine retention in primary care but were less than the period which was management pathway had reduced
after long and in depth consultation analysed for the baseline. It was unnecessary admissions to hospital
there were patient safety concerns intimated at the start by clinical and reduced the number of visits for
and clinical governance issues stakeholders that numbers would be the patient. It was agreed to move
surrounding the training of small but they were lower than forward to the next phase and that
community nurses about first time originally predicted. The evaluation of negotiations should continue with key
catheterisations in the community that stage one identified: people in order to commence the next
were unable to be resolved. stage of testing. However, progress in
this area has been slow. The
membership of the group has
increased inviting colleagues from the
out of hours team to join. Meetings
Figure 15: Stage one - acute urine retention pathway have been held with primary care
PATIENT 1
colleagues to negotiate
commencement of the next stage
A&E with MI
Went in
Discharged
with
TWOC by
community
Successful
Discharged
unfortunately, to date there has still
retention catheter nurse to GP been no sustainable and robust
agreement made to establish the
PATIENT 2 clinical management pathway for
Presented Discharged Admitted with TWOC’d Successful
acute urine retention across the
to EAU with symptoms on the dischrge but health community.
catheter related to ward has since
upper GI died
cancer

PATIENT 3

Presented Cathetered TWOC by Failed TWOC
to OOH by OOH GP community Referred back to urology
nurse team. Seen in 11 days


Good idea - tested - can deliver Buy-in - ownership - responsibility Despite all the challenges and
patients receiving right care in the Gaining buy-in, ownership and difficulties, the principles of the
right place at the right time - so responsibility from all key stakeholders pathway appear to be right and there
what went wrong what have we is not easy and dealing with the are benefits that can be realised and
learned diversity of agendas and differences is support the transferability of the
difficult without strong clinical and Winning Principles.
Clinical champion: During the initial managerial leadership.
testing one of the clinical champions
from the PCT left and it was difficult GP compliance to the pathway
to find another to join with the High quality care does save money
General Practitioner with Specialist and GP are in a good position to take
Interests (GPSI) to help drive the work. this pathway forward and benefit
The GPSI was a great support and more than cancer patients.
helped refocus the group to work
together to progress to next stage of
testing Figure 16: The perceived benefits of the acute urine retention pathway

Eliminating and managing
the risk factors
For Patients
There was a reluctance to reach No attendance at A&E
agreement surrounding first time No admission
Not as many handoffs
catheterisation in primary care and the as original pathway
need to secure a safe environment as Direct referral
back to urology
per local clinical governance team
catheterisation policy. The clinical
governance issues became the focus
point rather than re -examining the
patient care pathway and these issues For Acute Trust Perceived For PCT
were not resolved, but testing moved. Reduction in LOS Benefits Development of
Reduction in of Acute Urine a clear pathway
Further work in this area is required if inappropriate across the
Retention
care is to be delivered in the admissions
Pathway
Whole Health
Community
community.

It takes time
Not to underestimate the length of
For Staff
time it takes to ensure all key Reduction in
representatives from primary and patients returning
to acute trust for
secondary care are round a table, trial without catheter
engaged, have a clear communication A defined pathway
Collaborative
plan and signed up from the working
beginning. Dedicated time was also
allocated with individuals attempting
to overcome ongoing reluctance to
consider changing working practices.


Winning
Principle 4

Self Management Programme (SMP)
for cancer patients and carers
Sherwood Forest Hospitals NHS Foundation Trust

Background
Patients and carer's had raised Figure 17: Out of hours pathway for cancer patients
(EMCN 2008 - data period: 07/07/2008 - 31/12/08)
frustrations regarding unnecessary
admissions to hospital for symptom
Collapse, slips, trips & falls 9 13 26
management. Baseline analysis
Diarrhoae, constipation 18 1 1
showed that four presenting
Emergency 1 4
symptoms dominated, these were
End of life 1
shortness of breath, pain,
Infection 2 6 2
falls/collapse and diarrhoea, which Pain 18 15 4
represented 65% of recorded SOB 33 4 4
symptoms, 76% of these symptoms TIA 3 10

were related or possible related to the Unable to cope 1
patients cancer (Table 1 East Midlands Urinary/urology 6 3
Cancer Network). Treatment related 11 3 1

Bleeding 7

Taking an integrated approach Unwell 4 10 5

to developing a patient Self
0 5 10 15 20 25 30 35 40 45 50
Management Programme (SMP)
A patient self management Related Possible Related Unrelated
programme (SMP) aimed to empower
cancer patients and their carers in
managing their own symptoms was
developed for testing. The programme consisted of a total of • Fatigue
five sessions each session involved an • Benefits
15 different organisations were interactive element. • Social services
involved in the development, bringing • Supporting the needs of carers
different perspectives and expertise. Range of topics covered in the self • Nutrition
The Self Management Programme management programme • Cancer information
would provide advice, support and • Pain management • Complementary therapies
information on symptom • Anxiety and coping • Look good feel better
management, coping strategies and • Breathlessness • Support groups.
living with cancer. • Exercise

Figure 18: Integrated working community

Sherwood Forest Hospitals NHS Foundation Trust Expert Patients
East Midlands Cancer Network Crossroads North Notts
Social Care Services Look Good Feel Better
Macmillan Cancer Support Department of Work & Pensions
John Eastwood Hospice Job Centre Plus
Notts County Teaching PCT Complementary therapists
Nottinghamshire Health Informatics Service Nottinghamshire Community Health
Nottingham University Hospital Trust


Impact and outcomes
A course evaluation (reproduced from Figure 19: How useful was what Figure 20: Where would you rate
you learned? your overall experience of the course?
the Glasgow Caledonian University
Caring With Confidence, Knowledge
and Skills Training For Carers) was 22%
completed by all course attendees on 33%
the final day of the programme and a
focus group was arranged for six
weeks following the end of the course 11%
to evaluate learning. 67% 67%

A pre-course evaluation was
completed on week one and repeated
three months post course to assess
Extremely useful Very useful Very good Excellent
the impact on the attendees everyday
lives. The questions were all based on A little use

symptoms and situations over the last
two weeks and the evaluation was
taken from 'Macmillan New Figure 21: Fatigue
Perspectives course evaluation'. Each 10
Pre SMP Post SMP
of the evaluation areas was scaled 9
from 1-10 with 10 being a negative
(10 being the most problematic)

8
Evaluation scale 1-10

result and 0 being most positive. 7

6
The questions were themed across the 5
following areas: Fatigue, Pain, Stress, 4
Daily Activities (chores, socialising etc)
3
and Exercise. Since attending the SMP
2
67% of all patients felt that their
1
levels of fatigue had decreased, 83%
0
of all patients felt that their levels of Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
pain and stress had decreased and Patient
there ability to perform daily activities
had increased. 100% of patients said
that they had not changed the Figure 22: Pain
amount of exercise they were 12
undertaking since the completion of Pre SMP Post SMP

the course.

10

8

6

4

2

0
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
Patient


The benefits identified from
Figure 23: Stress
testing the SMP
10 Quality
Pre SMP Post SMP
9 • Reduces pathway delays -
8 Integrated working has ensured

7 health and social sectors work
6 together identifying social problems
5 prior to crisis point as opposed to
4 the current pathway
3
• Offer a proactive new model of
2
care
• Delivers care in the most
1
appropriate setting
0
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 • 86% of patients prior to the course
Patient were not receiving their full benefit
entitlements.

Figure 24: Daily activities Productivity
4.5
• 43% of attendees managed an
Pre SMP Post SMP anxiety attack, where they had
4
previously attended A&E for

3.5

treatment
3
• Potentially released 19.5 bed days
2.5
(three patients x 6.5 day average
2 LOS)
1.5 • Potential financial cash flow release
1 of £6,870 (£80 A&E standard tariff
0.5 + £340 bed day tariff x 3 patients)
0 • Techniques taught resulted in
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 prevented anxiety related
Patient
admissions.

Patient experience
Averted A&E attendances • Values patients’ time and addresses
There were 3 (43% of test patients) A&E attendances averted during the test patient stakeholder expectations
due to techniques learnt at the SMP. • Delivers care at home where
necessary and where appropriate
• Empowers patient to access
Cash flow release £ information and services across
(A&E only based standard
health and social care.
tariff of £80)

Test (six weeks and seven patients) £80 x 3 = £240

3 x average LOS 6.5 days =
Potential bed delays released during test
19.5 bed days


Lessons from other integrated working
communities
Two of the integrated communities • Integrated working is the future and
were unable to produce case studies it can work and benefit the whole
relating to their work as they felt the health community, but it will take
work had not come to fruition. years, it's a longer term strategy.
Discussions with these organisations The testing has shown us how
and other (non- test sites) who had difficult this can be but given us
experiences of integrated working valuable lessons to build upon.
highlighted the following complexities • There can be difficulties in
and key areas of learning: establishing a shared purpose and
• Integrated working across aligning priorities across
organisations requires a high input organisations. This requires a
of time and a dedicated resource to managed programme of change.
accelerate the pace of delivery. • Keep the focus on
• Local trusts and organisations are patient/client/carers benefits.
under considerable pressure and
need to balance the day to day This demonstrates the difficulties of
work with trying out new ideas. The establishing a shared purpose and
willingness is there but the reality is alignment of priorities across
that often this is difficult. organisations and illustrates that
• Strong leadership is vital for integrated improvement requires a
integrated working. managed programme of change.
• The cancer agenda is huge and
although seen as a priority by some What theses two sites would have
organisations it is not seen as a done differently?
priority across all organisations • Join the work up - there are lots of
involved. The alignment of priorities separate pieces of service
can be difficult and all the improvement and redesign going
integrated organisations want to on, but they are in silos, separate
gain something from testing. projects.
• Not all organisations want to share • Focus on service improvement that
the burden of improvement. benefits all patients - whole
• Bringing different organisations systems.
together to work on a common goal • Cancer should not be seen
makes common sense, but the separately, we are trying to fit it into
different organisations have existing pieces of work.
different values and cultures and • Dedicated individuals leading the
this can get in the way of progress work.
and needs time to understand. • Be realistic about the time - things
• Forming relationships and trust is take much longer than expected.
the key to successful integrated
working.
• Integrated working can expose the
short-comings of organisations and
people and there are those who will
not wish to take this risk.


A practical service improvement framework
to support integrated working
Using a practical service improvement
framework for testing, the integrated
working communities share the
challenges they faced, and make
recommendations for other
organisations attempting to achieve
integrated working.

Figure 19: Service Improvement Framework supporting integrated working

Processing map Areas for testing
Home to home reviewed for clarity
Identify repetition and rework and agreed

Data gathering Stakeholder event all Develop working
Notes analysis organisations/services groups to take
Patient discovery interviews involved forward testing ideas

Analysis Identify Visioning Is it the
Baseline from What are you Testing cycles right solution to
what is the
different trying to Test out address the
real problem real problem?
perspectives achieve? ideas

Gather patients views

Case for change Agree the Evaluation
Evaluate Plan the redesign and Evaluate the
and check Implementation implementation of the
implementation benefits. What
sustainability improvements
of the tested idea is the difference?

Spread and Outcomes
Patient & staff
adoption reported to
questionnaires
strategy executive groups

Prepare business case What has been the
based on outcomes impact of the testing.
What the integrated sites did impact of testing Quantify


Challenges faced and overcome
The following identifies the challenges the integrated working communities faced and how they overcame them.

Main challenges Overcoming the challenge Outcomes
identified by all sites (what they did)

Engagement/time Establish an executive steering group with appropriate Commitment and enthusiasm from
Engaging strategic and leadership from all organisations involved stakeholders involved in this work.
clinical leadership

Engagement of all key Organise visioning events for all involved across the Tapping into to the power of
stakeholders patient pathway - home to home. patients, extremely valuable

Lead in time Ensure good planning build in realistic time frames

Delivering the same Align the testing work with differing organisational
message for different priorities that meet local/national indicators
audiences/organisations

Overcoming reluctance to Nominate a champion/s in each organisation - create
change a culture of ownership

Reluctance to consider Develop smaller working groups to take forward the
change in working practices areas of testing

Leadership Take a three pronged approach to leadership, Developing a culture that allowed
Achieving appropriate executive, clinical and operational leaders all need to for working in true partnership
leadership across ALL be involved
organisations involved Executive steering groups are helpful for providing
direction

Communication & Develop communication pathways between all Sharing ideas and practices and
coordination organisations involved improving knowledge of each
Organisations need to others organisations
understand each other and
how they differ Building new and lasting
relationships for future working
Complexity of establishing Develop clear, concise, graphical communication and
meetings with multiple process algorithms Improved communication with GPs
organisations averted inappropriate admissions

Ensuring all involved are A news letter is a quick and effective way to Patients and carers learn from peers
aware of progress communicate to a wider audience as well as professionals

Information/data Develop outcome measures at the start of the testing Sharing patient information across
Measuring the impact of organisations involved has been
change Agree methods for data collections relatively easy, with the support of
the right people
Integration of systems Involve people from your IT departments early in the
work

Governance differs across Involve the appropriate people, think wider than the
organisations changes to the service delivery

Distractions Review the scope of the work on a regular basis to Be realistic - some things may need
keep the work on target to take a priority for a short period
of time e.g. Swine Flu campaign


Key learning: Patient and carer experience

The integrated working communities
identified common themes around the
patient/carer experience involving

Communication;
• Lack of and inconsistent Information
• Unclear pathways of care that were
difficult to navigate
• Lack of clarity surrounding where
and who to go to for support
• Patients/carers continue to be
confused about who to contact and
where to go out of hours.

Valuing patients time;
• Admissions into hospital were not
always necessary but became the
default as patients did not know
where to go
• Easily managed symptoms were
presenting as emergencies and
could be managed at home
• Unnecessary long lengths of stay for
patients admitted as an emergency.

Patient choice and preferred
place of care;
• High numbers of emergency
admissions ending in death within
the first 24 - 48 hours of admission,
as integrated working was not
evident and patient choice and
preferred place of care not activated
or communicated.


Achieving integration - 12 recommendations

The integrated working communities demonstrated that integration can be achieved, but that integration in reality is
stretching many organisations. The sites make the following recommendations

1. Communication: Develop a 10. Evaluate and measure: Agree
robust communication mechanism the measurable outcomes across
between all organisations to the different organisations. So all
ensure engagement of all key achieve and can show
stakeholders from the beginning. improvement in the quality,
2. Leadership: Do not commence efficiency and the patients
unless executive, clinical and experience; remember to capture
operational leadership has been and demonstrate the impact and
identified across ALL agree what success looks like.
participating organisations. 11. Time: Do not under-estimate the
3. Patient, user and carer time needed to establish and build
involvement: Listen - Start the relationships. This is crucial and
conversations with the users at without investment in time and
the beginning they really know people, integration is unlikely to
what happens, it happens to be successful.
them! 12. Stability and sustainability:
4. Involvement: Cancer networks Keep testing the strength of the
are a useful resource, they have integrations. A team is only as
the ability to work across good as its weakest link.
organisational boundaries and
bring organisations together.
5. Integration champions: identify
and establish a champion within
each organisation.
6. Engagement and ownership:
‘It takes willingness, determination and a desire from all
Equal playing fields, acknowledge the organisations, teams and disciplines of staff involved
all the issues and ways of different
working, identify the common to overcome the challenges if they are to win through to
denominator with and across all
organisations involved.
deliver services in a truly integrated way to patients.’
7. Win win: Identify the wins for
each organisation aligned to the
organisations strategic objectives.
8. Direction: Establish a steering
group - ensure members have the
necessary skills to action and
influence decisions.
9. Assumptions: Don't make them
and where you have, test them
out- a solution identified as
successful in one area may not
work in another - adapt.


Conclusion

Testing the transferability of the
Winning Principles
Transferring the Winning Principles
into an integrated working approach
to deliver services for cancer patients
and their carers can be achieved.
However what the organisations and
the range of patients, carers and staff
involved in this work have
demonstrated is that this is not easy
to do. It involves significant
challenges, and it needs a real sense
of determination if organisations are
to win through to work in this way.
The test sites have shared with us
their experience of integrated working
and this embraces valuable learning
that will assist other organisations
with the integrated delivery of cancer
services.

This work supports the current health
landscape. Delivering improvements in
access and quality for cancer patients
and their carers will remain a focus of
continuous improvement (Revision to
the Operating Framework for the NHS
in England 2010/11). The programme
will continue to support spread and
disseminate the practical learning
across the NHS to benefit all patients.

An integrated approach: the transferability of the winning principles: sharing the learning

An integrated approach: the transferability of the winning principles: sharing the learning

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