Fracture Liaison Service Case Study: Service improvement with additional

fundingThe Haywood Hospital

Zoe Paskins @zpaskinsSenior Lecturer and Honorary Consultant Rheumatologist

Haywood Rheumatology Centre, Stoke on Trent Keele University

Overview: a story of 2 parts

• Service expansion: our ‘journey’

• Other service improvement initiatives

Stoke-on Trent

Our FLS: Nurse-led one-stop clinicCatchment (acute Trust) 500,000

Fracture Liaison Service first commissioned by SoT PCT 2009

Physical presence in fracture clinic to identify patients – mornings only

One stop clinic for DXA, assessment, lifestyle

advice, bloodsTreatment

recommendations to GP

£

Letter to GP recommending referral

in to clinic

££ Rheumatology tariff, WL

Bad for

• Patients

• GPs

• Commissioners

Lessons learnt:Number 1

Be prepared with all the arguments for commissioners – ‘moral’ and financial

2012-3

Fracture liaison Service first commissioned by SoT PCT

2009

2012/13Business case first submitted

to NS PCT

2013-4Fracture liaison

Service first commissioned by

SoT 2009

2012/131st Business case

submitted to NS PCT

1st Business case approved in principle …

Commissioners left2013/14

June 2014Clinical Lead of service changed

2014

Fracture liaison Service first

commissioned by SoT

2009

2012/13Business case first submitted to NS

PCT

Business case approved in

principle Commissioners left

2013/14

June 2014Clinical Lead of service changed

Peer review of osteoporosis

serviceOct 2014

NOS involvement

Peer reviewCommissioning workshop Face to face - help sort prioritiesBy e-mail - draft documents – service spec,

business case v 2.0, cost analysis

Lessons learnt:Number 2

Attendance at these meetings is really important!

NOS involvement

Peer reviewCommissioning workshop Face to face - help sort prioritiesBy e-mail - draft documents – service spec,

business case v 2.0, cost analysisMeeting with commissioners - moral support

Fracture liaison Service first

commissioned by SoT 2009

2012/13Business case

first submitted to NS PCT

Business case approved in

principle Commissioners

left2013/14

June 2014Clinical Lead of service changed

Peer review of osteoporosis

serviceOct 2014

Jan 2015Business case

re-visited

Verbal agreement to commission

Jan 2015

Fracture liaison Service first

commissioned by SoT 2009

2012/13Business case first submitted

to NS PCT

Business case approved in

principle Commissioners

left2013/14

June 2014Clinical Lead of

service changed

Peer review of osteoporosis

serviceOct 2014

Jan 2015Business case

re-visited

Verbal agreement to commission

Jan 2015

No contractJuly 2015

• No written confirmation of approval received (or money, or contract) despite chasing ++

• We started tentatively to clear waiting list (overtime)

• New staff posts not approved without contracts• Morale of existing staff suffering

• Then.. An email about something else, to someone else

(part of) my reply

“……………….This is also particularly embarrassing given that the National osteoporosis Society have highlighted our FLS unit in a recent high profile journal article and cited the case of Stoke as a commissioning success. They are in constant contact with me about the progress on this venture and I should not like to have to tell them that the CCG are only prepared to fund a partial service.”

Lessons learnt:Numbers 3,4 & 5

Follow up all meetings with something in writing

Keep staff informed all the way

Using clout of NOS?

June 2014Clinical Lead of

service changed

Peer review of osteoporosis

serviceOct 2014

Jan 2015Business case

re-visited

Verbal agreement to commission

Jan 2015

No contractJuly 2015

August September

2015 – commissioned

Peer review of osteoporosis

serviceOct 2014

Jan 2015Business case

re-visited

Verbal agreement to commission

Jan 2015

No contractJuly 2015

August September 2015 – commissioned

Our next mission: South

Staffs 2017

Email to someone else, about something else… June 2015

“We therefore request that you provide a response outlining how you will deliver the FLS within the identified cost envelope including a trajectory for the management of the backlog as unfortunately there will be no additional money to fund this.”

End of part 1!

Other service developments: peer review driven

“Opportunity to refine the FLS-DXA-OP clinic pathway cutting out the GP step”

Solution: LMC not CCG!

“Review roles – including .. job plan review, line management”

One of the solutions:

“There is little evidence of integrated and seamless care across secondary, community and primary care”.

Solutions?

• 72 responses!

• >10 GPs gave emails for future contact

• Lots of helpful suggestions Reduced length of report Changed policy on blood results

Service away (half) day• The task:How do we demonstrate our excellence?What are our key outcomes?How can we deliver better value/ be more efficient?How do we deal with increasing referral rates?How can we be more patient centred?

• (Some) actions/outcomes: Evaluation of our helpline

Patient feedback on all elements of service

Changed follow up policy for DXA

Invite patients to our service meetings/ future away days

Summary

• Importance of maintaining follow up with commissioners after initial agreements

• The value of NOS peer review

• But.. You don’t need a peer review to improve your service!