Strategic Clinical Networks The holy grail of integrated care
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Transcript of Strategic Clinical Networks The holy grail of integrated care
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Date September 17
Strategic Clinical Networks
The holy grail of integrated care
DEBateman NCD Neurology
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12 SCNs in England
4 million people per SCN
700k per SCN with a neurological condition
What are they for?
What can they do?
How can they do it?
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Strategic Clinical Networks
Large geographical area
Connect the network & join up care
Coordinate complex care pathways
Designed around patients’ needs
Unique opportunity to do this with support
• Permanent structures for continued improvement
Never achieved previously
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Why is this so important?
Current spend 5.3 billion!
No more money!
Service redesign
Change of roles
Permanent structures for continued improvement
Neurology conditions ideally suited to this approach
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Problems with neurology services
Poor care
Poor access to care
Poor value for money
Lack of expert staff
Lack of clear pathways of care
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What are neurological conditions?
Common disorders
Headache & migraine 90% life time prevalence in women
Life threatening
Meningitis, encephalitis, SAH, GBS, status epilepticus
Rare but difficult
MND,myasthenia, mitochondrial disease
Long term conditions
Parkinson’s disease 1 :1000
Multiple sclerosis 1:800
Epilepsy 1:250
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Where & how ?
Access to care?
3 ways
Acute emergency
Scheduled care OP dept
Long term care
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What is commissioned?
Neuroscience specialist commissioning e.g. rare neuromuscular disorders
Tertiary rehabilitation in some areas NSC
OP scheduled care CCG
What about acute and long term neurology conditions?
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What do patients want?Neurological Alliance
Local service
Quick & accurate diagnosis
Rapid access to expert support & Rx
Support to self manage their condition
Reduced admissions & LOS
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Acute neurology servicesunder the radar!
1 : 10 admissions - Neurological
3rd most frequent speciality after cardiology & respiratory
Current process : triage to general physician
inappropriate care due to unavailability of local neurologist
Delay in referral & misdiagnosis
Increased LOS
Inappropriate use of investigations
Great concern but no champion! (charity or GP)
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NASH
41% DGH no policy for acute seizure care
35% DGH no policy for status epilepticus 10% mortality
48% DGH no policy of further referral
66% known epilepsy
3.5% admitted to a neurology ward
% admitted greater than for COPD
52% access to epilepsy nurse
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Can this be done better?
Liaison neurology
75% seen within 24 hours
Halves LOS
30% change in diagnosis
Management change 80% Epilepsy patients
Reduced costs saving 150K in typical DGH
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Leeds model (Dunn)
• Daily consultation service to Acute Medicine
• 3 Liaison Rounds on Acute Medical Unit
• 2 Acute Clinics, direct access for Acute Medicine
• Training in Acute Neurology
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Leeds model
LOS 8 days to 2 days over nearly 10 years
For 200 patients this is a Saving of about 500k
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Inequity
Why should the standard of care be different to :
Acute stroke?
Gastroenterological emergencies etc.?
Epilepsy deaths and admissions static past 10 years
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How?
Modify neurology DGH job plans to include liaison work
Appoint acute neurologists
Emergency clinics to prevent admission
Reduce scheduled care- see later !
CCGs to commission and DGHs to provide acute care
from neurologists
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Neurology OP clinics (scheduled care)
↑by 10 % per year
1 : 125 adult population see a neurologist in OP
In some areas majority seen in the centre (40%)
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Who is seen in the routine OPD?Is this good value use of
neurology?
20 % headache
70% migraine & tension headache
30 % no neurological diagnosis
Functional & psychological 16%
Epilepsy 14%
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How can this be improved?
Intermediate H/A & Epilepsy clinics
more economical
better patient satisfaction
GPwSI to filter referrals for a group of CCGs
E mail triage of referrals
• ↓ by 40% patients seen
NeuroMail/telephone clinics
Remove chronic neurology- see next!
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What are long term neurological conditions?
Life time prevalence Ep,MS,PD & others
6 per 1000
3000 patients in 500K population
25 % never seen a PD nurse
60 % trusts have no epilepsy nurse
PD nurses reduce consultant time by 40%
Admission rates ↓ by 50 %
Self funding !
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Who should look after them & how?!
Key worker NOT neurologist!
NeuroCare teams i.e. stroke care
Led by GPwSI supported by local neurologist
MND,epilepsy,MS,PD & other LTC
Specialist nurses & AHPs
Continuing health care teams
Social care integration
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Suggestion 1NeuroCare teamsNeuroCare teams
Develop local generic neurology networks for long term conditions alongside stroke on a 500k population basis
GPwSI, specialist nurse, AHPS etcMND,PD,MS etc
Improve care, more cost effective
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Suggestion 2
Measures to reduce acute neurology admissions- Savings!
Improve access to neurology opinion in DGH for acute admissions
urgent clinics, liaison neurology sessions, ED protocols
The Dunn model
On a 500 k basis achieved for CVA
7day working (NCEPOD&NASH)
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Modernise OP (scheduled) care
GPwSI headache, epilepsy, general, NeuroMail
GP education programmes
CCG integration in SCN planning
Suggestion 3
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Outcomes
Domain 1 preventing acute illness & dying prematurely
Domain 2 improving QUAL for LTC
Domain 3 helping recovery
Better outcomes & value
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Measuring success?
Patient experience surveys
Clinical audit tools
Disease registry
Neuro navigator :
web based tool for patients carers health staff
Accountability, responsibility
PAC committee