The Map of Medicine in the North West Update August 2009

James WalkerMap of Medicine Programme Lead NW SHA Chief Information & Knowledge Office

NHS Care Record Service

Choose and Book

Electronic Transmission of Prescriptions

New National NetworkPicture Archiving &

Communications Systems

The Map is a Core Component of NPfIT:

GP2GP

The Map of Medicine

The Case for Change in Healthcare!• The requirement to deliver World Class Commissioning• NHS Operating Framework - working in a ‘cash constrained’ environment PCTs judged by results• Developing patient centric services, more personalised care - services closer to home, money

following the patient• More choice of providers including independent sector• More information / knowledge about what choices to make• Greater emphasis on quality of services and outcomes – PROMS – Commissioning for Quality

(CQINS)• Reconfiguration & Modernisation of Healthcare • Patient Safety issues – Need to reduce medico-litigation

US data collated by Professor Bill Runciman, President, Australian Patient Safety Foundation from McGlynn et al; NEJM 2006 Vol 348; p2635-45

Closing the Gap

Semmelweis, Vienna 1847• High rates of death due to puerperal fever (childbed fever) • Women delivered by physicians

or students mortality rate

(13–18%) • Women delivered by midwives

or trainees (2%)

Prof. Klein:

Inadequate hospital ventilation

Prof. Semmelweis:

Handling cadavers prior to delivery

Instituted mandatory hand washing

Mortality plummeted to 2%Best, M et al. Qual Saf Health Care 2004;13:233-234

150 years later...Marshall and Warren – Helicobacter pylori• Published seminal paper in the Lancet in 1983

• NICE guidance 2000; Regimens to eradicate Helicobacter pylori

• 17 years to become standard best-practice

• How many unnecessary gastrectomies and selective vagotomies?

c10,000

Drugs like Thalidomide, Cox-2 inhibitors

Overuse of antibiotics - MRSA and antibiotic resistance

Drug-drug interactions

Others yet to be identified

The Case for Change in the NW

Highest rates for heart disease and stroke

Highest rate for long term mental health problems

2nd highest rates - deaths from cancer and smoking related illnesses

Average life expectancy 3 years less than the UK best

16% people on benefits

Nearly a quarter of children live in poverty

23% of adults binge drinkers

60% of adults overweight or

obese

Which Pathway should I take?

Feeling lucky?

Public Health Team

SUS Data

Diabetes Guidelines

Population profile

Chronic Heart Disease NSF

Internal memorandum

Business Objects Reports

Trust Board Report

My Documents

Draft Service Review

Prescribing data

The Problem

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Blackburn With Darwen B

Blackpool C

Bolton D

Bury E

Central and Eastern Cheshire F

Central Lancashire G

Cumbria H

East Lancashire I

Halton & St Helens J

Heywood, Middleton & Rochdale K

Knowsley L

Liverpool M

Ma nchester N

North Lancashire O

Oldham P

Salford Q

Sefton R

Stockport S

Tameside & Glossop T

Trafford U

Warrington V

Western Cheshire W

Wirral X

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NWSHA Map of Medicine RAG Status January 2008 Map Views

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Blackburn With Darwen B

Blackpool C

Bolton D

Bury E

Central and Eastern Cheshire F

Central Lancashire G

Cumbria H

East Lancashire I

Halton & St Helens J

Heywood, Middleton & Rochdale K

Knowsley L

Liverpool M

Ma nchester N

North Lancashire O

Oldham P

Salford Q

Sefton R

Stockport S

Tameside & Glossop T

Trafford U

Warrington V

Western Cheshire W

Wirral X

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NWSHA Map of Medicine RAG Status April 2008 Map Views

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Ashton, Leigh & Wigan A

Blackburn With Darwen B

Blackpool C

Bolton D

Bury E

Central and Eastern Cheshire F

Central Lancashire G

Cumbria H

East Lancashire I

Halton & St Helens J

Heywood, Middleton & Rochdale K

Knowsley L

Liverpool M

Ma nchester N

North Lancashire O

Oldham P

Salford Q

Sefton R

Stockport S

Tameside & Glossop T

Trafford U

Warrington V

Western Cheshire W

Wirral X

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NWSHA Map of Medicine RAG Status September 2008

= LHCs with Live view on CSC instance

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Ashton, Leigh & Wigan A

Blackburn With Darwen B

Blackpool C

Bolton D

Bury E

Central and Eastern Cheshire F

Central Lancashire G

Cumbria H

East Lancashire I

Halton & St Helens J

Heywood, Middleton & Rochdale K

Knowsley L

Liverpool M

Ma nchester N

North Lancashire O

Oldham P

Salford Q

Sefton R

Stockport S

Tameside & Glossop T

Trafford U

Warrington V

Western Cheshire W

Wirral X

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NHS NW Map of Medicine RAG Status July 2009

= LHCs with Live view on CSC instance

All 24 PCT Led Local Health Communities have their own ‘view’ of the Map of Medicine

NHS NW Objectives for the Map

• To make the Map of Medicine available to all NHS & Social Care organisations

• To inculcate Clinical Ownership & uptake of MoM• To exploit the potential of the Map to support improved

care outcomes to support WCC & Healthy Horizons• To facilitate improved Clinical Governance• To implement an ‘evidence based’ knowledge tool• To implement a sustainable MoM Programme• To make the Map of Medicine a single point of

reference for patient-centric care, regardless of where care is delivered: Primary, Secondary or Tertiary Care

• Developing a vision for the Map to support improved care outcomes in NHS NW

Context - Current Status

• Sponsor - Alan Spours the NHS NW Chief Information & Knowledge Officer (CIO) is driving the national NHS CIO network for MoM adoption

• SRO Dr Andy Coley’s NHS NW Chief Clinical Officer & Co-Founder of Clinical Leads Network www.cln.nhs.uk

• SHA resources in place to implement MoM & raise awareness• 100% Technical enablement of MoM in the NW• Utilisation of MoM in 22/24 PCT Led Local Health Communities• Strong clinical engagement• Utilising MoM to improve & standardise health care provision• Utilising the Map to support enhanced quality of care in NW• Striving to win ‘hearts & minds’ of clinicians• At the early stage of a move towards BAU for MoM

Facilitate Redesign & Delivery of Health Services:

Delivering Patient Centred Services

Empowering Patients & Clinicians

Improving Quality of Health Care

Delivering Seamless Services

Making Better Use of Resources

Objectives of Map Roll Out in NHS NW - What Are We Aiming to Achieve ?

The Map of Medicine is developed In partnership with clinicians and….

What is the Map of Medicine?

Framework for sharing clinical knowledge across care settings

Localisable benchmark for clinical processes

Evidence based care pathways available in any setting

Saves re-inventing the content wheel locally

Access is via Smartcard and from within N3

How do I access the Map?

Patient Access via NHS Choices website http://healthguides.mapofmedicine.com

• Registration Authority – process by which users will gain access to NHS Spine applications:e.g. MoM, Choose & Book, ETP & Summary Care Record Service etc

• Access to services by smart card• Single sign-on process described during

procurement

Registration Authority – Process

Users Smart CardPlus PIN

NASP and LSPapplications

Trust PC

LocalNetwork

/ N3

SmartCards – Will Look Like This..Chip & PIN - Only a lot better looking!

James Walker

Modernisation Programme Manager

E&N Herts NHS Acute Trust

There is a clear need for improving knowledge management

• “The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.”

• J A Muir Gray, Director of Clinical Knowledge, Process and Safety - Connecting for Health, NHS

Improved knowledge management can help prevent and minimise:

• Errors and mistakes

• Poor quality healthcare

• Waste

• Variations in policy and practice

• Poor patient experience

• Overenthusiastic adoption of interventions of low value

• Failure to get new evidence into practice

Localising the Map of Medicine

Localising the MapLocal Administrative Information

– Adding administrative detail • e.g. contact details, clinic

information, opening times etc.• links to websites or intranet sites

– Simple process

Clinical Localisation– Changes to the national care

pathways• adding, changing or deleting

information – More complex involving stringent

local clinical governance

•Improve communication of local information and local patient pathways

•Increase relevance as a knowledge, governance and communication tool

•Gain local ownership, adoption and support

•Knowledge sharing of international evidence & best practice

•Opportunity to map current practice

•Undertaking service redesign to:meet government targets e.g. 18 week RTTsupport Practice-Based Commissioning

•Improve transparency and communication across:care settings (community/primary care/secondary care)

related departments sectors

Rationale for localising the Map

Supporting the Independent Sector

• ‘IS CATS Provider Care UK Provide Clinical Services to 10 Greater Manchester PCTs– The use of the Map will improve the quality of referrals into GM NHS

CATS as well as secondary care AND improve the quality of discharge summaries

– IS CATS manages patients in the top 6 specialties: musco-skeletal medicine including orthopaedics & rheumatology, ENT, Urology, General Surgery and Gynaecology for 30% of these referrals for the 3rd largest city in the UK

– IS CATS Provide services for part of the Pt journey– The Map Pathways are visible across the GM Region in Primary & Acute

Sector– Provides transparency for referral criteria & the Pt journey– Clinicians from primary and secondary care clinicians agreed that the

management of such patients on 50 Pathways should be based on the pathways in the Map of Medicine to ensure quality

Commissioning – Modernisation Developments communicated via Map of Medicine in the Wirral

AMD Pathway ModernisationQuantitative Benefits

Qualitative BenefitsPatients were waiting 10 weeks for appointments, this has been reduced to 3 weeks. A real risk of patients losing their sight has been addressed.

Data from 2008 is showing a saving of around £500 per patient for 30 patients per month

This single pathway development will save approximately £180,000

There are 100 pathways in development on the Wirral. Potential savings can be assessed from all of these:

Map Supporting ReconfigurationCumbria PCT reconfiguration programme ‘Closer To Home’

•Referral Management based on the Map of Medicine Care Pathways. •Referral Criteria reviewed with clinicians and published on the Map

In 2007/08, Cumbria PCT spent £12.5M on first referrals which was £406k above expected (based on the England average). Potential savings can be assessed:

£1M could have been saved if the 22 most extreme performing practices reduced their referrals to match the England average.

£624k could have been saved if 10 practices reduced their referrals to match the England average.

If this benefits work were applied to other workstreams the return could be huge, they need to be quantified and realised in one or two areas and then cascaded across the organisation and quantified.

Date source NHS Comparators data, https://nww.nhscomparators.nhs.uk/NHSComparators/Login.aspx

Map Supports World Class Commissioning

– World class commissioning will deliver better health and well-being for all:

– People will live healthier and longer lives – Health inequalities will be dramatically reduced.– It will deliver better care for all:– Services will be evidence-based and of the best

quality – People will have choice and control over the

services that they use, so they become more personalised.

– It will deliver better value for all:– Investment decisions will be made in an informed

and considered way, ensuring that improvements are delivered within available resources

– PCTs will work with others to optimise effectivecare.

– The Map supports WCC Objective 5 – Provide ‘evidenced based care’

The Operating Framework signalled that incentives and interventions will be directly linked with Commissioning Assurance

“PCTs …be held to account for, and rewarded for, their development towards world-class commissioning through one national assurance system that will focus on commissioning outcomes, competencies and governance”

Operating Framework 2008/09, page 46

Map Supports Advancing Quality

• Supporting ‘Advancing Quality’ (AQ)– AQ a NW SHA World Class Quality Programme– AQ incentivises Acute Trusts to consistently deliver

Quality– AQ Indicators to be embedded in the Map of Medicine– Primary Care see Referral Criteria– Acute Trusts are rewarded to ‘Quality Care’

Advancing Quality Focus

• 5 Clinical Conditions

- Acute myocardial infarction (AMI)

- Heart failure

- Community Acquired pneumonia

- Coronary artery by-pass graft (CABG)

- Hip/Knee replacement surgery

• 105 Clinical measures

• 3 year project evaluated Oct 2003 - Sept 2006

• Hospitals in top 2 deciles rewarded for quality scores

Advancing Quality Indicators tobe embedded in the Map of Medicine

• Evidence based consensus clinical measures• Examples –

Aspirin at arrival (AMI)

Prophylactic antibiotic 1 hour prior to surgical incision (H&K)

Smoking cessation advice /counselling (CHF)

Blood culture collected prior to 1st antibiotic administration (P)

In patient mortality rate (CABG)

Map Pathways are end to end

Acute Hospital Acute Hospital

Acute Hospital Acute Hospital Community Hospital Community Hospital

Community Hospital Community Hospital Mental Health Trust Mental Health Trust Mental Health Trust Mental Health Trust Primary Care Trust Primary Care Trust

Primary Care Trust Primary Care Trust GP Practice GP Practice

GP Practice GP Practice

Diagnostic & Diagnostic & Treatment Centre Treatment Centre

Diagnostic & Diagnostic & Treatment Centre Treatment Centre Community Community PharmacyPharmacy

Community Community PharmacyPharmacy Social Service Social Service Social Service Social Service NHS Direct NHS Direct

NHS Direct NHS Direct

Ambulance Trust Ambulance Trust

Ambulance Trust Ambulance Trust

Integrated Working Integrated Working Integrated Working Integrated Working

Patients cross organisational boundaries Patients cross organisational boundaries Patients cross organisational boundaries Patients cross organisational boundaries

407 Pathways Available to patients via NHS Choices website

http://healthguides.mapofmedicine.com

•Supports PROMS•Supports CQUINS•Supports PALS•Supports Darzi Quality Indicators

The Map supports Quality Measures

Culture v Technology

“The significant problems we have cannot be solved at the same level of thinking with which we created them! –

Albert Einstein

Increasing Clinical Workload!

• The Map of Medicine offers high quality clinical information visualised in over 400 patient pathways. It serves as a single healthcare knowledge source that will speed the delivery of evidence based best practice across healthcare organisations; this evidence is continually monitored, reviewed and updated. The Map of Medicine is endorsed by the NHS and the NHS National Library for Health (NLH) and is developing initiatives in partnership with the NHS Institute they work closely with the Royal Colleges, including the Royal College of Physicians & the Royal College of GPs . The Map also work with NICE and the National Patient Safety Agency

• The Map of Medicine is working with EMIS & TPP to develop integration, they are also working with InPS and iSoft, and engaging with Out of Hours plus Acute suppliers i.e.Lorenzo & Cerner, it is anticipated that integration will be incremental from 2009 onwards.

Benefit summary

Patients • 407 Pathways available to patients on www.nhs.uk or

http://healthguides.mapofmedicine.com Patient pathways online.• Increased patient confidence as pathways are evidence based• Improved communication across organisational boundaries• Increased patient safety through access to informationNHS staff• Easier access to up-to-date information, 24 hours/day• Supports healthcare planning, PbC reconfiguration, modernisation• Enables demand management – Appropriate referral information• Facilitates coordination between Health & Social Care• Supports 18 Week RTT targets• Provides knowledge support• Supports Clinical GovernanceGP practices• Timely access to information to support patient care• Clinical Governance updates• Improved communication (Information Governance)

• Improved Pt safety, online access to BNF/NLH specialist libraries• Supports Continuous Professional Development (CPD)• Out-of-Hours patient care will be based on up to date pathways

Programme Impact Summary – Map of Medicine

Primary impact on

GP practices: Awareness of changes to core business processes.

• Information Governance• Clinical Governance

Communication NICE, NSF Data Set Change Notice changes

• Integral to Modernisation• Supports PBCAcute Care• Improved communication• Improved Pt safety• End to End Pt pathwaysUnscheduled care settings:

A&E, OOH awareness of local business process redesign.

PCTs: Reconfiguration, Planning resources; Management of clinical & patient informationSupports PBC

Key dependencies

Internal •Clinical ownership•CEO ownership across LHC •LHC Governance arrangements•LHC resources•Practice based Commissioning•Advancing Quality Programme•Smartcard access •Stakeholder engagement•World Class Commissioning

External •Map of Medicine•Acute ownership/engagement•GP practice sign up •Urgent and emergency care resources•Local Service Provider – Key Supplier of NHS systems as hosts for HW•Integration in strategic clinical solutions: GPSoC, CaB, Lorenzo, Cerner, Out of Hours

.

Programme overview / objectives

NHS NW Vision for the MapWhat By Whom By When

Optimise the delivery of Quality Healthcare in the most appropriate setting by technically enabling access to the Map across the NHS NW - Completed

JW April 2009

Embed the use of the Map of Medicine as a key strategic tool for reconfiguration/modernisation

JW October 2009

All 24 PCT Led Local Health Communities to use the Map of Medicine as a core tool for Commissioning of Services

JW March 2010

Embed the Map as a core tool for providing clarity and transparency for who does what in the clinical process

JW March 2010

Embed the Map of Medicine as a core tool to support World Class Commissioning JW March 2010

Embed the Map as a Core tool to support the delivery of Transforming Community Services JW March 2010

Embed the Map as a core tool to support ‘High Quality Care for All’ Include the Map as a reference tool in the ‘quality metrics’ process

JW March 2010

Include the Map as part of the NHS NW SHA response to ‘Measuring for Quality Improvement’,

JW March 2010

Include the Map as a core tool to support the NHS North West Quality strategy JW March 2010

Inculcate the Map as a tool to support the SHA Quality Boards, Quality Accounts and Quality Observatories.

JW March 2010

Raise awareness and adoption of the Map of Medicine by patients and carers across the NHS NW http://healthguides.mapofmedicine.com on the NHS Choices Website

JW March 2010

Include Pathways and the Map of Medicine in GPSoC & Choose and Book contract renegotiations

JW September 2009

To embed the Map of Medicine as part of the NHS North West Deanery agenda JW March 2010

Darzi &

the Map

in the NW

Map Logins 2007/08

12.5 %

12.5 %

12.5 %

12.5 %

12.5 %

12.5 %

12.5%

12.5 %

Map Logins 2008/09

The Map of Medicine in the North West a significant Change Management Programme

A programme that will only succeed with clinical ownership www.cln.nhs.uk

Thanks…..

NW SHA Map of Medicine lead

James.walker@northwest.nhs.uk