Meeting the challenge together... delivering care in the most appropriate setting

NHSNHS Improvement

Transforming Inpatient CareProgramme for Cancer Patients

Meeting the challengetogether... delivering care inthe most appropriate setting

HEART

STROKE

CANCER

DIAGNOSTICS

Supporting delivery...

Contents

Foreword 4

Introduction: Question: Why focus on cancer inpatients? 5

Delivering care in the most appropriate setting 8• National programme overview• New models of care: Transforming Inpatient Cancer Care• The Winning Principles

Testing, spreading and sustaining 10

Step One: Getting started 10• Planning and engagement• Base-lining: Cancer Commissioning Toolkit• User involvement

Step Two: Measuring quality that is fair,personalised, safe and effective 14

Step Three: Capturing the learning of testing,spread and sustainability 17

Useful resources 18

3Meeting the challenge together... delivering care in the most appropriate setting

www.improvement.nhs.uk/cancer

4 Meeting the challenge together... delivering care in the most appropriate setting


The Cancer Reform Strategy set out the benefits both for patients and for the NHS oftransforming inpatient care for cancer patients. Too many patients are being admitted asemergencies when, with suitable planning, alternative models of care could have been put inplace. Once admitted, the length of stay is often unnecessarily prolonged because of failureto define and implement inpatient care pathways and because of delays in decision making.Better education for patients would lead to self management approaches which could alsoreduce unnecessary admissions.

The Transforming Inpatient Care Programme, led by NHS Improvement – Cancer and theNational Cancer Action Team, has been established to support local initiatives to improveinpatient care for cancer patients. Pilot sites are now starting to test new ideas working withpartners in primary care and social care.

‘Meeting the challenge together... delivering care in the most appropriate setting’ has beendesigned to support the pilot sites but will also be of interest to other organisations attemptingto reform inpatient care. It builds on the ‘four winning principles’ that were identified fromprevious testing. Key to the success of this phase of the programme will be spread andsustainability to achieve the maximum impact. It is vital that we capture learning fromindividual pilot sites, both about what does and what does not work, in order that thebenefits are optimised as soon as possible.

Mike Richards

National Cancer Director

Foreword

Question: Why focus on cancer inpatients?• Answer: To ensure quality that is fair, personalised, safe and effective



• Answer: To promote partnership working, the alignment of systemsand combined leverage for improvement

• Answer: Because it’s an area that’s had little attention

My time in hospitalwas their time,not mine.‘’

Andy’s reflections

My name is Andy Millward. I am a 55 year old man,who was diagnosed in October 2004 with metastaticprostate cancer, a form of site specific cancer that wasso advanced that I was only given eighteen months totwo years to live. I am very fortunate, in that I havethus far been able to defeat that timetable andprognosis, but the majority of my subsequenttreatment has been successfully managed whilst athome, which is very much where I, along with manyothers on similar cancer journeys, wish to be. I havehad two hospital admissions since then, both via theemergency pathways at my local hospitals and bothadmissions related primarily to severe pain. Theprocess of accessing inpatient care was both difficultand traumatic for both my wife and I andunnecessarily burdensome, as we had to negotiate verydifferent processes and locations to eventually arrive atthe oncology ward that could attend to my specificdifficulties.

I cannot fault the level of care offered as aninpatient (and in line with many of the audits that Iknow have been carried out, some of my time wasspent unnecessarily on general medicine wards).However, whilst recognising that staff who haveresponsibility for us have serious considerations of riskand clinical governance to consider, I think we aspatients could be given more responsibility andinnovative resources to manage more at home. Fromexperience, I do also believe that I could very easilyhave been discharged sooner, thereby shortening mylength of stay. This is the real challenge for all of usand I therefore warmly welcome the launch of thenational strategy on in-patient care and potentiallikely alternatives to managing cancer journeys likemy own away from hospital.We also need to ensure that even if acute admission isabsolutely necessary – and not just a default positionof the system – that treatment and care in hospital iskept to an absolute minimum.

Andy Millward,Nottingham (September 2008)

Answer: There are some key interfaceswith the social care system

Firstly, the whole system is acknowledged to becurrently unsustainable due to the gap betweenfunding and demographic and demand pressures. TheGreen Paper, currently in design phase, will beaddressing this. Whatever the answers, it can beassumed that funding will remain very tight.

Secondly, improving the inpatient experience does tosome degree depend on social care, especially if thereare plans to reduce lengths of stay, move care closerto home and support early discharge. Taking thistogether with funding pressures, it will require wholesystems solutions involving social care, includingensuring that financial incentives work for social aswell as primary/community care.

Thirdly, the Government’s Putting People First(December 2007) transformation programme presentsthe system with the challenge of transforming theway in which services are delivered to put control inthe hands of service users and carers. By 2011 allservice users of social care will have the right to useindividual budgets to choose how their care isarranged, and those who fund their own care will beoffered the same level of advice and support as thosereceiving state funding. In redesigning pathways,account should be taken of how choice and controlwill operate for patients.

Fourthly, each region now has coordinatedarrangements for care and support improvement, withJoint Improvement Partnerships overseeingprogrammes of work, and Regional Improvement andEfficiency Partnerships allocating what funding there isin a coordinated way. It is important that any healthsystems improvement work is able to link to thesenew arrangements.

Simon WilliamsDirector of Community and Housing,National Lead for Urgent Care

(User feedback)



Q U E S T I O N :• Answer: Because it matters

to patients



Answer: A move from a care deliverychain to a whole care system

Delivering the next stage of the Cancer ReformStrategy will require increased levels of integratedworking alongside substantial redesign of services toensure that services are relevant and responsive toservice users. Commissioners have a vital role inleading thinking on new services whilst supportingproviders to work together, innovate and thinkdifferently about the scale, scope and style of serviceswhich will be required outside of traditional settings.Commissioners will need to set out clear servicestrategies which focus on supporting an increase infor example self-management. This will undoubtedlycreate opportunities for new ideas and new providersin the area of cancer care.

Andrew DonaldChief Operating Officer, Birmingham East & North PCT(September 2008)

Answer: Care being delivered in themost appropriate setting andimproving outcomes is a keycommissioning role

Doing this in a methodical and explicit way to developnew models of care brings acceptability andsustainability into consideration. Extending this workbeyond secondary care and involving morestakeholders increases the complexity but theimportance and potential benefits of this work makeit worthwhile. A challenge faced by a PCT is workingwith the systems in place and developing new ways ofcommissioning new models.

Philippa MuirHead of Specialist Commissioningand Clinical Networks, Oxfordshire PCT

Why focus on cancerinpatients? This isno longer a questionbut an opportunityfor action...

Why focus on cancer inpatients?



A programme of work has been established, supported by NHS Improvement and the Cancer ActionTeam, working with key organisations, users, charities and professional bodies. The overall programmecovers six priority workstreams.

Delivering care in the mostappropriate setting

This document focuses onsupporting the delivery of theNew Models of Care: TransformingInpatient Care.

HES

Lead - CancerAction Team

Lead - NHSImprovement



Lead - (TBC)

Lead -NationalCancerServicesAnalysisTeam



Previous testing identified four winning principles that can improve length of stay management,avert unnecessary admission, deliver care in the appropriate care settings, improve efficiency,quality, promote value for money and importantly value the patients’ time.

Winning Principles

1. Unscheduled (emergency)patients should be assessedprior to the decision to admit.Emergency admission should bethe exception not the norm.

2. All patients should be ondefined inpatient pathwaysbased on their tumour typeand reasons for admission.

3. Clinical decisions should bemade on a daily basis topromote proactive casemanagement.

4. Patient and carers need toknow about their conditionand symptoms to encourageself-management and to knowwho to contact when needed.

The task now is to:

• Ensure that these winningprinciples are spread andembedded across the NHS

• Test new ideas with newpartners such as primaryand social care

• Sustain proven improvementsto achieve maximum impact

www.improvement.nhs.uk/winning_principles



Tip 1:Create a shared vision – time and effort spent inagreeing high quality and performanceindicators at the start will enable the team tostay focussed.

Tip 2:Keep the service users and carers central.

Tip 3:Create co-production energy – work withan approach that encompasses professional,organisational and functional boundariesto create partnership environments.

Tip 4:Define the workstream scope– there are many projectinitiation documents

available but it is worthagreeing which one you are

going to adopt to ensureappropriate links are correctly made at the start.

Tip 5:Test small step changes - one service user at atime makes the experience safe and controlled.

Tip 6:Engage partners early in discussions. Makesure you are not just shifting existing serviceswithout the infrastructure to support andadding more unnecessary steps into the process.

Tip 7:Use clinicians and leaders as a catalyst toimprove care at all stages.

Tip 8:Use and involve the local network serviceimprovement team as a resource.

Tip 9:Focus on really understanding the problemnot jumping to the solution.

Testing, spreading and sustainingStep One: Getting Started



Good planning can inspire changethat leads to improvements

• Identify the key people to be involved early on in the workstream.• Who are the key stakeholders?• Clinical and managerial leadership is critical to success.• Have you included data and informatics and finance, primary care andsocial care?

• Establish the steering/working group.• Has the group got the people with the knowledge and skills? Can they make the decisions?• Do they have service improvements skills?• Knowledge of heath and social care processes?• Is there service user Involvement?• Is their agreed local accountability and responsibility for delivery?• Knowledge of commissioning?• Information gathered from all perspectives (service users, staff,commissioners, partnerships etc).

• Identify, understand and define the ‘real’ problem not the solution.• Review data to understand demand, activity and variation in performance.• How are your improvements going to be measured and monitored?Have you included qualitative and quantitative performance indicators?

• Match the collection of baseline data with the scope of the problem identified.• Remember that no data will be perfect and beware of analysis paralysis(collecting everything that tells you nothing).

• Break the data down into sections of information to help you identifywhat needs to be collected and analysed.

• Look for the 80/20 rule (Pareto principle) this happens to 80% of our users;focus on the 80% first, look for trends in retrospective data.

• Keep clinicians, leaders and key people involved.• Identify (visioning) and design the ideas to tested.

• Seek and build continuous and meaningful engagement with the publicand service users, involve them in shaping services.

• Have an understanding of different user engagement options, includingthe opportunities, strengths, weaknesses and risks.

• Routinely invite service users and the public to respond to and comment on issues.• Ensure that users and the public understand how their views will be used, which decisionsthey will be involved in, when decisions will be made, and how they can influence improvement.

• Communicate widely about ideas being tested.• Test the idea (maybe more than one testing cycle).• Capture results, benefits and measure the impact. Match across to your performance indicators.• Capture the learning (the things that work and those that didn’t documenting reasons why).• Communicate regularly with the whole team and partnerships - keep the message short and snappy.• Ensure identified ownership of action points.

• Analyse the results and quantify the impact of actual and potential.• Identify benefits- e.g. quality, cost, outcomes.• Identify risks.• Evaluate the alternatives.• Make recommendations.• Build your business case on evidence.

• Recommendations for implementation (provide the evidence that supports your testing).• Commissioners want to see the evidence.• Celebrate your achievements.• Share the learning - publicise your work.• Prepare your spread/adoption strategy.• Include how you will measure sustainability.

Leadership andengagement

Knowledge andskills – the basics

Planning theimprovementworkstream

Engagement withpublic and serviceusers

Test out your ideas

Evaluation

Implementation –spread and sustain

Planning



Use a simple approach: Apply a practical framework fortesting, spreading and sustaining

Use available resources for gatheringbaseline information

The Cancer Commissioning Toolkit (CCT)The Cancer Reform Strategy (2007) identified betterinformation and stronger commissioning as two of thekey drivers to achieve the goal that cancer services inEngland should be amongst the best in the world. TheCCT is a one stop online library of key cancerinformation and data which can be easily accessed foruse. The Cancer Commissioning Tool provides thestarting point by providing useful baseline andbenchmarking information.

The Cancer Commissioning Toolkit (CCT) inpatientchapter is divided into three key sections

AnalysisBaseline from

different perspectives

Evaluate andcheck sustainability

ImplementationImplement the idea

Spread/AdoptionStrategy

Identify thereal root of theproblem

VisioningWhat are you trying

to achieve?

Testing CyclesTest out the idea’s

Is it theright solution toaddress the realproblem?

Case for changePlan the implementationof the tested idea. Buildthe case for change

EvaluationEvaluate the benefitsWhat is the difference

Agree the redesign& implementation ofthe improvements

NO

YES

To help you with local baselines a seriesof questions have been developed intoan inpatient checklist which is availableat the back of this document. Most ofthis information should be available inyour local organisations.

The Cancer Commissioning Toolkit willhelp you to define who needs to beengaged and define who will drive theworkstream – commissioning, primarycare, secondary care or social care

You will still need to capturea local baselineTo find out locally and to understand whatlies beneath the numbers of the CCT.

YES

’‘



• Find out why your length of stay is X andbed days Y

• Tip 1: Don’t look at the numbers of the CCT inisolation from the whole improvement picture

for the patient• Tip 2: Don’t jump to solutionsbased on the numbers without

identifying the realproblem• Tip 3: Think about:

‘How can you really managelength of stay if you do not knowwhat the right length of stay is?’•Tip 4: Do not get complacent, ifyou identify from the CCT datathat you are in the higher ormiddle quartile - there is

always room for improvement.

Getting the user involvedUser involvement is increasingly becoming acceptedby planners, service providers and users. The need tolisten and act on the views of users and the public isan integral part of improving quality and delivery ofhealthcare.

There are many different approaches to userinvolvement; start by identifying what already existsacross the health community.

User involvement• Patient Advice and Liaison Services (PALS)• Studying the complaints and compliments• Suggestion boxes and comments slips• Local organisational audit and national audite.g. Health Care Commission Annual HealthCheck, National Cancer Audit

• Study the organisations website forsuggestions/comments. It is also worthwhileexploring what is currently happening in localareas to gain feedback from patients forexample:• Patient and public involvement forums• Local Involvement Networks (LINKs)• Patient groups: User groups, carer groupsand disease support groups

• Expert Patient Programmes• Patient participation groups in primary care.

The involvement of users can result in anumber of benefits for the organisation.

User involvement• Raises your awareness of the issuesthat impact on service users

• Helps to clarify how health services canbe improved and redesigned

• Helps to identify issues and supporttheir improvements to make thebiggest impact for service user needs

• Challenges the professional views andexisting approaches to services.

User involvement - methods• Questionnaire surveys• Satisfaction surveys• Interviewing• Discovery interviews• User diaries• Focus groups• Workshops• Reader panels• User panels• Citizens’ juries• Local 18 week patient experiencesurveys.

The inpatient test sites used a variety ofthese methods, for example, patientsatisfaction surveys were developed toensure that there were no adverseeffects on patient experience due tochanges in their pathways.

I much preferred coming today care for my antibioticsas I was able to have mytreatment early enough toallow me to go home andcare for my disabled wife.

www.improvement.nhs.uk/winning_principles

(Patient interview)

Capturing your baseline



Tip 1:To be able to realise benefits - it is important toagree the measures (metrics or indicators) rightat the start of the workstream with all partners.

Tip 2:Measures (metrics/indicators) should reflectthe whole performance spectrum:

• Quality and patient experience• Efficiency and value for money• Effectiveness and impact of improvements• Alignment with national indicators acrosspartnerships.

Tip 3:Set up a data capture systemfor continuous monitoringof improvement at the start.

Tip 4:Feedback regularly on theimprovements made.

Step Two: Measuring that quality is fair,personalised, safe and effective

A true measure capturesall the benefits thateveryone can gain.



Number of social care clients receiving self directedsupport per 100,000 population – designing thecare and support package that best suits theirspecific needs

The percentage of people with a long-termcondition supported to be independent and incontrol of their condition

Timeliness of social care assessments and socialcare packages following assessment

The average weekly rate of delayed transfers ofcare from all NHS hospitals, acute and non-acute,per 100,000 population aged 18 and over

The ability of the whole system to ensureappropriate discharge from hospital

Self reported experience of social care usersperceptions of services

User reported measures of respect and dignity intheir treatment

Number of emergency bed days per head ofweighted population

Percentage of all deaths that occur at home - endof life care, access to appropriate care enablingpeople to be able to choose to die at home

Waiting times targets

‘Vital Signs’Indicators for progress againstnational/local priorities for PCTs

Identifying the potential alignment of national and localindicators with Transforming Inpatient Care

‘National Indicators’Local Authority and Local AuthorityPartnerships for adult health and wellbeing

Cancer ReformStrategy (CRS)New ModelsTransformingInpatient Care

Rates of hospital admissions forambulatory care

Proportion of people with long termconditions supported to be independentand in control of their condition

Patient experience of access toprimary care

Number of delayed transfers of care per100,000 population (aged 18 and over)

Timeliness of social care assessmentand package

Self reported experience of patientsand users

Patients and user reported measures ofrespect and dignity in treatment

Number of emergency bed days perhead of weighted population

Ambulance conveyance rate to A&E

Proportion of all deaths that occurat home

Percentage of patients receiving theirfirst definitive treatment for cancerwithin two months of urgent referralfor suspected cancer

Percentage of patients seen within 18weeks for admitted pathways

Winning Principle 4

Winning Principle 4

Winning Principle 1

Winning Principle 1Winning Principle 2Winning Principle 3

Winning Principle 3

Winning Principle 4

Winning Principle 3

Winning Principle 1

Winning Principle 4

Winning Principle 2

Winning Principle 3

Remember, measures provide evidenceand motivate stakeholders:



Transforming Inpatient Carehas the potential of:

• Reducing cancer bed days by 25%per SHA

• Ensuring inpatient care for cancer doesnot exceed 12% of all inpatient beddays (baseline CRS 2007)

• Ensuring costs do not exceed the2008 baseline

• Reducing emergency admissionsby 5%.

Capturing and measuring the quality,efficiency and impact through theNHS Improvement microsite

The microsite will be one of a cluster ofspecialised websites linked to the CancerCommissioning Toolkit and the NHSImprovement website.

The microsite is being developed tosupport the new models workstream. Itwill present specific information and datarelating to the impact of testing, spreadand the sustainability of the work beingundertaken by the provider sites activelyinvolved the workstream.

The microsite will be a ‘working webspace’ that will allow organisations toreview their historic activity, scenarioplan, quantify their assumptions andmeasure the actual and potential impactof their improvement ideas.

The microsite will go live in January 2009and will continue to evolve and developduring 2009.

Providers are motivated to reducelength of stay and to release capacity.

PCTs are motivated to reduceinappropriate admissions and beddays over trim points.

Patients do not wantto be in a hospitalunnecessarily -adding no valueto their well being

or treatment.

Early interventionby social care. Earlysupportive dischargebenefit - cost saving inthe community - rightsupport at theright time.



To enable the learning to be collated and shared,three approaches have been developed, that togethercan enhance the delivery of improvement across thenew models workstream and build the momentum forspread. (The learning diary/spread planner andsustainability check list can be found in the backpocket of this document).

1. The Testing Learning Diary

Capturing the elements of the ‘Testing process’ (Aim,Measures, Process and Impact) will help to support alearning framework that will enable the key outcomesof the ‘testing phase’ to be shared with the widerNHS.

The Inpatient Learning Diary is a tool which collatesthe learning from the testing, and helps to guidethe sites through the testing approach by a seriesof questions. This is available on:www.improvement.nhs.uk/improvementsystem.

To learn objectively from the whole process, theproject needs to be reviewed in order to establishwhat has been accomplished, and to also learn fromwhat did not go so well. This will enable allorganisations involved to learn from the experienceand to share that learning with others.

2. Spread Planner

Success is often gauged by how quickly an idea israpidly adopted and spread. Having a spread strategycan eliminate the gap between what is and what canbe. It promotes equity of service delivery in order thatall can gain from the benefits. The spread planner is aguide to spreading the winning principles and otheroutcomes and benefits from testing. It derives fromthe experience of the early test sites, Institute forHealth Improvement (IHI) and the work of EverettRodgers (Diffusion of Innovation 2003).

Step Three: Capturing the learning for testing,spread and sustainability

3. Sustainability Checklist

It is important to develop a plan forsustainability which ensures that wecreate lasting improvements.

The sustainability check list focuses onsome key questions to assist you indeveloping your strategy.



Useful resourcesService Improvement Information• NHS Improvement, Transforming Inpatient Care, Winning Principleswww.improvement.nhs.uk

• Gold Standards Framework (GSF)www.goldstandardsframework.nhs.uk

• Liverpool Care Pathway for the Dying Patient (LCP)[email protected]

• Palliative Carewww.endoflife.nhs.uk

Social Care Information• Adult Social Care: The Government’s Green Paper and the LGA’s Campaignwww.lga.gov.uk/lga/aio/275402

• Putting Patients Firstwww.nationalhealthcouncil.org/initiatives/putting_patients.htm

• High Impact Changes for Health & Social Carewww.csip.org.uk/silo/files/hics-doc-11th-march.pdf

• Care Support Independence: Meeting the needs of a changing societywww.orderline.dh.gov.uk

Health Information• Our NHS Our Future: High Quality Care for All (Lord Darzi)www.ournhs.nhs.uk

• Cancer Reform Strategywww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_08100

• Cancer Commissioning Toolwww.canceruk.net

• Department of Healthwww.dh.gov.uk

• World Class Commissioningwww.dh.gov.uk/en/managingyourorganisation/commissioning/worldclasscommissioning/index.htm

• Our Health, Our Care, Our Saywww.dh.gov.uk/en/Healthcare/Ourhealthourcareoursay/index.htm

• National Planning Guidance ‘Vital Signs’www.dh.gov.uk/publications

User and Public Involvement• Department of Health (2004). Choose and Bookwww.chooseandbook.nhs.uk

• Department of Health (2005). Creating a Patient Led NHS -Delivering the NHS Improvement Planwww.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4127453&chk=NXIecj

• Department of Health (2006). Developing a Stronger Local Voicewww.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4137040&chk=U6PSmq

• Department of Health (2006). Reward & Recognitionwww.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4138523&chk=vDLLsV

AcknowledgementsWith our thanks to:• All the Test Sites for their continuingcommitment tothis national workstream

• Professor Mike Richards• Simon Williams• Andy Millward (User Representative)• Philippa Muir• Dr. Brian Cottier• Andrew Donald• Celia Ingham Clark, National Clinical Lead• Cancer Action Team• NHS Improvement Team: Dr Ann Driver,Angie Robinson, Marie Tarplee, CatherineStrong, Jim Farrell, Wendy Gray

For further information please contact:

Dr Ann DriverDirector, NHS ImprovementEmail: [email protected]: 07900 223142

Angie RobinsonNational Improvement Lead, NHS ImprovementEmail: [email protected]: 07900 223346

Marie TarpleeNational Improvement Lead, NHS ImprovementEmail: [email protected]: 0791 7233248

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHSNHS Improvement

NHS Improvement

Formed in April 2008, NHS Improvement bringstogether the Cancer Services Collaborative‘Improvement Partnership’, Diagnostics ServiceImprovement, NHS Heart Improvement Programmeand Stroke Improvement into one improvementprogramme.

With over eight years practical service improvementexperience in cancer, diagnostics and heart, NHSImprovement aims to achieve sustainable effectivepathways and systems, share improvement resourcesand learning, increase impact and ensure value formoney to improve the efficiency and quality ofNHS services.

Working with clinical networks and NHSorganisations across England, NHS Improvementhelps to transform, deliver and build sustainableimprovements across the entire pathway of care incancer, diagnostics, heart and stroke services.

©NHS Improvement 2008 | All Rights Reserved

HEART

STROKE

CANCER

DIAGNOSTICS

Health & Medicine

Meeting the challenge together... delivering care in the most appropriate setting