Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England

 
Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
Right person, right place, first time

Transforming
elective care services
neurology

Learning from the Elective Care Development Collaborative
Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
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                                                                                                                                              Right person, right place, first time
Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
Introduction
	The national context and
                                   Contents									                                                      click    to return to this page
  challenges facing elective
  care services in England
	The national general surgery     Introduction                                                                                                 4
  challenge
  he Elective Care
 T                                 The national context and challenges facing elective care services in England                                 5
 Development Collaborative
	Overview of ideas being tested   The national neurology challenge                                                                             6
  and described in this guide
	Essential actions for
  successful transformation
                                   The Elective Care Development Collaborative                                                                  8
 1.	Rethinking referrals:
                                   Overview of ideas being tested and described in this guide                                                   9
		 a. Standardised referral
			 pathways and
			 structured templates           Essential actions for successful transformation                                                            10
		 b. Shared learning
			 opportunities                      1.    Rethinking referrals:
		 c. Increasing use of
			 Advice and Guidance            			       a. Standardised referral pathways and structured templates                                       12
 2.	Shared decision
     making and self-
     management support:
                                   			       b. Shared learning opportunities                                                                 17
		 a.

        Self-management
        education and support
                                   			       c. Increasing use of Advice and Guidance                                                         22
			     for headache and
			     migraine                       2.    Shared decision making and self-management support
 3.	Transforming
     Outpatients:                  			       a. Self-management education and support for headache and migraine                               27
		 a. Community migraine
			 clinics                            3.    Transforming outpatients:
		 b. Community MDT clinics
  aking transformation
 T                                 			       a. Community migraine clinic                                                                     31
 forward

                                   			       b. Community MDT clinic                                                                          36
                                   Taking transformation forward                                                                              40

 3                                                                                                            Right person, right place, first time
Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
Introduction
	The national context and
                                   Introduction
  challenges facing elective
  care services in England
	The national general surgery     This handbook is for commissioners, providers and those leading the local transformation
  challenge
                                   of neurology elective care services. It describes what local health and care systems can do to
  he Elective Care
 T
 Development Collaborative         transform neurology elective care services at pace, why this is necessary and how the impact
	Overview of ideas being tested   of this transformation can be measured. It contains practical guidance for implementing and
  and described in this guide
	Essential actions for
                                   adopting a range of interventions to ensure patients see the right person, in the right place,
  successful transformation        first time.
 1.	Rethinking referrals:
		 a. Standardised referral        The list of interventions is not exhaustive and reflects
			 pathways and                   those tested in the fifth wave of the Elective Care
			 structured templates           Development Collaborative using the 100 Day Challenge
		 b. Shared learning              methodology. General medicine, neurology and radiology
			 opportunities
                                   were the specialties in this wave and this handbook is
		 c. Increasing use of
			 Advice and Guidance            just one of the resources produced to share learning.
 2.	Shared decision               Further handbooks, case studies, resources, discussion
     making and self-              and methodology can be found on the Elective Care
     management support:
                                   Community of Practice pages.
		 a.   Self-management
			     education and support      Interventions are grouped by theme within this handbook
			     for headache and
			     migraine                   and include ‘how-to’ guides. The success of interventions
 3.	Transforming                  designed to transform local elective care services should
     Outpatients:                  be measured by changes in local activity following
		 a. Community migraine           implementation of the intervention and performance
			 clinics                        against the Referral to Treatment (RTT) standard. Patient
		 b. Community MDT clinics        and professional outcomes and satisfaction should also be
  aking transformation
 T                                 measured (NHS Improvement, 2018).
 forward
                                   You can learn about the interventions tested in previous
                                   waves (MSK, gastroenterology, diabetes, dermatology,
                                   ophthalmology, cardiology, urology, ENT, respiratory,
                                   gynaecology and general surgery) and find all the
                                   handbooks and some of the many case studies on our
                                   webpages.
 4                                                                                                    Right person, right place, first time
Transforming elective care services - neurology Learning from the Elective Care Development Collaborative - NHS England
Introduction
	The national context and
                                   The national context and challenges facing
  challenges facing elective
  care services in England         elective care services in England
	The national general surgery
  challenge
  he Elective Care
 T                                 The NHS is experiencing significant pressure and                    Timely access to high-quality elective care is a key
 Development Collaborative
	Overview of ideas being tested
                                   unprecedented levels of demand for elective care.                   priority under the NHS Constitution.
  and described in this guide      Around 1.7 million patients are referred for elective consultant-   The NHS Long Term Plan sets out the ambition to provide
	Essential actions for            led treatment each month. Between 2011/12 and 2016/17,              alternative models of care to avoid up to a third of face-to-face
  successful transformation
                                   referrals rose annually by an average of 3.7% per year.             outpatient appointments. In 2017/18 there were 119.4 million
 1.	Rethinking referrals:                                                                             outpatient appointments, almost 80% more than in 2007/08.
		 a. Standardised referral        Over the 12 months to December 2018, growth in GP referrals         The rate of patient attendance at these appointments decreased
			 pathways and                   decreased by 0.4%. Total referral growth in 2018/19 was 1.6%        from 81.6% in 2007/08 to 78.4% in 2017/18. There has been an
			 structured templates                                                                               increase in occasions where the patient ‘Did Not Attend’ (DNA),
                                   at December 2018, against planned growth of 2.4%. Keeping
		 b. Shared learning
                                   the GP referral growth rate below plan represents a significant     but a more marked increase in hospital and patient
			 opportunities                                                                                      cancellations.
		 c. Increasing use of
                                   achievement in redesigning pathways across primary and
			 Advice and Guidance            secondary care and implementing interventions across the            This makes the redesign of elective care services a must-do for
 2.	Shared decision               elective pathway, to reduce avoidable demand and ensure that        every local system, to achieve better demand management that
     making and self-              patients are referred to the most appropriate healthcare setting,   improves patient care (clinically and from a quality of experience
     management support:
                                   first time.                                                         perspective) while also improving efficiency. It is essential to
		 a.   Self-management                                                                                understand the drivers of demand and what can be done to
			     education and support      At the end of March 2019, the number of people waiting over         improve upstream prevention of avoidable illness and its
			     for headache and                                                                               exacerbations, including more accurate assessment of health
			     migraine                   52 weeks had halved since the year before, and the number
                                   of people waiting less than 18 weeks had increased. However,        inequalities and unmet need. This includes addressing the needs
 3.	Transforming
     Outpatients:                  growing demand means that the proportion within 18 weeks            of local populations and targeting interventions for those
                                                                                                       people who are most vulnerable and at risk (NHS Long Term
		 a. Community migraine           is below the constitutional standard for referral to treatment
			 clinics                                                                                            Plan, 2019). Technology offers digitally-enabled possibilities in
                                   target of 92%.                                                      primary and outpatient care to support this transformation.
		 b. Community MDT clinics
  aking transformation
 T                                                                                                     The Friends and Family Test (FFT) results for March 2019 showed
 forward                                                                                               that overall satisfaction with outpatient services remained high,
                                                                                                       with 94% of 1,391,002 respondents saying that they would
                                                                                                       recommend the service to a friend or family member; 3% saying
                                                                                                       they would not recommend the service, and the remaining 3%
                                                                                                       saying either ‘neither’ or ‘don’t know’. It is important to take
                                                                                                       steps to ensure that patient satisfaction remains high.

 5                                                                                                                                Right person, right place, first time
Introduction
	The national context and
                                   The national neurology challenge
  challenges facing elective
  care services in England
	The national general surgery     Neurology covers many different conditions from                  working in small and medium acute trusts (Royal
  challenge                        migraine to motor neurone disease and management                 College of Physicians, 2011) with some hospitals having
  he Elective Care
 T                                 of chronic pain. The number of people living with                no acute neurology service at all (The Neurological
 Development Collaborative         neurological conditions in England is rising (currently          Alliance, 2018). Annual reviews of neurological patients
	Overview of ideas being tested   12.5 million) and will continue to increase. The current         by a specialist such as a nurse is a measure included
  and described in this guide
                                   service provision cannot meet the needs of patients.             in many of the National Institute of Health and Care
	Essential actions for
  successful transformation        One in 10 GP consultations related to neurology in               Excellence (NICE) guidelines relating to neurological
 1.	Rethinking referrals:         2011 (The Neurological Alliance, 2018). From 2012/14 to          conditions. In practice these rarely happen (The
		 a. Standardised referral        2015/16 there was a 14% increase in hospital admissions          Neurological Alliance, 2018).
			 pathways and                   for people with a primary diagnosis of a neurological           • Commissioning is fragmented. CCG engagement with
			 structured templates
                                   condition, and a 10% increase in emergency hospital               neurology is poor, compared to other conditions and
		 b. Shared learning
			 opportunities
                                   admissions (The Neurological Alliance, 2018). The actual          care pathways are fragmented and poorly co-ordinated.
		 c. Increasing use of
                                   number of first outpatient appointments decreased                 In some cases, not recognising and treating a comorbid
			 Advice and Guidance            year on year by 5.0% in 2017/18 and 2.5% in 2018/19.              mental health condition can lead to inpatient admissions.
 2.	Shared decision               However, waiting times have continued to rise with the            Optimising care pathways and specially designed services
     making and self-              proportion of patients waiting less than six weeks for            to bring together neurology and mental health will
     management support:
                                   a first outpatient appointment falling from 35.8% in              result in system savings and better patient outcomes (The
		 a.   Self-management
			     education and support      2016/17 to 32.4% in 2018/19 and the waiting list growing          Neurological Alliance, 2018).
			     for headache and           by 17% from March 2017 to February 2019. This suggests
			     migraine                   a lack of secondary care capacity in neurology rather           • A national shortage of neurology consultants. The
 3.	Transforming                  than a reduction in demand. Current challenges and                shortage of neurologists in small and medium acute
     Outpatients:
                                   opportunities in neurology include:                               trusts means that often those presenting with a
		 a. Community migraine
			 clinics
                                                                                                     neurological condition are unnecessarily admitted
                                   • Unwarranted and unnecessary variation in service                because specialist opinion is not available at the
		 b. Community MDT clinics          provision. People with long term neurological
  aking transformation
 T
                                                                                                     front door, or have a longer length of stay because
                                     conditions benefit from a multidisciplinary approach            their condition is not initially accurately diagnosed
 forward
                                     involving not only neurology consultants but specialist         (Royal College of Physicians, 2011). Better provision of
                                     nurses, GPs with extended roles (GPwERs) and allied             community specialist services would help prevent crises
                                     health professionals (AHPs). However, there is variation        and unplanned admissions, and also facilitate better
                                     in availability and provision of this type of support           discharge (The Neurological Alliance, 2018).
                                     (Royal College of Physicians, 2011). Patient access is also
                                     affected by variation in the number of neurologists

 6                                                                                                                          Right person, right place, first time
Introduction
	The national context and
                                   The national neurology challenge
  challenges facing elective
  care services in England
	The national general surgery     • Poor communication between primary, community,                 • Managing expectations of patients and carers. Self-
  challenge                          secondary and social care. Integration of health                 management is a key element for many neurological
  he Elective Care
 T                                   and social care (and access to both) is a key part of            conditions. Shared development of patient management
 Development Collaborative           maximising patient experience and outcomes. Increasing           plans can empower patients to self-manage (Royal
	Overview of ideas being tested     demand for neurological services needs to be supported           College of Physicians, 2011), however only 15% of
  and described in this guide
                                     by better communication between care settings.                   neurology patients currently have care plans, with 82%
	Essential actions for
  successful transformation          There is significant concern among GPs about the time            of neurology patients saying they have never been
 1.	Rethinking referrals:           taken from referral for patients to see a consultant             offered a care plan (The Neurological Alliance, 2018).
		 a. Standardised referral          neurologist. Referral triage and access to specialist            As with all long-term conditions, the mental health
			 pathways and                     Advice and Guidance could be used to filter referrals,           needs of people with neurological conditions need
			 structured templates
                                     reduce unnecessary referrals and free up secondary care          to be considered. Integrated psychological support
		 b. Shared learning
			 opportunities
                                     capacity. (The Neurological Alliance, 2018). Greater use         and social prescribing can better meet the needs of
		 c. Increasing use of
                                     could be made of GPs to manage headache and follow               neurological patients without placing further demand
			 Advice and Guidance              up conditions in remission, potentially with practices           on the stretched specialist neurology workforce (The
 2.	Shared decision                 working in a networked manner to manage these                    Neurological Alliance, 2018).
     making and self-                patients with support from the local neurologist (Royal
     management support:                                                                            Not all of the challenges and opportunities above could
                                     College of Physicians, 2011).
		 a.   Self-management                                                                             be tackled by the teams during their 100 Day Challenge.
			     education and support      • Maximising the role of community nurse specialists.            However, input from key stakeholders helped to
			     for headache and
			     migraine                     Due to the shortage of neurology consultants, the              develop the challenge framework for Wave 5 and the
 3.	Transforming                    specialist nurse role and particularly a community nurse       ideas tested.
     Outpatients:                    role is a valuable resource for increasing patient access to
		 a. Community migraine             treatment. Access to a well co-ordinated multidisciplinary
			 clinics                          team is key to the provision of good care and maximising
		 b. Community MDT clinics          patient outcomes, particularly in a community setting
  aking transformation
 T                                   (The Neurological Alliance, 2018). GPwERs and specialist
 forward
                                     nurses have the potential to improve care, reduce follow-
                                     up requirements and (re)admission rates (Royal College
                                     of Physicians, 2011).

 7                                                                                                                         Right person, right place, first time
Introduction
	The national context and
                                   The Elective Care Development Collaborative
  challenges facing elective
  care services in England
	The national general surgery     NHS England’s Elective Care Transformation Programme supports local health and care systems to work together to:
  challenge
                                      	Better manage rising demand for elective care services.
  he Elective Care
 T
 Development Collaborative            	Improve patient experience and access to care.
	Overview of ideas being tested
  and described in this guide         	Provide more integrated, person-centred care.
	Essential actions for            As part of this programme, the Elective Care Development Collaborative has been established to support rapid change led
  successful transformation
                                   by frontline teams. In Wave 5 of the Elective Care Development Collaborative, local health and care systems in south west
 1.	Rethinking referrals:
                                   Hampshire, Liverpool, north east Essex and Salford formed teams to develop, test and spread innovation in delivering
		 a. Standardised referral
			 pathways and                   elective care services in just 100 days (the 100 Day Challenge). You can find more about the methodology used here.
			 structured templates
		 b. Shared learning
                                   The teams used an intervention framework to structure their ideas around three strategic themes:
			 opportunities
		 c. Increasing use of
			 Advice and Guidance
                                    Rethinking                 Shared decision making and                                             Transforming
 2.	Shared decision
                                    referrals                  self-management support                                                outpatients
     making and self-
     management support:            Rethinking referral        Taking a universal personalised care approach means that:              Transforming
		 a.   Self-management             processes to ensure        • People are supported to stay well and are enabled to make            outpatients means
			     education and support       they are as efficient                                                                             considering how patient
			     for headache and                                         informed decisions and choices when their health changes.
			     migraine                    and effective as                                                                                  pathways and clinic
 3.	Transforming                   possible means that        • People with long term physical and mental health conditions          arrangements (including
     Outpatients:                   from the first time          are supported to build knowledge, skills and confidence and          processes) ensure that
		 a. Community migraine            a patient presents           to live well with their health conditions.                           patients always receive
			 clinics                         in primary care,           • People with complex needs are empowered to manage their              assessment, treatment
		 b. Community MDT clinics         patients should              own condition and the services they use.                             and care from the right
  aking transformation
 T                                  always receive                                                                                    person, in the right
 forward
                                    the assessment,            Shared decision making is a collaborative process through which a      place, first time. This
                                    treatment and care         clinician supports a patient to make decisions about their treatment   may not be in secondary
                                    they need from the         and care that are right for them. This should be considered at every   care. Virtual clinics,
                                    right person, in the       stage of the patient pathway and can incorporate digital health        technological solutions
                                    right place, first time.   tools, personalised care and support planning, social prescribing,     and treatment closer to
                                                               patient choice, patient activation and personal health budgets.        home are all possibilities.

 8                                                                                                                           Right person, right place, first time
Introduction
	The national context and
                                   Overview of ideas being tested and described in this guide
  challenges facing elective
  care services in England
	The national general surgery          Intervention                                              The opportunity
  challenge
                                                            If a standard neurology pathway is used practitioners should have access to relevant
  he Elective Care
 T
 Development Collaborative                                  guidance and information when making or receiving referrals. Referral quality should be
	Overview of ideas being tested    Standardised referral   more consistent and the number of unnecessary referrals should reduce. This should mean
  and described in this guide            pathways           patients are seen as soon as possible by the right clinician.
	Essential actions for
  successful transformation                                 If learning and knowledge about neurology conditions is shared between practitioners,
 1.	Rethinking referrals:                                  patients should receive effective treatment and advice earlier. Primary care practitioners
		 a. Standardised referral           Shared learning       should build their knowledge, confidence and expertise reducing the number of referrals
			 pathways and                                            into secondary care and improving the quality of referrals made.
			 structured templates
                                       opportunities
		 b. Shared learning
			 opportunities                                           If GPs can access specialist advice it helps them to manage patients more effectively in
		 c. Increasing use of                                     primary care and avoid unnecessary referrals into secondary care. This should also improve
			 Advice and Guidance             Increasing the use of   the quality of referral information that accompanies the patient.
 2.	Shared decision                Advice and Guidance
     making and self-
     management support:
		 a.   Self-management                                     If patients have high quality information about their condition and multi-channel self-
			     education and support         Self-management       management education and support, they will be able to better manage their own
			     for headache and
			     migraine
                                    support for headache    symptoms which will improve patient outcomes and experience.
 3.	Transforming
                                        and migraine
     Outpatients:
                                                            Patients benefit from an extended appointment with a specialist, where they can discuss
		 a. Community migraine
			 clinics                                                 their headaches and receive support with putting together an initial management plan. A
		 b. Community MDT clinics
                                        Community           community migraine clinic means that patients receive in-depth specialist support earlier
  aking transformation
 T
                                       migraine clinic      and closer to home and demand for acute neurology outpatient services is reduced.
 forward
                                                            Management of certain conditions, such as multiple sclerosis (MS) or chronic pain, requires
                                                            specialist doctors, nurses and allied health professionals to work together as a
                                                            multidisciplinary team (MDT). If MDT reviews are provided in the community patients can
                                                            receive the right management and access to specialist opinion earlier, GPs can receive advice
                                   Community MDT clinic
                                                            and guidance on management and more patients can continue to be managed in primary
                                                            care, reducing demand on outpatient services.
 9                                                                                                                     Right person, right place, first time
Introduction
	The national context and
                                   Essential actions for successful transformation
  challenges facing elective
  care services in England
	The national general surgery     The actions below are essential for creating the culture of change necessary to transform
  challenge
                                   elective care services and are relevant to the interventions described in this handbook.
  he Elective Care
 T
 Development Collaborative
                                   Establish a whole system team                                                      the system. Involving senior clinicians as early as possible is
	Overview of ideas being tested                                                                                      crucial to reaching agreement and implementing changes
  and described in this guide      Consider who needs to be involved to give you the widest                           effectively across organisational boundaries.
	Essential actions for            possible range of perspectives and engage the right
  successful transformation        stakeholders from across the system as early as possible.                          The 100 Day Challenge methodology facilitates cross-
 1.	Rethinking referrals:         It is essential to include patients and the public in your                         system working. Working across multiple organisations
		 a. Standardised referral        work. Find top tips for engaging patients and the public                           in this way is essential to establishing effective Integrated
			 pathways and                   on the Elective Care Community of Practice.                                        Care Systems, which need to be created everywhere by
			 structured templates
                                                                                                                      April 2021 (NHS Long Term Plan, 2019).
		 b. Shared learning              Secure support from executive level leaders
			 opportunities
                                   Ensure frontline staff have permission to innovate, help
		 c. Increasing use of
			 Advice and Guidance            unblock problems and feed learning and insight back into                             People to involve from the start:
 2.	Shared decision                                                                                                    • People with lived experience of   Throughout the
     making and self-                                                                                                     using the service                 handbook you
     management support:                                                                                                                                    will find useful
                                     Useful resources:                       Allied health professions supporting       • Patient organisations and
		 a.   Self-management
                                                                             patient flow: a quick guide (NHS             representatives (including the    tips on who else to involve
			     education and support        Public Health England website                                                        voluntary sector)                 for specific interventions. It
			     for headache and
                                     Leading Large Scale Change (NHS         Improvement and NHS England, 2018)
			     migraine                                                                                                        • GPs and primary care clinical     is important to consider how
                                     England, 2018)                          Guidance for NHS commissioners on            and nursing staff                 you are addressing the needs
 3.	Transforming
                                     Facing the Facts, Shaping the Future    equality and health inequalities legal                                         of your local population and
     Outpatients:                                                                                                       • Radiology consultants
                                     (Health Education England 2018)         duties (NHS England, 2015)                                                     how interventions can benefit:
		 a. Community migraine                                                                                                • Service managers
			 clinics                                                                  Equality and health inequality NHS                                             people living in the most
                                     Useful publications and resources                                                  • Radiographers                     deprived areas; inclusion health
		 b. Community MDT clinics
                                     on quality improvement (The Health      RightCare Packs (NHS England,              • Sonographers
  aking transformation
 T                                                                           2017)                                                                          groups (including homeless
 forward
                                     Foundation, 2018)                                                                  • Business information analysts     people and rough sleepers);
                                     100 Day Challenge methodology           NHS England response to the                • Administrative team support       Gypsy, Roma, Traveller groups;
                                     (Nesta, 2017)                           specific duties of the Equality Act:       • Physiotherapists                  vulnerable migrants and sex
                                                                             Equality information relating to           • Commissioners                     workers; and people with
                                     Principles for putting evidence-based   public facing functions
                                     guidance into practice (NICE, 2018)                                                • Appointment booking staff         characteristics protected under
                                                                                                                        • IT team.                          the Equality Act 2010.

 10                                                                                                                                                 Right person, right place, first time
Introduction
	The national context and
                                   Essential actions for successful transformation
  challenges facing elective
  care services in England
	The national general surgery     Ensure the success of your transformation activity can
  challenge                        be demonstrated                                                        Indicators and metrics that may be useful for specific
                                                                                                          interventions are included in the relevant sections
  he Elective Care
 T
 Development Collaborative
                                   SMART (specific, measurable, attainable, realistic, time               throughout the handbook.
                                   related) goals and clear metrics that are linked to the
	Overview of ideas being tested                                                                          Some suggested indicators that are relevant to most
  and described in this guide      intended benefits of your interventions need to be
                                                                                                          interventions in this handbook are described below:
	Essential actions for            defined right at the start of your transformation work.
  successful transformation
                                   Key questions include:
 1.	Rethinking referrals:
                                   • What are you aiming to change?                                     Benefits         Suggested indicators
		 a. Standardised referral
			 pathways and
			 structured templates
                                   • How will you know you have achieved success?                       Improved         • Friends and family test score (FTT)
                                                                                                        patient          • Patient reported experience measures (PREMs)
		 b. Shared learning              You may wish to use a structured approach such as logic
			 opportunities                                                                                       and staff          scores (where available)
                                   modelling. Consider how you are going to include both                experience
		 c. Increasing use of            qualitative and quantitative data in your evaluation.                                 • Qualitative data focused on your overall aims
			 Advice and Guidance
                                                                                                                           (through surveys, interviews and focus groups)
 2.	Shared decision
     making and self-                Questionnaires can be extremely useful to obtain                                    • Number of complaints
     management support:             patient and staff feedback. Resources and top tips                 Improved         • Referral to treatment time
		 a.   Self-management              from the Patient Experience Network can be found                   efficiency
			     education and support        on the Elective Care Community of Practice.                                         • Waiting time for follow-up appointments
			     for headache and
			     migraine                                                                                                         • Overall number of referrals
 3.	Transforming                                                                                                        • Rate of referrals made to the right place, first time
     Outpatients:                    Useful resources for evaluation:
                                                                                                                         • Cost per referral
		 a. Community migraine             Making data count (NHS Improvement, 2018)
			 clinics                                                                                             Improved         • Patient Reported Outcome Measures (PROMs)
                                     How to understand and measure impact (NHS England, 2015)
		 b. Community MDT clinics                                                                             clinical           scores (where available)
  aking transformation
 T                                   Seven steps to measurement for improvement (NHS                    quality          • Feedback from receiving clinicians
 forward                             Improvement, 2018)
                                                                                                                         • Commissioning for Quality and Innovation (CQUIN)
                                     Patient experience improvement framework (NHS Improvement, 2018)                      indicators
                                     Evaluation: what to consider (The Health Foundation, 2015)                          • Quality and Outcomes Framework (QoF) indicators
                                     Measuring patient experience (The Health Foundation, 2013)
                                                                                                        Improved       • Ease and equity of access to care
                                     Guidance for NHS commissioners on equality and health              patient safety • Rate of serious incidents.
                                     inequalities legal duties (NHS England, 2015)
 11                                                                                                                                  Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         a. Standardised referral pathways and structured templates
	The national general surgery
  challenge
  he Elective Care
 T                                 What is the idea?                                              Primary care clinicians have easy access to the
 Development Collaborative                                                                        information they need when making referrals. This means
	Overview of ideas being tested   Standard neurology referral pathways are informed by           they have increased understanding of which cases to refer
  and described in this guide      best practice and ensure that patients see the right           and the correct information to include in these referrals.
	Essential actions for            person, in the right place, first time. Structured templates
  successful transformation
                                                                                                  Clinicians also have more information about best practice
                                   that are available on primary care IT systems can support      in prescribing which helps them make better decisions
 1.	Rethinking referrals:
                                   the use of standard referral pathways, ensuring that           with patients and reduces variability in medicines use and
		 a. Standardised referral
			 pathways and                   referrers understand where to direct patients and what         prescribing costs.
			 structured templates           information needs to accompany them.
		 b. Shared learning
                                                                                                  Secondary care clinicians receive the necessary clinical
			 opportunities                                                                                 and administrative referral details straight away and are
                                   Why implement the idea?                                        more likely to accept referrals first time. They may see
		 c. Increasing use of
			 Advice and Guidance
                                   Many patients with common neurological conditions,             fewer patients because more are managed in primary
 2.	Shared decision
                                   such as headache, can be managed in primary care with          care and/or the community.
     making and self-
     management support:           some guidance. For those with more complex conditions,
		 a.   Self-management            diagnosis can be difficult and it can take several
			     education and support      appointments for patients to see the most appropriate
			     for headache and
			     migraine                   specialist. This contributes to increased demand for
 3.	Transforming                  neurology services that often have a relatively small
     Outpatients:                  number of consultants. As a result, patients can wait a
		 a. Community migraine           very long time to access treatment.
			 clinics
		 b. Community MDT clinics        Structured referral templates that include referral criteria
  aking transformation
 T                                 and guidance can reduce the number of inappropriate
 forward                           referrals and improve the quality of referral information
                                   that accompanies the patient, avoiding unnecessary delay.
                                   This helps to ensure that patients who need to be
                                   assessed and treated by specialists receive appropriate
                                   care as quickly as possible and management options
                                   available in the community are started straightaway.

 12                                                                                                                       Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         a. Standardised referral pathways and structured templates
	The national general surgery
  challenge
  he Elective Care
 T
 Development Collaborative          We know it works
	Overview of ideas being tested
  and described in this guide       A pilot pathway and guidelines to assist primary care     full roll-out this would reduce the cost of headache
	Essential actions for             practitioners to manage patients with headache was        from £410,000 to £142,000, and create an increase in
  successful transformation         introduced by West Norfolk Clinical Commissioning         capacity of 979 first appointments per annum. (NICE
 1.	Rethinking referrals:          Group (CCG) after GPs expressed a wish for greater        shared learning database, 2018)
		 a. Standardised referral         access to imaging. The pilot was preceded by a well
			 pathways and                                                                              As part of the 100 Day Challenge:
			 structured templates            received educational programme provided by the
		 b. Shared learning               authors of the pathway. Twelve months after GPs were      Pre-referral guidance was implemented for headache
			 opportunities                   able to refer patients direct for MRIs there was a 29%    patients in north east Essex to advise GPs on when to
		 c. Increasing use of             reduction in headache referrals to the neurology          refer to secondary or community headache clinic and to
			 Advice and Guidance
                                    department. (Redhead et al, 2015).                        manage in primary care. During the 100 days 13
 2.	Shared decision
                                                                                              referrals were redirected from secondary care to the
     making and self-               An evaluation of GP direct-access CT concluded this
     management support:                                                                      community clinic. Overall waiting times for the
                                    pathway was the preferred choice of GPs for management
		 a.   Self-management                                                                       neurology service reduced from 28 weeks to 25 weeks.
			     education and support       of patients with chronic daily headache. This study also
			     for headache and            suggested that 86% did not require further specialist     In Liverpool, a pilot primary care multidisciplinary team
			     migraine                    referral suggesting an approximate cost-saving across     (MDT) for chronic pain identified that 27% of patients
 3.	Transforming                   the study group (4,404 scans) of at least £86,000         waiting for a specialist appointment could be managed
     Outpatients:
                                    (Simpson et al, 2010). Similar results were also shown in by their own GP with guidance. New primary care
		 a. Community migraine
			 clinics                         an evaluation of primary care access to CT for headache guidance for chronic pain was drafted and agreed by
		 b. Community MDT clinics         in Tayside and North-East Fife (Thomas et al, 2010).      the MDT for launch across Liverpool. A supporting
  aking transformation
 T                                                                                            digital template was also produced to automatically
                                    In the first three months of a new headache pathway in
 forward                                                                                      prompt referrers to use the guidance.
                                    Oxfordshire, 89% of all headache referrals were
                                    directed away from general neurology outpatients. At

 13                                                                                                                    Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         a. Standardised referral pathways and structured templates
	The national general surgery
  challenge
  he Elective Care
 T                                 How to achieve success
 Development Collaborative
	Overview of ideas being tested   The sections below include learning from sites in Wave 5 of the Elective Care Development Collaborative:
  and described in this guide
	Essential actions for            Work with stakeholders from across the local system to         • Ensure that referral forms can integrate with
  successful transformation        develop the pathways                                             local Advice and Guidance systems and patient
 1.	Rethinking referrals:
                                   • Review existing pathways and referral forms. Map the           management systems. Seek IT expertise from the start
		 a. Standardised referral
                                     patient journey for common pathways such as headache           to ensure that forms can be uploaded and adjustments
			 pathways and
			 structured templates             and seek input from stakeholders to understand what            can be made to improve usability (such as automatic
		 b. Shared learning                is working well and what needs to change. Consider             pop-ups and pre-population of patient details).
			 opportunities                    the needs of your local population, particularly those       • Communicate plans to referrers. Use a variety of
		 c. Increasing use of              that may be outliers in terms of GP referral rates or          methods, such as letters, posters and education sessions,
			 Advice and Guidance
                                     unplanned hospitalisations. Explore the reasons behind         to communicate changes to the pathway and why they
 2.	Shared decision
     making and self-                any variation, considering equality of access to services.     are needed.
     management support:             In particular, consider people living in the most deprived   • Agree key outcome measures and establish a
		 a.   Self-management              areas; inclusion health groups (including homeless             baseline to measure progress against. Seek input
			     education and support
			     for headache and             people and rough sleepers); Gypsy, Roma, Traveller             from stakeholders on the key metrics necessary to
			     migraine                     groups; vulnerable migrants and sex workers; and               demonstrate impact of your intervention.
 3.	Transforming                    people with characteristics protected under the Equality
     Outpatients:                    Act 2010.
		 a. Community migraine                                                                            Ensure you have considered the
			 clinics                        • Review pathways and templates from elsewhere.
                                     Understand what could work well locally and develop a          perspective of everyone who will be
		 b. Community MDT clinics
                                     version relevant to your local context.                        making and receiving referrals. Patient
  aking transformation
 T
 forward                                                                                            insight is key to pathway redesign.
                                   • Develop a smart template on the primary care patient           Ensure you consider equality and health inequality,
                                     record system that includes explicit referral criteria.        along with your legal duties to make reasonable
                                     This should prompt the referrer to access relevant             adjustments for disabled people.
                                     guidance when making a referral, thereby optimising
                                     opportunities for shared learning. However, try to
                                     keep the referral template and questions as simple and
                                     relevant as possible.
 14                                                                                                                       Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         a. Standardised referral pathways and structured templates
	The national general surgery
  challenge
  he Elective Care
 T                                 Implement the pathways and templates                            • Ensure all materials you produce are as accessible as
 Development Collaborative
                                   • Develop, test and refine on a small scale to                    possible. Work with your communications team to
	Overview of ideas being tested
                                     demonstrate early impact. This makes attempting to              ensure that materials are available in a variety of
  and described in this guide
                                     scale across multiple clinical commissioning group (CCG)        languages and formats, depending on the needs of your
	Essential actions for
  successful transformation          or sustainability and transformation partnership (STP)          local population. For example, this may include
 1.	Rethinking referrals:           areas much easier.                                              producing ‘easy read’, large print or audio versions for
		 a. Standardised referral
                                                                                                     disabled people or translations into the languages
			 pathways and                   • Ensure that the success is measured. In the early stages of     spoken most frequently in your area.
			 structured templates             implementation, feedback is key to future refinement.
		 b. Shared learning                We are working with NHS Digital to identify any
			 opportunities                    underutilised neurology codes which could be used to            Metrics to consider for
		 c. Increasing use of              capture data for improvement and audit purposes,
			 Advice and Guidance                                                                              measuring success:
                                     including the possibility of proposing a new clinical code
 2.	Shared decision
     making and self-                for headaches.                                                  In addition to the suggested overall impact
     management support:                                                                             metrics on page 11, you may wish to
		 a.   Self-management
                                     NHS England and NHS Improvement are                             consider the following metrics for this
			     education and support
			     for headache and             working with NHS Digital to improve                             intervention:
			     migraine                     coding of neurology activity to capture                         • Awareness and uptake (e.g. percentage of referrers
 3.	Transforming                    data for improvement and audit purposes.                          using the referral form).
     Outpatients:
		 a. Community migraine             In the interim speak with your Data Analyst Lead to             • Effectiveness (e.g. time spent completing the
			 clinics                          identify suitable codes that can be used for tracking             referral by the referrer, feedback on ease of use).
		 b. Community MDT clinics          activities along the pathway.
  aking transformation
 T
                                                                                                     • Quality of referrals made (e.g. time spent reviewing
 forward                                                                                               each referral once received, feedback from
                                   Provide useful information for patients                             receiving clinicians on the quality of referrals and
                                   • Consider the needs of patients using your service and             accompanying information, number of referrals
                                     provide appropriate information to help them make shared          returned to referrer).
                                     decisions about their treatment. It may be useful to refer
                                     to NHS England’s guidance on shared decision making.

 15                                                                                                                         Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         a. Standardised referral pathways and structured templates
	The national general surgery
  challenge
  he Elective Care
 T
 Development Collaborative          The following standards and guidance may be useful:
	Overview of ideas being tested
  and described in this guide
                                    Chronic pain: assessment and management (NICE,           Headache Pathway Case for Change (Cader & Wood, 2017)
                                    expected publication in 2020)
	Essential actions for                                                                      Medicines optimisation in long-term pain (NICE, 2017)
  successful transformation
                                    Commissioning better headache services (Bateman, 2015)
 1.	Rethinking referrals:                                                                   Migraine prophylaxis: flunarizine (NICE, 2014)
		 a. Standardised referral         Guideline scope Chronic pain: assessment and
                                                                                             Motor neurone disease: a guide for GPs and primary
			 pathways and                    management (NICE, 2018)
			 structured templates                                                                     care teams (Motor Neurone Disease Association and
		 b. Shared learning               Guidelines for All Healthcare Professionals in the       RCGP, 2015)
			 opportunities                   Diagnosis and Management of Migraine, Tension-Type,
                                                                                             Suspected neurological conditions: recognition and
		 c. Increasing use of             Cluster and Medication-Overuse Headache (British
			 Advice and Guidance                                                                      referral [NG127] (NICE, 2019)
                                    Association for the Study of Headache, 2010)
 2.	Shared decision
     making and self-                                                                        Quick Reference Guide for Healthcare Professionals:
                                    Headaches overview (NICE, 2018)
     management support:                                                                     Conditions for which over the counter items should not
		 a.   Self-management             Headaches in over 12s: diagnosis and management:         routinely be prescribed in primary care (NHS England)
			     education and support       Surveillance report 2016 [CG150] (NICE, 2016)
			     for headache and
			     migraine
 3.	Transforming
     Outpatients:
		 a. Community migraine
			 clinics
		 b. Community MDT clinics
  aking transformation
 T
 forward

 16                                                                                                                  Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         b. Shared learning opportunities
	The national general surgery
  challenge
  he Elective Care
 T                                 What is the idea?                                             Why implement the idea?
 Development Collaborative
	Overview of ideas being tested   Shared learning opportunities give practitioners and          Shared learning opportunities support management of
  and described in this guide      commissioners from across primary and secondary care the      demand for neurology services. The implementation of
	Essential actions for            chance to improve their knowledge and understanding of        shared learning opportunities may mean that:
  successful transformation
                                   current practice and outcomes for their patients.
 1.	Rethinking referrals:                                                                       Patients benefit from support to manage their condition
		 a. Standardised referral        There are many opportunities for shared learning,             in primary care.
			 pathways and                   including formal training or peer mentoring; system-wide
			 structured templates                                                                         Primary care clinicians gain a better understanding of
                                   shared learning sessions or events; optimising feedback
		 b. Shared learning                                                                            which cases to refer to neurology and the correct
			 opportunities                  from Advice and Guidance services or triage of referrals
                                                                                                 information to include in these referrals. Their knowledge,
		 c. Increasing use of            by specialists; multidisciplinary team case review meetings
                                                                                                 confidence and expertise improve, meaning that referrals
			 Advice and Guidance            and system wide audits.
                                                                                                 are only made into secondary care when necessary.
 2.	Shared decision
     making and self-              For neurology, key learning can be shared around
                                                                                                As the quality of referrals improves, receiving clinicians
     management support:           management in primary care of common conditions, such
                                                                                                have the information they need to accept referrals.
		 a.   Self-management            as headache, or guidance on prescribing and medicines
			     education and support
			     for headache and           optimisation. Local health inequalities can also be examined
			     migraine                   to best understand how to address these. Shared or
 3.	Transforming                  interprofessional learning is valued by clinicians and can
     Outpatients:                  help improve understanding of professional roles and also
		 a. Community migraine           enhance clinical learning (Pearson & Pandya, 2010).
			 clinics
		 b. Community MDT clinics
  aking transformation
 T
 forward

 17                                                                                                                       Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         b. Shared learning opportunities
	The national general surgery
  challenge
  he Elective Care
 T                                 How to achieve success
 Development Collaborative
	Overview of ideas being tested   The sections below include learning from sites in Wave 5 of the Elective Care Development Collaborative:
  and described in this guide
	Essential actions for            Plan for learning opportunities across your local system      by overthinking your offer. You may find that there
  successful transformation                                                                      is information available but people aren’t aware
                                   • Establish where there are gaps in learning. Ask
 1.	Rethinking referrals:                                                                       of how to access it, in which case you may wish to
                                      primary care practitioners which areas they would like
		 a. Standardised referral                                                                      focus on consolidating and promoting this material.
			 pathways and                      to explore and where there are areas for development.
                                                                                                 Alternatively, you may find that the available resources
			 structured templates              Ask secondary care clinicians and expert patients where
                                                                                                 are not fit for purpose in your local context, so adapting
		 b. Shared learning                 they think learning should be directed. The wider the
			 opportunities                                                                                these or designing your own may be a better option.
                                      range of people involved in planning the learning
		 c. Increasing use of
			 Advice and Guidance
                                      opportunities, the wider the range of perspectives.
 2.	Shared decision               • Identify where there are skills and expertise that can     Resources required
     making and self-
     management support:
                                      be utilised. Think about who will be producing, giving     • Information resources,          • Visibility of
		 a.   Self-management
                                      and receiving the education and information materials.       including patient                 consultant
			     education and support         Engage clinicians from across primary and secondary          testimony.                        and specialist nurse
			     for headache and              care from the beginning and ensure the mutual benefits
			     migraine                                                                                 • Posters and leaflets to           among GPs, e.g. leading
                                      of shared learning are explained and understood so that                                        workshops.
 3.	Transforming
                                      people are willing to give of their time and knowledge.      reinforce key learning
     Outpatients:
                                                                                                   points after an event.          • Filming equipment
		 a. Community migraine           • Keep key stakeholders involved. Organisational
			 clinics                                                                                      • A venue to hold the               and editing support
                                      support and local ownership are vital for engagement.                                          for ongoing training
		 b. Community MDT clinics                                                                        session, or via e-learning
                                      Send full updates by email and take the opportunity                                            package, e.g. video, FAQs.
  aking transformation
 T                                                                                                 forum, e.g. video.
 forward                              to present at any clinician meetings or events. Through
                                                                                                 • Administrative support to       • People with lived
                                      engaging with people from across the system, you may
                                                                                                   promote and co-ordinate           experience who are
                                      be able to start having different conversations, share
                                                                                                   the event and pull                willing to share their
                                      learning and improve the care being delivered.
                                                                                                   together the resources            experience.
                                   • Review existing resources to establish what is most          developed by the team.
                                      and least helpful. It is easy to get stuck and held back

 18                                                                                                                          Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         b. Shared learning opportunities
	The national general surgery
  challenge
  he Elective Care
 T                                 Decide upon the approach you will take
 Development Collaborative                                                                         Inviting patients to describe their
                                   • Training and peer mentoring in primary care.                  experiences and insight can be a
	Overview of ideas being tested
  and described in this guide        Specialists can deliver structured training and become        powerful way to optimise learning.
	Essential actions for              peer mentors for clinicians who do not have the same
  successful transformation          level of specialist knowledge. Mentors can come
 1.	Rethinking referrals:           from a range of disciplines including general surgery       • Develop and share resources. These may include
		 a. Standardised referral          consultants, specialist nurses and pharmacists.               specific information such as algorithms, information
			 pathways and
			 structured templates           • Shared learning events and forums. These can count            packs or resources for patients. Such resources can be
		 b. Shared learning                towards continuing professional development (CPD).            invaluable when planning subsequent meetings and
			 opportunities                    They usually have a specific focus and bring together         events and it is useful to plan an easy method by which
		 c. Increasing use of              individuals with similar interests and learning needs.        resources can be shared.
			 Advice and Guidance
 2.	Shared decision               • Virtual multidisciplinary team review meetings. These       • Identify suitable venues and dates. Ensure events are
     making and self-                allow a team of professionals from across primary and         easily accessible and appealing to the intended attendees.
     management support:                                                                           Keep costs low or free for attendees wherever possible.
                                     secondary care to gain holistic oversight of complex
		 a.   Self-management                                                                            Consider holding shared learning events during
			     education and support        patients. They allow for learning and expertise to be
			     for headache and             shared and are an opportunity to ensure that care             scheduled CPD time and ensure an appropriate venue is
			     migraine                     pathways and treatment plans are integrated and               available to keep travel time to a minimum and
 3.	Transforming                    aligned across the multidisciplinary team.                    maximise attendance. Remember to promote relevant
     Outpatients:
                                                                                                   resources developed at the event. It may be useful to
		 a. Community migraine           Plan ahead for implementation                                   identify administrative support to help coordinate
			 clinics
		 b. Community MDT clinics        • Identify a specific focus and engage expert presenters.       venues and invites for speakers and participants.
  aking transformation
 T                                   A specific focus (such as a theme or patient cohort) for
 forward                             an event or virtual review meeting ensures that attendees
                                                                                                   Ensure you consider equality and health
                                     know what to expect and can get the most out of the
                                                                                                   inequality, along with your legal duties
                                     opportunity. This needs to be communicated in good
                                                                                                   to make reasonable adjustments for
                                     time to enable cases to be prepared for discussion and
                                                                                                   disabled people.
                                     to ensure that all relevant clinicians can attend.

 19                                                                                                                      Right person, right place, first time
Introduction                     1. Rethinking referrals
	The national context and
  challenges facing elective
  care services in England         b. Shared learning opportunities
	The national general surgery
  challenge
  he Elective Care
 T                                 • Promote shared learning opportunities to the intended
 Development Collaborative           audience. Approach your local communications team either         The following standards and guidance may be useful:
	Overview of ideas being tested     in the CCG or local trusts to help you produce information       Care of People with Neurological Problems (Royal
  and described in this guide        resources and market any events and materials. Work with         College of General Practitioners, 2019)
	Essential actions for              local clinical networks to attract attendees and ensure the
  successful transformation                                                                           Commissioning better headache services (Bateman, 2015)
                                     right people are involved. Get dates into diaries as far in
 1.	Rethinking referrals:           advance as possible.                                             Guidelines for All Healthcare Professionals in the
		 a. Standardised referral                                                                           Diagnosis and Management of Migraine, Tension-Type,
			 pathways and                   • Optimise informal opportunities for shared learning. For         Cluster and Medication-Overuse Headache (British
			 structured templates             example, referral mechanisms may be a useful tool for            Association for the Study of Headache, 2010)
		 b. Shared learning                improving communication and sharing learning between
			 opportunities                    referrers and specialists across primary and secondary care.     Headache Pathway Case for Change (Cader & Wood,
		 c. Increasing use of              When consultants respond with feedback on the referral,          2017)
			 Advice and Guidance              referrers can share this learning with colleagues for future     Headaches overview (NICE, 2018)
 2.	Shared decision                 reference. Work across the system to enable shared learning      Management of migraine (with or without aura) (NICE,
     making and self-
     management support:
                                     to happen organically alongside developing formal learning       2015)
                                     opportunities.
		 a.   Self-management                                                                               Motor neurone disease: a guide for GPs and primary care
			     education and support      • Think about ways to be inclusive. Consider the timing and        teams (Motor Neurone Disease Association and RCGP,
			     for headache and
			     migraine                     accessibility of sessions to increase attendance (for example,   2015)
                                     for people with caring responsibilities outside of work).
 3.	Transforming
                                     Ensure shared learning is delivered in a variety of formats.     Quick Reference Guide for Healthcare Professionals:
     Outpatients:
                                                                                                      Conditions for which over the counter items should not
		 a. Community migraine           • Share learning as widely as possible. If the speakers and        routinely be prescribed in primary care (NHS England)
			 clinics
                                     participants are happy to be filmed, it can be useful to share
		 b. Community MDT clinics                                                                           Stroke rehabilitation in adults [CG162] (NICE, 2013)
                                     education online to enable those who could not attend to
  aking transformation
 T                                   benefit from the learning.                                       Suspected neurological conditions: recognition and
 forward                                                                                              referral [NG127] (NICE, 2019)
                                   • Seek feedback and review your learning offer regularly.
                                     Consider the best way to evaluate each shared learning           The Long Term Plan for the NHS: Getting it right for
                                     opportunity and ensure that they meet your key aims.             neurology patients (The Neurological Alliance, 2018)
                                     Further iterations and opportunities should be developed         Equality and Health Inequality NHS RightCare Packs (NHS
                                     based on the feedback received and impact achieved.              England, 2017)

 20                                                                                                                         Right person, right place, first time
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