DGE0007

Written evidence submitted by John Finlay

Table of contents

1.00 Introduction

2.00  Failures of Project Management (2004-2011): Executive Summary

3.00 Health and Social Care Integration: Staff Resources and Benefits Analytically Estimated: Executive Summary

4.00 Failures of Project Management (2004-2011): Comments and Recommendations

5.00 Health and Social Care Integration: Staff Resources and Benefits Analytically Estimated: Comments

6.00 Health and Social Care Integration: Staff Resources and Benefits Analytically Estimated: Recommendations

7.00 Conclusions

Appendix 1 Lessons learned - NHS + Manufacturing + Research & development.

Appendix 2 A list of types of Long Term Conditions

Appendix 3 Caseload Management for District Nursing: Patient Weighting

Appendix 4a Productive Time and DoH Efficiency Pie (visual chart)

Appendix 4b Productive Time Programme (visual chart)

Appendix 5 Single Assessment Process (SAP) - transcript of 10 minute training video

Table of Contents (continued)

Appendix 6 Newcastle Nursing Staff - hours and cost analysis

Appendix 7 Examples of Information on Reform; IT software implementations and general initiatives

Appendix 8 Ten High Impact Changes for Service Improvement and Delivery (Change No 7) - via the Modernisation Agency.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.00 Introduction

The reason for my submission to your Committee is because I have had a unique insight to the outcomes experienced during IT Community Software Implementations - part of the National Programme for Information Technology (NPfIT) (later known as Connecting for Health). I was employed as the Change and Benefits Delivery Manager within the Department of Informatics and Project Management at NHS North of Tyne (I.e., North Tyneside; Newcastle and Northumberland Care Trusts) from (2004- 2011).

In addition to the above NHS employment, most of my working life focussed on productivity improvement and the production of management and labour cost controls in both manufacturing and research and development environments.

During my 6 years working on NPfIT projects - I documented a considerable amount of information in a ‘Brain Dump’ relating to ‘Reform’ in general - published by the numerous ‘Silos’ of excellence within the NHS. (see Appendix 7)

However, for this submission, I am focussing on 2 key issues for your consideration as follows:

2.00 Failures of Project Management (2004-2011): Executive Summary

The procedures used by Accenture and Computer Science Corporation (I.e., external consultants for software implementations) in conjunction with the NHS during NFfIT projects were not fit for purpose. Because of the way the Project Initiation Documents (PIDs) were designed and jointly approved - the ‘Future ways of working’ were unable to be documented prior to the project ‘going live’ - resulting in inadequate scrutiny by staff ‘Users’. The benefits expected from the implementation could only be identified at a ‘high level’ as opposed to detailed, tangible and quantified as to be expected from a supposed ‘Benefits-led’ approach. Once detailed staff training was possible - inadequacies in the software became apparent causing staff-retraining and general staff disruption. Unfortunately, instead of ensuring that the first project of its kind to go live was proven to be viable - other projects in different areas of the country were commenced - causing inadequacies to be cascaded.

In 2011, I was aware that North of Tyne Primary Care Trusts had engaged wholeheartedly on Agile Project Management as well as redesigning their own PID methodology. I think it is critical that the previous critical shortcomings have been erased and rectified by the new approach.

3.00 Health and Social Care Integration: Staff Resources and Benefits Analytically Estimated: Executive Summary

Information gathered during my experiences in the NHS and Industry led me to realise it was possible to analytically estimate the future resources required for the implementation of Health and Social Care Integration - plus identify tangible benefits to be delivered - plus show how staff remuneration at all levels could be enhanced.

The inspiration for detailing this methodology came from viewing a simple but powerful 10 minute communication video produced by Northumberland Care Trust (See transcript in Appendix 5) - depicting the experiences of a patient with Long Term Conditions ‘Before’ and ‘After’ the expected implementation of the Single Assessment Process (SAP) software.

The statistical basis for the methodology was founded on the (often reported) quote that 5% of the population (I.e., patients with Long Term Conditions) is responsible for 80% of NHS resources.

The long term ‘Future ways of working’ can be developed by a Team of experienced NHS staff - especially with Long Term conditions. They would develop this after being advised of all likely reforms and software outcomes. (see examples in Appendix 7)

The demand for resources for patients with Long Term Conditions is reported to be fairly stable for months - so a one month case study extracted for analysis of a patient’s notes would be reasonably representative of routine activity and resources used.

A detail of ‘hands-on’ estimated times spent by community nurses visiting patients produced by a community nursing team is attached (see Appendix 3) and highlights the type of management information that is currently in use.

Using the above knowledge and information I documented a detailed methodology to highlight and explain how these projections could be made in the form of a ‘Special Communication Project’ (See details in section 5 below)

Prior to the abolition of the Primary Care Trusts; Regional Health Authorities and the Department of Health’s Change and Benefits Team - the Chief Information Officer at the North East Regional Health Authority trusted my methodology and had agreed with the Department of Health to fund my proposed ‘Special  Communication Project’  for 3 - 6 months. Unfortunately, I was unable to be released from my routine duties within the timeframe that the funding was available.

As I have never seen anything published to compare in quality with the above methodology - I strongly recommend that it should be reviewed and implemented if positively appraised. The outcomes would be tangible to NHS and Care staff and members of the public. As opposed to MPs talking about £billions of investment - something tangible will be better to communicate. (A good news story for a change)

4.00 Failures of Project Management: Comments and Recommendations

The failures outlined in the executive summary (see 2.00 above) caused most projects to fail from the very beginning of the National Programme for Information Technology (NPfIT) and were responsible for excessive retraining time and costs. Staff morale was severely affected and increasingly generated a widespread apathy to change - especially with the Single Assessment Process (SAP) where staff were fully committed in principle to the benefits of a common electronic patient record - accessed by all community staff; GPs; and social care staff.

I have no knowledge about the improvements that have been made in this area since 2011- but, whatever project management methodology is used - it is critical that both the ‘Current’ and ‘Future’ process maps are produced before any project goes ‘Live’. If a benefits-led approach to projects is still the aim - then this is the only way to efficiently determine the tangible benefits to be delivered and quantified.

5.00 Health and Social Care Integration: Staff Resources and Benefits Analytically Estimated: Comments and Recommendations:

The best way to understand the potential to be delivered by the above is to read how the methodology of analytical estimation is detailed in the outline of a proposed ‘Special Communication Project’ below:

5.1 Special Communication Project

The Long Term Impact of Health and Social Care Integration - Projections and Quantification of Resources to Assist Workforce Planning

5.1.1 Introduction:

“Major health reform is currently underway, in particular shifting services towards more community and home-based care. The long-term impact of health and social care integration on the NHS workforce remains unclear, and dedicated funding for NHS reform does not clearly show the associated workforce costs.”

This proposed unconventional “Special Communications Project” is designed to detail and highlight just such tangible information.

5.1.2 Background:

In the UK in general, one of the key failures has been the inability to increase the nation’s productivity. The key reasons are;

       Management at all levels’ failure to understand the basic principles on how to make productivity happen.

       Employee and trade union fear of change as increased productivity is often seen as a threat to jobs.

       Lack of investment (or in the case of the NHS - investment made without the expected benefits being delivered due to inefficient implementations)

This recommended project will highlight how the NHS will be able to predict future staffing requirements while identifying tangible benefits to be delivered through the integration of Health and Social Care.

However, because of the project’s unconventional approach, it is thought critical to credibility and “buy-in” to detail both previous NHS and non-NHS work experiences that combined to give inspiration to the development of this Special Communications Project. In chronological order, the thinking behind how the long-term impact of the Health and Social Care Integration project arose (and could be determined and quantified) is listed in Appendix 1

5.1.3 Methodology for Estimating Future Workload and Skills Requirements (i.e., the specific details and calculations behind the Special Communication Project)

 

-          Contact relevant senior managers at NHS; Social Services and Local Councils to ensure “buy-in” from the top.

 

-          Outline aims and expectations of the project.

 

-          Select six patients ensuring that all major Long Term Conditions’ (LTC’s) types are selected for examination (Two will be sufficient at first to establish the credibility and “relative” ease of compilation. On the advice of an “informed” GP - both should involve a patient with diabetes – one with Level 3 “High Complexity” case management requirements and the other with Level 2 “More Complex” care needs).

Note: It is critical to the understanding of the potential resource demands (and the basic assumptions and calculations for this project) that demand for the above type of patient is normally both regular and recurring – over many months.

See Appendix 2 as a reminder of the most common types of Long Term Conditions (LTC)

 

-          Select 2 suitable GPs and the relevant LTC Team of clinicians and get them to recommend two “representative patients” who would be willing to be involved in the project. (Note: Ensure that the patient and NHS Quality Assurance approval is granted which may take about 6 weeks lead time. The total lead time to report the first two examples would be approximately 6 months – assuming good co-operation from senior management)

 

-          Get approval of all Departmental Heads (e.g., Medical Director; Director of Nursing; Director of Social Services etc.) with respect to the involvement of their departmental leads involved with LTC care (i.e., to get approval to use their staff and their patient files for the project). Note: Again, “explanation”, and “communication” to staff on the long term goals of the exercise is important and critical to the successful collection and collation of estimated data – the foundation on which resource workloads (current and projected) will be based.

 

-          Select one typical month’s patient activity for analysis. Advice from a GP is that it would be better to use a last year medical student to extract the information from the GP’s patient’s notes as they have experience in dealing with them.

 

-          Identify all daily activity during the month on a worksheet – highlighting the details as laid out in the example below:

 

Day/Date

 

Tuesday 6th May 2017

Time

Location

Description of Care given

 

Clinician Name & profession

Grade

Used

Reqd.

10.30

Home

Diabetic monitoring

C Smith

Com Nurse

5

5

 

 

Blood Pressure

C Smith

Com Nurse

 

5

3

2.30

Home

Assess bath aid requirement

H Brown

O/Therapist

5

5

 

-          For each activity – go to the clinician’s base to do a follow up analysis in the clinician’s files (i.e., to examine the information recorded – by whom and how provided - and to estimate the times taken. Using some examples from Community Nursing: I would refer to NHS North Tyneside PCT’s Caseload Management estimates which were split into 5 time categories – see a detailed list in Appendix 3 and summary examples as follows:

Average time

(minutes)

 

Care

Weighting

Code

0 – 10

Diabetic monitoring

Blood Pressure

1

1

DM

BP

10 – 20

Simple Dressing

Immunisation

2

2

DR

IMM

20 - 40

Catheterisation

Complicated dressing

4

4

CATH

Comp DR

40 - 60

Continence assessment

Terminal care

6

6

Cont ass

TC

60 - 90

Complex Care

8

CC

 

Note: The above time estimates are for “hands-on care” only and exclude “travel to” and “travel from” the home/previous patient and entering data at base. (This is a critical separation as all travel is “indirect work” and contributes nothing to the care of the patient)

-          Summarise the months information with an “easy to view” layout for analysis as follows:

 

-          Using the above “extracted” information, extrapolate the following “Current ways of working”- monthly summary:

       “Hands-on” care time =?

       “Indirect travel” time =?

       Highlight duplication and inefficiencies with administrative inputs.

       Summarise the variation on skill levels used to identify the potential efficiency loss. (Note: the variation in cost between nursing grades 3, 4, 5, 6, and 7 is +17%, +20%, +23% and +20% respectively. (i.e., the difference between grade 3 and grade 7 is +107%)

       Comment on the frequency and appropriateness of care provided (e.g., is a home visit necessary? Is there anyone more appropriate? Role redesign?)

Note: it is highly likely that many of the names of patients with LTC on the NHS computer database will also be on the Social Services database – giving potential for rationalisation of visits and resources. (Note: Newcastle City Council Adult Services’ budget for year 2006 -7 was £50M. This included such services as Professional Support; Home Care; Meals; Day Care; Direct Payments; Equipment; Overnight Respite; Planned Short-Term Residential Care and Meals)

 

-          Inform the LTC Team of all the known recommended “Business Changes”; “IT implementations”; and potential for role redesign etc. etc. (See Appendix 7) - so that they are then able to devise a “Long-term Future Way of Working”.

 

-          Once the “Future Way of Working” is established – calculate the benefits from the likes of the following:

       Cost savings and a total of “freed-up” more highly skilled hours from using the most appropriate members of staff (e.g., phlebotomist on grade 2/3 to take blood samples instead of district nurse on a higher grade). Note: There are occasions when it is still practical for the higher grade to do – e.g., when visiting the patient to perform another episode of care.

       Cost savings and the addition of “released” skilled clinical hours from a reduction in “indirect” travelling time – made available by better planning  (Note: As a bi-product - there will also be reduced recruitment costs due to increased staff availability)

       Improved service delivery and time saved from reduced duplication of data recording, generation and collation – this assumes new systems being in place. (Note: this has been evidenced when paper-based systems have been replaced by direct computer entry – of which the Podiatry Department at Newcastle Primary Care Trust was a particularly successful example).

       Cost savings and quality improvement arising from role redesign. (e.g., having care staff and new technology in the patient’s home)

With more services being aimed at nearer the home, there is an opportunity to delegate functions and add skills to the lower skill care providers while releasing the more highly skilled to more appropriate tasks. This can then be replicated throughout – making best use of scarce resources with improved job satisfaction and possibly better remunerations for all.

       Quantify savings of better decision-making. Better prevention and care in the Community saves a minimum of 50% from expensive unplanned admissions to hospital. (Note: during a communication exercise with Community Nurses it was interesting to see their great surprise when learning of the high cost savings from their “preventative actions”). 

 

-          Scale up the above estimated savings and benefits to give a perspective on the impact of reforms for the 5% of the patient population that use 80% of the NHS resources. (Note: this rough statistic that is frequently quoted in NHS publications needs closer examination – a more detailed analysis is highlighted in the NHS Modernisation Agency’s “10 High Impact Changes for Service Improvement and Delivery” – Change Number 7) (See Appendix 8)

 

-          Scale up the “more elementary” benefits and savings above which can also be attributed to the other 95% of patients. (e.g., cutting out repetition in collection and recording of personal and clinical patient information – evidenced when moving from paper to electronic records/files and “GP to GP patient data transfers” etc.)

 

As a development of the above detailed analysis – the natural extension would be to investigate the potential for an efficient Resource Management System where the potential for productivity improvement and cost savings is substantial. (Note: A Discussion Document on this subject was presented to the North of Tyne Joint Special Projects Board and the principles outlined were well received). The key productivity improvements would come from the following:

-          Assisting management to realise the potential benefits outlined in report sections 6.10 and 6.11 below and with reference to publications listed in Appendix 7.

 

-          Maximising available resources to the full. (At present, senior Community managers do not have the tools to manage effectively as they are at a distance from day to day activities. Within Community Teams the demand/supply situation is constantly changing with new patients; variations in complexities of patients; staff illness, holidays, training etc.; - as a result “peaks” and “troughs” are constantly occurring – causing either lack of productivity or stress for staff teams.

Only an efficient Resource Management System could resolve this complexity. A review of some relevant web sites claimed that up to 30% savings are possible – with case studies quoted.

 

Note: Changes such as the above can create a huge cultural re-think and animosities. The old clichés will be “rolled out” about not being a factory – however, the NHS is still about making efficient use of limited skilled resources in a constantly changing and demanding environment. See Appendix 1 section 4 for relevant comments.

5.1.4 Cost and Benefits Analysis:

 

It should be apparent that the “Future State” NHS environment involving Social Services and Local Councils will yield massive financial savings as well as more patient focused care. (e.g., see Appendix 4 a and 4b as an example of the scale of what was estimated from a “Future State” situation in NHS England by the Modernisation Agency’s Productive Time Programme)

With respect to the costs of this Special Communication Project, the time estimates of the required project staff would be as follows:

 

       Two patients volunteering for the duration of the project.

       Quality Assurance Team involvement = 5 days.

       Two GP’s selecting and communicating with patients = 2 x 7 days = 14 days

       One last year medical student analysing case notes = 10 days

       Project Manager = 6 month duration but 40 - 60 day’s workload.

       External consultant = 6 month duration but 80 day’s workload

       Specially formed team with LTC knowledge to oversee and audit the “Current State” and “Future State” working processes, costs, innovation suggestions etc. = 6 month duration = 10 x 20 days = 200 days seconded time.

 

6.00 Recommendations:

 

The recommendations are as follows:

 

6.10 Appraise and authorise the methodology for estimating future workload and skills requirements as laid out in Report Section 5 for the first two case studies.

Note: The outcome from this will be the construction of a “skeleton” picture of NHS community resource usage – from which a more “full body” figure can be developed.

 

6.11 Appraise the outcomes from case studies 1 and 2 above, learn lessons and authorise the determination and extraction of information from case studies 3, 4, 5, and 6.

 

6.12 Create an Implementation Team at the highest level within the structures of the Department of Health and Social Services to fulfil the following functions:

 

-          To use information gained from case studies 1 and 2 above (i.e., with the most up-to-date reform information available)

 

-          to devise an Implementation Programme that links the detailed workload and skills estimates and potential to the “Final Solution” – i.e., a tangible vision of what Health and Social Care Integration will look like in 2027 or 2037 or 2050. (Who knows?!)

 

-          To initiate numerous projects and sub-projects that will be needed to create and to ensure that a clear tangible vision can be viewed, monitored, controlled, enthused and directed – from “Bottom to the Top '' and from “Top to the bottom”.

-          Investigate the potential for using a Resource Management System for both the Implementation Programme and Health and Social Care Integration in general.

( i.e., Propagate the start and end goals to all interested parties – then continue with regular updates to show how each project (or sub-project) at its conclusion will help to show progress towards the jig-saw’s final picture – and/or how many bits are still lying on the table.)

 

7.00 Conclusion:

The stimulus for the writing of the above document was a response to years of frustration from seeing wasted potential as well as too much focus on negative minutia. It is all too easy for staff to get “bogged down” in routine and understandable set-backs and forget the well-understood and accepted “theoretical” principles behind the long term goals of reform.

This Special Communications Project is designed to provide a catalyst and motivation to all staff in the NHS; Social Services; Local Councils; the media and the general public. It is intended that the outcomes of the project will show a clearer picture of the “Future State” and potential of the NHS reform agenda. The detailed pieces of analysis will act as the individual pieces of the final jig saw. “Theoretical Principles” can therefore more readily be described as “Practical Principles”.

The most important outcome will be that “negativity” towards progress can be put into perspective and the quantification of the ‘Future State’ benefits will encourage an “Invest to save” culture.

Within the NHS, there is no shortage of knowledge of what improvements can be achieved in the long term. To anyone with detailed insight of events over the last few years – their minds will be saturated with information from “outcomes from software initiatives”; case studies; examples of potential role redesign; “lessons learned seminars” etc., etc.,

 

In complement to the above – it is only through a detailed analysis of routine and recurring activities of such a resource-demanding group of patients with LTC that future NHS workload resources can be efficiently quantified and predicted – i.e., with maximum scrutiny and confidence - but most importantly focus and control.

 

 

 

 

Appendix 1

“Lessons Learned”

NHS and non-NHS work experiences that combined to give inspiration to the development of this Special Communications Project.

 

1 When involved in a fully comprehensive review of a poorly performing manufacturing department - I realised for the first time the dramatic impact to output and unit costs that better training and improved productivity could make.

 

2 Responsibility for the collation and production of Management and Labour Cost Controls for a medium sized manufacturing company provided me with an important lesson on productivity and performance – i.e., the benefits of regular examination and monitoring of key statistics such as “Productive Time”; “Indirect Time”; “Lost Time”; “Premium Costs”; “Departmental Costs” to the maintenance of an efficient operation. (Note: These controls were a copy of those used by the Courtauld Group - involved in clothing manufacture where cost effectiveness was critical to competitiveness). This knowledge came back into mind when analysing the efficient and effective use of community staff resources at North Tyneside Primary Care Trust.

 

3 At GlaxoSmithKline (Research and Development) there was an impressive lesson on how a company can “Invest to save”. (i.e., the intention by a project manager to spend an additional one-off £50K on an alternative part-producer – saving £25M over the patent period from the world-wide sales of an innovative asthma aerosol inhaler). Some years later – the thought was “So what about NHS reform potential?

 

4. At GlaxoSmithKline (Research and Development) there was alarm when the profits from their most successful drugs were being severely reduced after the expiry of the patent period (15 years) – due to aggressive competition from generic manufacturers.

In response, they set up a “New Products Introduction” Department to find ways of minimising these losses. One of their key findings was that for every day “lost” during the “patent period” of a successful drug – it was costing £1M.

 

The knock-on effect was that regular excuses from suppliers (e.g., Huntingdon Life Sciences) were not to be tolerated and pressure was brought to bear regarding the eradication of “Late delivery” of services (e.g., animal study reports).

Huntingdon Life Sciences had then to confront their inefficiencies – and found it difficult to come to terms with the fact they needed a proper Resource Management System (i.e., something  that the manufacturing industry had been using for a generation). Why should they have been surprised? – They were also similarly trying to coordinate effective use of limited staff resources and highly expensive and overloaded equipment such as within the critical Mass Spectrometry Department).  

 

5. Viewing the high level yearly benefits of £2.9bn expected from the English NHS Reforms depicted in the “Productive Time Programme” diagram (Appendix 4b) helped to show someone at the NHS Modernisation Agency had a vision for the future. (This represented up to half of the total efficiency gains from Health). It explained that the objective was to make better use of staff time. It was not about getting staff to work harder, but about enabling staff to work smarter, spending more time on where it matters for them and for patients: quality direct contact care.

There were said to be significant opportunities for both cost efficiency and quality improvement through the integrated implementation of the following change strategies:

       Process: High Impact Changes (HIC)

       People: Workforce Reform

       Technology: NHS Connecting for Health

 

Addressed locally as part of a whole-system approach, these strategies constituted the key enablers to maximising service improvement at an organisation level. See Appendix 4a and 4b

6 The easy viewing of a 10 minute training video produced by the Northumberland Care Trust as part of their communication exercise when introducing a new software package. This was inspirational to both myself and a seconded project manager from the Department of Health. This communications exercise was part of the NHS North of Tyne’s pilot project (on behalf of the Department of Health) to implement the Single Assessment Process (SAP) for older People. This simply told story was effectively a case study of a patient’s outcomes “Before” and “After” the introduction of the new software – highlighting better cooperation, communication and efficiency between professional staff/clinicians, both NHS and Social Services. A transcription of the video is detailed in Appendix 5.

 

7 During software implementations for Community Nursing, Podiatry and Physiotherapy, details of the “Current” and “Future” ways of working had to be established. These were greatly assisted by close working relationships with clinicians seconded as Business Change Managers from their departments to the Department of Informatics and Project Management.

Inefficiencies and deficiencies in the “Current” ways of working were to be clearly defined and quantified – therefore enabling the benefits of the proposed software implementations to be calculated.

 

During these project implementations, the three most enlightening revelations were as follows:

(a)   By chance, seeing notes from a “Seminar on Patients with Long Term Conditions” absent-mindedly left on a photocopier at North Tyneside PCT - stating that 5% of the population with Long Term Conditions accounted for 80% of the NHS resources consumed. This seemed especially interesting information as the classic management consultant approach to appraising a failing company’s performance is to examine the 20% of products that generate 80% of the revenue/profit. (i.e., Pareto Analysis) It therefore came to mind that a close examination of how resources for patients with Long Term Condition (LTC) were used would be the most efficient way to analyse and project future NHS demand.

(b)   The wage differential for District Nursing grades 4,5,6 and 7 compared to grade 3 is +17%, +40%, +73% and +107% respectively. So, when the workload of the various grades includes doing less skilled work than their pay scale merits – there will often be a reduction in productivity. Such potential efficiency short-comings should not be underestimated as the annual total hours and costs incurred by District Nursing North of Tyne (NoT) were 474 w.t.e. and £12M respectively. See Appendix 6 for an extract from Newcastle PCT’s Electronic Staff Record as an example of staff hours and costs. Report Section 5.10 & 5.11 plus Appendix 7 highlight other more general examples of how resource availability can be improved.

(c)    It was interesting to see the Workload Estimates used by Community Nursing Managers at North Tyneside Primary Care Trust. These individual estimates of time to care for a variety of patient needs are used to provide adequate resources to meet patient needs on a daily basis. Appendix 3 highlights the variety of times allocated for the different complexities of patient care.

 

In summary, over a six year period as the Business Change and Benefits Realisation Manager at NHS North of Tyne I experienced both the positive and negative outcomes resulting from numerous IT software initiatives – at local and national levels. Detailed information on “Best Value”; “Service Improvement”; “Staff feedback on Initiatives”; “Benefits Delivery” and “Departmental Expenditures” from all of these has been documented for future reference.

FOOTNOTE: Prior to the abolition of the Primary Care Trusts in England - the Chief Information Officer at NHS North East had agreed with the Change and Benefits Team at the Department of Health to find funding for the Special Communication Project.

However, local PCT priorities meant that it could not be undertaken within the time-scales of the available funding.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix 2

Long Term Conditions

A Reminder of the of the Main Conditions

  1. Coronary Heart Disease (CDH)

 

  1. Chronic Obstructive Pulmonary Disease (COPD)

 

  1. Diabetes

 

  1. Neurological Conditions (e.g., MS, MND, Parkinsons)

 

  1. Stroke

 

  1. Asthma

 

  1. Chronic Renal Failure

 

  1. Mental Health Disorders

 

  1. Palliative Care / Cancers

 

 

 

 

 

 

 

 

 

Appendix 3

District Nurse Caseload Management – Patient Weighting

 

Average

Time

 

Weighting

Care

Code

0 – 10 minutes

1

Insulin

Neocytaman

Other injections

Eye Care

Diabetic Monitoring

Blood Pressure

INS

CYT

INJ

EC

DM

BP

10 -20 minutes

2

Catheter care / Bladder washout

Continence review

Venepuncture

INR

Simple dressing

Sutures / clips removal

Ear syringing (1 ear)

Immunisation

Zolodex injection

Pressure areas / leg care

Stoma care

CATH/SV

Cont R

IVB

INR

DR

ROS/RO

ES1

IMM

ZOL

PAC

STOM

20 – 40 minutes

4

Unilateral compression bandages

Ear syringing 2

General assessment

Catheterisation

Palliative support

Bowel management

Complicated dressing

Comp 1

ES2

ASS 3

CATH

PALL

BC

Comp DR

40 – 60 minutes

6

Bilateral compression bandaging

Doppler assessment

Doppler review

Continence assessment

General assessment

Chronic Disease Management

 

 

 

COAD oxygen assessment

Terminal Care

COMP 2

DOPP

DOPP R

Cont ass

Ass 4

NSF C

NSF D

NSF S

NSF O

COAD

TC

60 – 90 minutes

8

Complex / Continuing Care – i.e., numerous interventions at one visit.

CC

 

 

 

 

 

 

 

 

 

 

Appendix 4a

Productive time:

Productive Time is about making better use of staff time. It is not about getting staff to work harder, but about enabling staff to work smarter, spending more time on where it matters for them and for patients: quality direct contact care.

Productive Time is expected to yield £2.9bn yearly benefits by 2007/08 against a 2003/04 baseline. This represents up to half of the total efficiency gains for Health and nearly a fifth of the cross-governmental efficiency review savings.

DH efficiency pie - image

 

There are significant opportunities for both cost efficiency and quality improvement through the integrated implementation of the following change strategies:

       Process: High Impact Changes (HIC)

       People: Workforce Reform

       Technology : NHS Connecting for Health

Addressed locally as part of a whole-system approach, these strategies constitute the key enablers to maximising service improvement at an organisational level.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix 4b

 

 

 

 

 

 

 

 

Appendix 5

The Patients Story (i.e., a fictitious Joan Collins)

Extract from the Single Assessment Process (SAP) 10 minute training video

“Existing” ways of working as told by patient:

'Hello, my name’s Joan, - Joan Collins – no, not that one; the one that was Joan Davison before I married George Collins.

They’ve asked me to tell you about my recent experiences in and out of hospital - so you can learn something from me. I don’t know what - but I do know things could have been better.

Anyway, I’m a coeliac you see which means I can’t eat anything with wheat - it’s a blooming nuisance - no bread, no cakes or biscuits, and I suffer from mild angina and asthma.  I’ve started becoming quite out of breath at times.  I’m a bit of an anxious person and when I get anxious my asthma seems to get worse and when I get a cold then my chest goes to pot.  Not that I go far to catch a cold.  I get quite bored really and my daughter tells me I dwell too much on my health.

I’ve been thinking that there’s something in what she says - and you don’t like to call the doctor out without good reason, do you?

Anyway my chest had been getting worse over the last few weeks so I called the doctor out last week, because it was very wheezy.  I couldn’t breathe well at all.

'Hello' he says when he'd put his stethoscope on my chest and then takes my blood pressure - 'You have got a bad chest. I think we'll get you down to the Hospital for some tests.  So the doctor phones the hospital and gives them my name, address and so on and then he phones the ambulance and does the same again!

So the ambulance takes me and George to the hospital, but when we got there we had to wait in Accident and Emergency for a couple of hours until we were seen.  Then I get asked lots of questions, name, address, date I was born…… ; I told them the doctor had phoned it all through, but they said it was 'procedure'- then they took some blood for tests and I got admitted to Ward 10. 

Guess what - we got asked the same stuff again – it’s blooming mad if you ask me. It was about what help we need to stay at home.  I had to give the usual information – names, date of birth, medication and so on.  She asked if I'd like to go to day care. 'I most certainly do not' I said.  'Why would I want to go and sit with a bunch of “old fogeys”?  I like to go out shopping or to bingo but I don’t want to go to a day centre full of people who need looking after.  What do they think I am?

After the social worker had gone George's community nurse came round. She’s really nice and while she was here the occupational therapist came as well because I need help getting in and out of the bath.  She said she'd come to 'assess my daily living activities'.

Guess what…. she had another form to fill in!  She says she knows the nurse who comes in on a Friday to put our tablets into the little boxes.  It’s funny that  because she has her own paperwork, which she keeps in our sideboard with all our details on - but she’s the only one who looks at that.

Anyway George sits with me for a couple of hours, before he says he thinks he should be off.  There’s been nobody along to tell us what’s going on, they are busy with another admission, and my chest is just the same - so there doesn’t seem much point  in him hanging about.

I caught the nurse and asked what we were waiting for.  The nurse said I’ve got to wait for the doctor to come and give me a diagnosis before they can implement my treatment.  So not much progress there then.

Anyway on the way home George gets lost - he forgot where to get the bus and started walking and was picked up by a Good Samaritan - good thing - I can’t imagine what was in his mind – it’s ten miles home - he must have been, mad;  …can’t understand why he didn’t call a taxi.

The next day they reckon I need to see the consultant who deals with people with anxiety problems.  He's off sick and in the end I had to wait 4 days to see his senior registrar.

Because of Georges lapse – he’s not in good health anyway (he's had a heart bypass and his memory isn’t good) - my daughter came down to stay with him while I was in hospital.  Her husband wasn’t happy - he had to take time off work to look after the kids …(- aside ).  Make a nice change for him!

My chest started to get better with the antibiotics and some oxygen, and they gave me some new tablets for my anxiety. When I got discharged they gave me some of the antibiotics and nerve tablets - but they only lasted a week. I don’t know why the doctor didn’t give me them at home in the first place, though - they are just the same as what I usually get - I suppose my chest had got too bad by the time he visited.

I tell you what though, I wasn’t half glad to get out of hospital - I hardly ate for the first two days - I didn’t like to tell them I was a coeliac. I didn’t think I’d be in long - not that it made a lot of difference - the gluten free diet means you don’t get what the others do - they just give you something simple. No bread, no pastry, and no sauces - they just take out the bits with wheat!  The dietician was nice when she came round though; she had lots of advice about what I should do when I got home.  I think she should start with the ward staff, but I didn’t like to say anything.

Anyway when I get home everything's upside down - my home is not my own. My daughter has to have things her way and has reorganised my kitchen so I don’t know where anything is. She’s looked after George well, but she's reorganised everything of his too - so he’s even more confused

The social worker came round today, to 'assess my care package' she said - I thought she was going to give me a nice food parcel or something at first - but it was about what help we need to stay at home.  I had to give the usual information – names, dates of birth, medication and so on.  She asked if I'd like to go to daycare. 'I most certainly do not' I said.  'Why would I want to go and sit with a bunch of “old fogeys”? I like to go out shopping or to bingo but I don’t want to go to a day centre full of people who need looking after.  What do they think I am?

After the social worker had gone George's community nurse came round. She’s really nice and while she was here the occupational therapist came as well, because I need help getting in and out of the bath.  She said she'd come to 'assess my daily living activities'.

 

Guess what…. she had another form to fill in!  She says she knows the nurse who comes in on a Friday to put our tablets into the little boxes.  It’s funny that because she has her own paperwork, which she keeps in our sideboard with all our details on - but she’s the only one who looks at that.

 

As Joan finishes - cut back to Paul Edmonds

I'd now like to ask you to consider a number of questions relating to the video you’ve just seen - details are in worksheet 2

FACILITATOR

Please turn to worksheet 2 and in pairs/threes answer the questions – 5 minutes per question.  Put the question number and answer on ‘post-its’.  At the end of the exercise - collate on pre-prepared flip charts.

WORKSHEET 2 - SINGLE ASSESSMENT –JOAN’S TALE

Questions:

1.              Is this person centred practice?

2.                            Did you feel Joan had a say in what happened to her?

3.                            How could the assessment of this individual’s and joint circumstances have been improved?

4.                            What could have been done to prevent hospital admission?

5.                            How could the stay in hospital have been approved? (Did they mean improved?)

6.                            Who could coordinate the care better?

 

FACILITATOR

 

Let’s jump ahead 5 years and look at what has happened to Joan (i.e., post SAP introduction)

 

JOAN COLLINS 2

 

''Hello!  I don’t know why but they asked me to talk to you again - do you remember (not getting forgetful are you?) they asked me to talk to you five years ago when I’d been into hospital and there was a right kerfuffle.

They said that by listening to me would help make things better.

Well, my chest is still awful and George is worse – can’t remember anything now, but I must say these young people who look after us are not doing a bad job, even if they don’t look old enough to have left school.

For instance, my chest went off again last month but the home care knew that they had to report it early to the doctor.  When he came out he was a new one I’d not seen before.

 

Hello Mrs Collins he said, I’ll just look up your details. He looked up our records on the computer he’d brought with him and after he’d examined me he said –We’ll try to treat you at home so you and George aren't too disrupted - but if you do need to go into hospital we’ll be able to put in carers to look after George, or at least give your daughter time to plan a visit.

He had all the details there in front of him - hardly asked a daft question!  He knew I was a coeliac - so he said he wouldn’t prescribe tablets with wheat germ in - some of them have it you know - and there was a link through to George’s records so he was able to look him up too.  He could even tell me the social worker's name and when I’d last been in hospital and the work that the Occupational Therapist did to get our house rigged up to cope with our problems.  They call it a ‘smart house’ - mind you, I’ve always been home proud, you know, and they can tell in the call centre who’s been in to make the lunch or tea, whether we’ve locked the front door, and we can talk to them if we like '.  They’ve even arranged for someone to pick us up and take us to the Club on a Wednesday and bring us back later on.  We’re fine when we’re with our old friends – they see us right.  It is all pretty good really.

 

 

 

 

 

 

 

 

 

Appendix 6

 

Newcastle PCT Hours and Cost Analysis

(Building from the “bottom up”)

 

Job Title

Grade

Staff

Nos

W.T.E.

£A/Salary

(midpoint)

£T/Cost

(Annual)

£Cost + 23% O/H

District Nursing

(all over the city)

 

 

 

 

 

 

Health Care Asst.

3

49

30.52

15,446

471,412

579,836

Auxiliary Nurse

4

1

1.0

18,039

18,039

22,188

Staff Nurse

5

62

51.09

21,646

1,105,894

1,360,250

District Nurse

6

60

50.33

26,720

1,344,818

1,654,126

District N/Sister

7

9

7.7

31,906

245,676

302,182

Sub-Total

 

181

140.64

113,757

3,185,839

3,918,582

 

 

 

 

 

 

 

D/Nurse Student

(University Based)

 

 

 

 

 

 

Student D/Nurse

5

15

6.5

21,646

140,699

173,060

Sub-Total

 

15

6.5

21,646

140,699

173,060

 

 

 

 

 

 

 

COPD

 

 

 

 

 

 

Resp.Sup. Worker

3

1

1

15,446

15,446

18,999

Liaison Nurse

6

2

2

26,720

53,540

65,731

Com/Matron

7

4

3.8

31,906

119,967

147,559

 

 

7

6.8

74,072

188,853

232,289

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: It has been reported that NHS England have recently introduced a new additional grade of nurse to the ones detailed above.

 

Appendix 7

Examples of the information on reform, IT and technical initiatives that have been collated were derived from time working at NHS North of Tyne as the Business Change and Benefits Manager.

See list below:

  1. Full background material relating to the development of the Single Assessment Process (SAP) – a software package for person centred care designed in consultation with Accenture to assist with the healthcare of older people / patients with Long Term Conditions. Note: This includes a 10 minute video highlighting a patient’s comments on her quality of care pre and post the implementation of the SAP software.

 

  1. “Review of the Single Assessment Process” project for older people (SAP) – identifying “lessons learned” and making recommendations for any proposed re-launch.

This was co-authored with the Assistant Director of Nursing (Generalist Services).

  1. The Modernisation Agency’s “Productive Time Programme” projected savings diagram.

 

  1. Service Improvement Initiatives:

       NHS 2010-2015: From Good to Great. Preventative, People-centred, Productive.

       Changing Workforce Programme (New Ways of Working in healthcare).

       The Working in Partnership Programme (WiPP) – creating capacity in General Practice.

       The Social Services White Paper “Our Health, Our Care, Our Say”.

       Resource Management System – reasons for development

       Practice-based Commissioning (PBC) Services being provided North of Tyne (06/07) (“indicative costs only”)

       SHA East of England 2006/7 Annual Report: service redesign for PBC (Case studies detailed)

       A Beginners Guide to Payment by Results

Footnote:  There is an “endless” list of such information from both the Scottish and English NHS Publications.

 

Appendix 8

NHS Modernisation Agency

“10 High Impact Changes for Service Improvement and Delivery: a guide for NHS leaders – Change No 7”

 

Statistical Quotes Extracted

       78% of all healthcare spend relates to people with Long Term Conditions.

       80% of GP consultations relate to Long Term Conditions.

       For patients with more than one condition costs are 6 times higher than those with only one.

       Patients with Long Term Conditions or complications utilise over 60% of hospital bed days, often as a result of emergency admission.

       10% of inpatients account for 55% of patient days; 5% account for 42% of patient days.

       In the NHS Pilots of the American Evercare System, 3% of the at-risk over 65’s accounted for 35% of the unplanned admissions for that group.

       Between 50-80% of that cohort were not known to district nursing services or social services.

“This leads us to believe that we must change how patients with Long Term Conditions are supported by the NHS if we are to improve the quality of care, reduce the fear, anxiety and needless cost of having to go into hospital and enable people to lead fuller lives with their families and communities”

Note:

NHS Greater Glasgow and Clyde’s “Strategic Framework for the Management of Long Term Conditions – Delivering change to 2015” makes similar stratified risk levels of care for LTC patients as follows:

(3% to 5%) = high complexity/vulnerability

(15% to 20%) = more complex cases

(70% to 80%) = supported self-care

June 2023