Putting the policy into practice

CPD accreditation

This webinar has been approved by the Federation of the Royal Colleges of Physicians of the United Kingdom for 1 category 1 (external) CPD credit(s). To claim the credit please email hughskelton@neurologyacademy.org

Webinar overview:

• 'The importance of engaging with the new systems'
  Prof Jeremy Hobart
• The national perspective on ensuring the MS optimal pathway presents a clear picture of how adoption of a pathway can support service integration.
  Georgina Carr
• A practical example from Liverpool of how the MS service there is trying to develop an integrated pathway liaising with the new systems across Cheshire and Merseyside and how stakeholders have been brought together to support and integrate elements of the pathway.
  Dr Ian Pomeroy
• The impact of GIRFT on integration and system working
  Jennifer Duffy
• Panel discussion

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Webinar summary

Professor Jeremy Hobart, Consultant neurologist, University Hospitals, Plymouth

As of April 2021, there are 40-plus integrated care systems (ICS) across the UK. Come April 2022, these will become the “future of healthcare”, said Jeremy.

“They will become legal entities,” he said. “We should engage with them because they will be holding the budgets and the power, and because The Raising the Bar for MS Audit has demonstrated quite categorically that the impact MS teams have had on service change has been very limited.”

The national perspective on ensuring the MS optimal pathway presents a clear picture of how adoption of a pathway can support service integration.

Georgina Carr, CEO, Neurological Alliance

The NHS is about to undergo the most “far reaching legislative reforms in a decade,” said Georgina.

The plans were set out in a Government white paper in February, and ICS, which will have consequences for MS services and how they are commissioned, are expected to be legislated for in May’s Queen’s Speech

“So why should all this matter to us? I think the focus on integration within the white paper will be absolutely pivotal for service improvement.

It talks about bringing relevant bodies together – acute trusts, trusts, local authorities, etc – through local ICS boards, to look at setting out kind of service improvement initiatives and services that will meet the needs of the population within that area.

“It also talks a lot about how data digital and technology should be better used in the system to enhance health and care outcomes,” said Georgina.

The commissioning of disease modifying therapies (DMTs) currently sites within specialised commissioning though there is a chance this will be devolved under the new structures.

“There is a risk that this could heighten regional unwarranted variation in terms of the DMTs that are available at a local level.”

Integrated care

Integrated care should improve outcomes and reduce inequalities in access to care, said Georgina, adding that there was system-wide need to optimise pathways.

The National Neuroscience Advisory Group, she explained has been working across the community to develop a suite of optimum pathways.

As well as condition-specific pathways, the group has also created a set of “horizontal pathways” which pull out common essential themes such as rehabilitation, genetics, mental health, and transition from paediatric to adult services.

An optimum MS pathway was put out to public consultation last year, and is expected to be published in the coming months.

What next?

“I would urge you to use the optimum pathway with colleagues in your region to critically access your own service,” said Georgina. “And I’d urge you to work really closely with people with MS with people with neurological conditions.”

Co-creation helps teams to understand what good care looks like, what outcomes and experiences are associated with that model, and how to meet expectations, she explained.

The MS community should also make better use of data to identify and bridge gaps, and to “bolster” health economics work.

“Finally, I just urge you to share good practice. If you are reviewing the pathway in your local area, there are a number of networks and tools that are available for you to use… we don’t want then to just sit on the shelf.”

The impact of GIRFT on integration and system working

Jennifer Duffy, divisional manager for neurology services, Walton Centre

Getting It Right First Time (GIRFT) is a national program designed to improve medical care within the NHS. Jennifer explained that it allowed centres to benchmark themselves against others in the region and identify potential areas of improvement.

“Our deep-dive GIRFT review highlighted good practice – that we have a highly effective and efficient outpatient model, effective and embedded clinical pathways, notably the headache and post seizure pathways, and it also noted our effective and efficient integrated neurology nurse service,” explained Jennifer, adding that the programme recommended the centre share its best practice with others.

“It also gave us some areas to focus on, specifically our responsiveness to the acute element of our model.”

The programme recommended the Walton Centre consider:

• introducing neurology wards at each of the partner hospitals
• introduce frequent ambulatory care at each of the partner hospitals
• accelerating access to neurology for patients presenting to partner hospital emergency departments
• delivering procedure-based outpatients service closer to people’s homes

Implementation

The team is exploring cohorting all neurological patients into one area within each district general hospital (DGH) site, Jennifer said.

“This allows for the opportunity to work with the DGH clinical teams and colleagues to develop their skills and knowledge,” she said.

They have introduced weekly ambulatory clinics across three partner sites, and this will be rolled out across the area. And, as of February The Walton Centre has also launched a Rapid Access Neurology Assessment (RANA) service for emergency department colleagues.

This service provides dedicated access to neurology registrar or consultant Monday to Friday 9am to 5pm. It also allows appropriate patients to be transferred to a RANA assessment area, which is led by a consultant with ring fenced time for this level of support, and access to diagnostics, including MRIs, CTs, and neuropsychology.

“Since RANA was introduced, we have already seen quite powerful benefits. We have had feedback that people are seen in the most appropriate way by the most appropriate person in the most appropriate environment,” said Jennifer.

She added that RANA was also helping to reduce unnecessary hospital stays and avoid unnecessary tests and procedures, while ensuring rapid diagnostics and timely treatment.

“We need to continually monitor, evaluate and re-evaluate, supported by GIRFT, and in partnership with the people who access the service, our colleagues, the community in the public and our charity organisations to support and shape our future state,” Jennifer concluded.

Building integrated pathways within new systems

Dr Ian Pomeroy, Consultant Neurologist, The Walton Centre

Dr Pomeroy gave a practical overview of a “work in progress” regional service redevelopment project, based on the optimum MS care pathway developed by the National Neuroscience Advisory Group

He said: “When you look at the pathway, some of the things that we could change were within our direct control and responsibility. Many other aspects were outside of the control of our own specialist team.

“It is clear that this requires more co-ordination and communication, and is perhaps a little more complex than what we have had before… I think it is about establishing what good care looks like.”

It is very much a “two-dimension route map”, rather than the NICE list of recommendations made in the 2014 NICE guideline, he said, adding this made it “much more complex to implement”.

Starting blocks

With the stated aim of building a clear understanding of future local-level service development across Cheshire and Mersey, and creating practical implementation plans, the team set up an initial meeting.

Held online due to the pandemic, it compromised 47 participants, including doctors, nurses, therapists, community teams, managers, commissioners, charities, patients, and carers.

The event started with a presentation from Dr Matt Craner, who shared his experience of setting up a new MS service at Frimley Park.

“This was a sobering reminder of the time, dedication and the drive required to affect service change, but it was also an inspiration, that this can be achieved,” said Ian.

As the centre of an established, large, regional hub and spoke model, the Walton Centre is starting from a strong position: it has a relatively large and varied MDT and offers a variety of services including specialized symptom management.

However, work from organisations such as the Neurology Academy and the MS charities show that more needs to be done to improve patient experience across the board.

A national piece of work from the MS Society, for example, found patients wanted, among other things, a greater focus on symptoms, rather than just DMTS, and greater access to services for people with progressive disease.

The meeting also heard that local data showed the MS hospital admissions were often caused by deconditioning, or not managing at home with disability, rather than relapses. This led to discussions around a lack of support at home and the issues surrounding urinary tract infection (UTI) treatment.

After this, the meeting was split into four breakout groups to answer the questions: what delegates think is important; what is currently being delivered well; and what do we need to target going forward.

Plan of action

The meeting concluded that the overall services were excellent, but each had room for improvement. The delegates created a list of main priorities which included point of access to deal with all questions in one phone call, clarity around the provision of relapse management, and the linking of MS services with ICS and primary care networks.

“This project is very much unfinished… we are grateful for any feedback and advice, and I hope that sharing our experience is of some assistance to those undertaking a similar challenge,” Ian concluded.

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