1 Vanguard Programme: Acute Care Collaboration Value Proposition November 2015 Version: 1 30 November 2015
2 ACC Vanguard: Moorfields Eye Hospital Value Proposition 1 Contents Section Page Section 1: Introduction 2 Section 2: Our context 3 Section 3: Vanguard Aims, Outputs and Logic Model 7 Section 4: Our programme 10 Section 5: Our proposed support package 15 Section 6: Summary and conclusion 17
3 ACC Vanguard: Moorfields Eye Hospital Value Proposition 2 Section 1: Introduction Moorfields Eye Hospital NHS Foundation Trust Moorfields is the leading provider of eye health services in the UK and a world-class centre of excellence for ophthalmic research and education. Our main focus is the treatment and care of NHS patients with a wide range of eye problems, from common complaints to rare conditions that require treatment not available elsewhere in the UK. Our unique patient case-mix and the number of people we treat mean that our clinicians have expertise in discrete ophthalmic sub-specialties. In 2014/15 we saw over half a million patients in our outpatient services and carried out almost 40,000 surgical procedures, making Moorfields the largest ophthalmic provider in the UK. We also provided care to 96,000 patients in our A&E department. We treat people in 23 locations in and around London, which enables us to provide expert treatment closer to patients homes. We also operate commercial divisions that provide care to private patients in both London and the Middle East. Moorfields innovative approach to delivering care across multiple satellite sites has been explicitly referenced in recent national policy. The Five Year Forward View highlighted the benefits of our model in helping to sustain local hospital services and enable smaller hospitals to remain viable. The Dalton Review categorised our approach as a contractual arrangement which it described as a service-level chain. More recently, the model has been cited as an example of franchising or networked care. Terminology will be important as we seek to describe the models that could be replicated across the NHS. In this Value Proposition we use the term networked care to describe the generic model of collaboration between providers, and the term satellite model to describe the approach currently delivered by MEH. Rationale for our vanguard Acute hospitals are facing increasing challenges to deliver safe and cost effective care, especially in smaller clinical specialties such as ophthalmology which often lack the benefits of scale in a local setting. In the absence of critical mass of patient numbers or specialty workforce, provision of care may become clinically or financially unsustainable. These difficulties are often compounded by competition generated by local commissioners and other providers. Moorfields has developed a satellite model that provides clinically and financially sustainable local access to high quality ophthalmic care, and a sustainable model of specialist treatment. We believe that the Moorfields satellite network model has potential replicability across the acute healthcare system and a key part of our vanguard will be to gather data to test this view. The aim of our vanguard is to consolidate our learning in delivering networked care, so that we, and the wider NHS, can develop a clear understanding of when and how this New Model of Care can enable acute hospitals to become clinically and financially sustainable. We want to describe what good looks like for networked care and how it can be implemented successfully across the NHS
4 ACC Vanguard: Moorfields Eye Hospital Value Proposition 3 Section 2: Our context: ophthalmology as a case study of the sustainability challenge Ophthalmology in the NHS has a particular set of sustainability and quality challenges. It is a small specialty in the overall context of an acute hospital where small volumes of sub-specialty care mean there are critical mass issues, an older population who want and need local access to treatment and a market in which cataract as well as other profitable ophthalmic treatment is delivered by many competitors. These issues are exacerbated by commissioning approaches to driving down cost which lead to provider competition and further fragmentation of services. Ophthalmology is rarely a high strategic priority specialty in acute hospitals (apart from when defending a tender to remove profitable elective services). Commissioners have focused on tendering ambulatory services to save money, which can result in a proliferation of sub-scale, poorly coordinated and unsustainable services without a plan to support chronic care, specialist or complex ophthalmology services. We need to review our current network, understand and standardise best clinical, operational and commercial practice. This will inform how we should further develop our network of eye care services and how we can support development of sustainable, high quality services. Moorfields was an early adopter of the principle that where appropriate clinical services should be provided within local communities, establishing high quality local eye centres where possible. We are recognised as an exemplar of a specialist provider working in a new and innovative way to deliver local services to residents outside of the acute hospital environment. Over time our reach has extended and we now treat people in 23 locations in and around London, as new localities and providers select us as their partner to provide their local eye care services, which enables us to provide expert treatment closer to patients homes. These services are organised as follows: Central base: District hubs: Satellite surgical centres: Satellite sites: our central London hospital on City Road provides comprehensive general and specialist outpatient, diagnostic and surgical services, emergency surgery and a 24-hour A&E. co-located with general hospital services our five district hubs provide comprehensive outpatient and diagnostic care as well as more complex eye surgery. our five satellite surgical centres provide more complex outpatient and diagnostic services alongside daycase surgery for the local area. we also have an additional seven satellite sites where the clinics focus predominantly on outpatient and diagnostic services in community-based locations closer to patients homes. Partnerships/Network models: Moorfields offers medical and professional support to four eye services managed by other organisations secondary and smaller primary care organisations working within high street optician practices.
5 ACC Vanguard: Moorfields Eye Hospital Value Proposition 4
6 ACC Vanguard: Moorfields Eye Hospital Value Proposition 5 Our satellite network model and site relationships The figure opposite illustrates the current Moorfields Eye Hospital satellite network model, the types of services provides and the relationships between sites, which are structured around 6 district hubs. The Moorfields network has grown in a largely unplanned way, through commissioner and provider requests. We recognise that our organic growth has often been responsive to individual organisational contexts. As a result our approach to assessing each new business opportunity and implementing our service-level chain model has not been standardised. We have been approached by several other organisations to provide advice to their eye units, including some who explicitly request implementation of the model. We recognise that extending our service-level chain model is not appropriate in all circumstances and therefore tailor our input. As a result, we also have extensive experience of providing advice and consultancy to partner organisations. There is clinical and managerial consensus that we would benefit from standardising our approach to assessing new business opportunities and implementing our service-level chain model. Some progress has been made in codifying our clinical pathways as well as developing an opportunity analysis toolkit.
7 ACC Vanguard: Moorfields Eye Hospital Value Proposition 6 Wider applicability of the Moorfields satellite network model across the NHS The issues described above in relation to ophthalmology are often applicable to other clinical specialties. The pressures facing smaller district general hospitals are often complex. It is increasingly difficult for these organisations to afford to deliver high quality care across all clinical specialties and sub-specialties. Understandably, smaller clinical specialties are rarely a high strategic or operational priority in such hospitals. The sustainability of some smaller clinical services can be called into question by a range of factors which relate to the size and scale of the service; Low patient volumes This will often mean an organisation is not able to provide a full range of sub-specialty expertise, resulting in patients being referred to another provider for more complex diagnosis or treatment. This can mean patients wait longer for treatment as well as travelling further to access care. Low patient volumes for certain conditions can be associated with poorer outcomes. Isolated and vulnerable workforce Any service which requires specialist staff to deliver complex care on a small scale is placing pressure on their workforce. There are limitations on the peer support available for clinicians (including training and clinical case review), issues of deskilling and the sustainability of the service during planned and unplanned staff absence is also called into question. This can impact on professional development as well as the quality of care provided. Investment in capital equipment. For equipment intensive specialties, it can be difficult for smaller organisations to justify the financial investment in specialist equipment. Despite these challenges, patient and commissioner expectation is that wherever possible a comprehensive range of services should continue to be provided locally. It is important to note that whilst delivering networked care can present a solution to many of these issues it can also create new challenges to safety and the balance between standardisation and local flexibility. Through our vanguard programme we will surface and examine these issues. Opportunistic commissioning and provider competition can create barriers to transforming services as the driver tends to be favour finance over sustainability and competition over coordination. Without a plan to adequately fund and develop specialist and tertiary services, the proliferation of these sub-scale and potentially unsustainable services is taking no account of the impact this is likely to have in the longer term. The aim of our vanguard is to consolidate our learning in delivering networked care, so that we, and the wider NHS, can develop a clear understanding of when and how this New Model of Care can support hospitals in becoming clinically and financially sustainable.
8 ACC Vanguard: Moorfields Eye Hospital Value Proposition 7 Section 3: Vanguard aims and outputs What are we trying to achieve? We want to consolidate our learning in delivering networked care so that: the NHS can develop a clear understanding of: (a) when and how this new model of care can support acute hospitals in becoming clinically and financially sustainable (b) the implications of extending models of networked care more widely across the service we, as Moorfields Eye Hospital, can deliver sustainable ophthalmology services that meet the needs of local populations and are delivered in an effective network We have identified three long term impacts that our Vanguard programme will deliver; 1. Patients will have greater access to locally delivered, clinically sustainable services 2. Acute hospitals will become more sustainable by working with partners in a network model(s) 3. Networked care will be supported by effective and sustainable governance structures, underpinned by a strong organisational culture We want to undertake further analysis of the factors that make us more effective in some settings. We re keen to learn what makes the biggest difference for patients, staff and partner organisations in getting things right first time when establishing a service in a new setting. By learning from the experience of other NHS organisations, as well as our own, we will codify the optimal approach to establishing and sustaining a service-level chain model. This will enable the NHS to implement such models at pace and scale, realising the benefits of clinical and financial sustainability across the system more quickly. We will undertake a comprehensive assessment of the opportunities and risks associated with an extended networked care model, learning from our own and others experience. This will consider both increasing the number of satellite sites as well as widening the geographic reach of the organisation. We will describe, evaluate and share the learning from our work so that it can be replicated and used across the NHS.
9 ACC Vanguard: Moorfields Eye Hospital Value Proposition 8 The outputs of our work Our programme will deliver four key outputs, which will deliver benefits for the wider NHS, and for Moorfields Eye Hospital; The critical success factors that need to be in place across a network in order for it to succeed. A toolkit that codifies best practice in establishing the need for and implementing networked care A publication outlining how the models of networked care can be extended whilst still delivering clinically and financially sustainable services Analysis of how networked care can be responsive to the needs of local populations whilst delivering consistent quality and service From our experience to date, we anticipate that this will include recommendations on how to; Ensure consistent quality of care (including clinical outcomes, safety and patient experience) across multiple sites Deliver a sustainable workforce model Develop equitable educational and research opportunities for staff and patients Maintain effective partnership working with numerous providers and commissioners Protect organisational reputation Sustain the local delivery of subspecialist activity in a way which is both clinically and financially viable Balance the need to centralise (to achieve standardisation) and devolve (to achieve localisation) For the wider NHS our programme will deliver a description of what good looks like for networked care, a toolkit than can be used to establish successful models of networked care in other locations, and a summary of the implications of extending models of networked care more widely across the NHS. The analysis will be available to inform national policy development and implementation in relation to viable smaller hospitals. For Moorfields Eye Hospital these outputs and the wider vanguard programme will enable us to determine the next phase of our network plan, including: where we should provide services in the future, how we can work with stakeholders to plan for all of the eye care for a population, how we should partner and work with other providers, the governance arrangements required for high quality services across growing and dispersed networks, and the organisational structures that can support this new model of care to be high performing, with a good culture and good reputation.
10 ACC Vanguard: Moorfields Eye Hospital Value Proposition 9
11 ACC Vanguard: Moorfields Eye Hospital Value Proposition 10 Section 4: Our Programme Overview of our approach The figure below provides an overview of our programme.
12 ACC Vanguard: Moorfields Eye Hospital Value Proposition 11 Programme Activities In order to create the outputs described in section 3 of this value proposition, in collaboration with partners from the NHS and commercial sector we will complete a detailed progamme of work, to include the following activities; Activity 1 Understanding existing models 2 Assess existing models 3 Undertake stakeholder review 4 Review lessons from other sectors and oversees Description We will describe and define the different models of networked care that are already in place in MEH and those that are used elsewhere across the NHS and commercial sector We will assess and review the existing MEH models of networked care, in terms of clinical quality and operational effectiveness and in relation to other aspects of the service including accessibility, patient experience, staff wellbeing, organisational culture and activity levels We will engage with key stakeholders, including patients, staff, provider partners and commissioners in order to assess the quality and reputation of the existing models of networked care in MEH and elsewhere We will build on the research undertaken as part of the Dalton review, researching and/or visiting examples of successful networks in other sectors and from health care in other countries. 5 Network analyses We will consider the themes arising from our review and identify the conditions under which networked care works well and when it doesn t. We will work with new systems in different parts of the country to explore how MEH could support the planning and delivery of networked ophthalmology 6 Detailed market analysis 7 Review networked care opportunities We will map activity levels and patient flow at a provider and commissioner level across the MEH network, and compare the output with local population needs assessments We will test the feasibility and implications of stretch in terms of geography and number of sites - for a networked care model.
13 Timescales and key milestones ACC Vanguard: Moorfields Eye Hospital Value Proposition 12
14 ACC Vanguard: Moorfields Eye Hospital Value Proposition 13 How we will evaluate and share the outputs The outputs of our programme will be shared with the New Care Models Programme, as they develop. We will work with the national team to determine how best the findings can be shared widely across the NHS. The outcomes of the programme are expected to be: accelerated establishment of networked care models across the NHS better care for patients delivered by standardising care, improving accessibility and minimising waste across the system reduction in start-up costs to establish a satellite network more efficient use of resources through establishing networked care better decision making for organisations considering a networked care model replicability of best practice in delivering networked care greater quality assurance in networks of care across the NHS widespread understanding of the benefits arising from different forms of networked care better understanding of the commissioning implications arising from widespread adoption of networked care We will work with the national team over the first three months of the programme to determine the most suitable approach to evaluation of the new care models.
15 ACC Vanguard: Moorfields Eye Hospital Value Proposition 14 Managing and Governing our programme Melanie Hingarani Clinical Sponsor for Vanguard Programme Patient Lead (to be confirmed) Jo Moss, Director of Strategy and Executive Sponsor for Vanguard Programme The Project owner and Steering group Chair will be the Director of Strategy & Business Development accountable for the delivery of the programme to the Trust Board through the Chief Executive and to the National Vanguard Team. The Vanguard Programme Director will be a full time seconded position reporting to the Director of Strategy & Business Development. The programme plan will be maintained by a designated project officer who reports to the Vanguard Programme Director. There will be administrative support. A clinical lead will be seconded part time to the programme to provide advice and leadership to clinical workstreams and engagement. Qualified clinical, nursing, allied professional and admin staff will be seconded to the programme as and when required to meet the activities needed to produce the outputs. A dedicated work stream lead from key departments will be in place to provide specialist expertise about Moorfields intelligence. The Programme Steering Group will consist of: Director of Strategy & Business Development (Chair), Patient Lead, Vanguard Programme Director, Vanguard Clinical Lead, Head of Communications, Project Oriel Director, Darzi Fellow, Project Officer secretary to the steering group. The Steering Group will meet monthly. The Board of Governors, and in particular the Patient Governors have been involved in the development of the programme. Further advice will be sought from the national team to determine the best way to fully involve patients in the programme in a meaningful way.
16 ACC Vanguard: Moorfields Eye Hospital Value Proposition 15 Section 5: Our Support Package The table below summarises the support we are seeking from the New Care Models Programme. Support Package Element Initial view of the support we need in the period December 2015 January 2016 Designing new models of care Evaluation and metrics Integrated commissioning and provision Empowering patients and communities Harnessing technology Workforce redesign Estates Communication and engagement Assistance in clearly conveying the national Vanguard and MEH programme to staff, patients and citizens. Understand innovative models of care through the NHS confederation integration pioneers programme. Access to evidence-based analytical support to segment the local population and then match tailored interventions to suit each group of patients within the community Understand models for seven day working from other Vanguards and applicability to networked care Support to develop and refine logic model Apply evidence summaries for interventions being implemented across each care model Support for local development of the evaluation strategy and evolve this over the life of the programme Start creating payment and incentive models to be tested locally Access to central legal advice for modifying commissioner and provider contracts Help with the baseline review of the way we are currently meeting the six principles for new care models Access to the national and local services available to Vanguards in supporting patient engagement Access to published examples of what good looks like for digital success Nationally agreed standard templates of information governance Dedicated technical and strategic support for connected digital solutions and information handling in different clinical scenarios Toolkit setting out the stages of effective procurement and contracting No support required in the initial stages No support required in the initial stages Develop, review and feedback on our communication and engagement strategies
17 ACC Vanguard: Moorfields Eye Hospital Value Proposition 16 Financial Resources Required in 2015/16 The table below summarises the resources required in 2015/16 to deliver the programme. Resource requirements for 2016/17 will be identified in the next version of the value proposition, by the beginning of January Activity 2015/16 Requirement 2016/17 Requirement Programme Management 186k 1.Understanding existing models 103k 2.Assess existing models 32k 3.Undertake stakeholder review 20k 4.Review international networks 26k To be identified in 2016/17 value proposition in early January Network analyses - 6.Detailed market analysis 48k 7.Review networked care opportunities - TOTAL 415k Less funding provided ( 300k) Total additional funding sought 115k
18 ACC Vanguard: Moorfields Eye Hospital Value Proposition 17 Section 6: Summary and Conclusion Moorfields is the leading provider of eye health services in the UK and a world-class centre of excellence for ophthalmic research and education. Our main focus is the treatment and care of NHS patients with a wide range of eye problems, from common complaints to rare conditions that require treatment not available elsewhere in the UK. We treat people in 23 locations in and around London, which enables us to provide expert treatment closer to patients homes. Acute hospitals are facing increasing challenges to deliver safe and cost effective care, especially in smaller clinical specialties such as ophthalmology which often lack the benefits of scale in a local setting. In the absence of critical mass of patient numbers or specialty workforce, provision of care may become clinically or financially unsustainable. Moorfields has developed a satellite model that provides clinically and financially sustainable local access to high quality ophthalmic care, and a sustainable model of specialist treatment. We believe that the Moorfields satellite network model has potential replicability across the acute healthcare system. The aim of our vanguard is to consolidate our learning in delivering networked care, so that we, and the wider NHS, can develop a clear understanding of when and how this New Model of Care can enable acute hospitals to become clinically and financially sustainable. We want to consolidate our learning in delivering networked care so that: the NHS can develop a clear understanding of when and how this new model of care can support acute hospitals in becoming clinically and financially sustainable, and the implications of extending models of networked care more widely across the service we, as Moorfields Eye Hospital, can deliver sustainable ophthalmology services that meet the needs of local populations and are delivered in an effective network Our programme will deliver four key outputs, which will deliver benefits for the wider NHS, and for Moorfields Eye Hospital; The critical success factors that need to be in place across a network in order for it to succeed. A toolkit that codifies best practice in establishing the need for and implementing networked care A publication outlining how the models of networked care can be extended whilst still delivering clinically and financially sustainable services Analysis of how networked care can be responsive to the needs of local populations whilst delivering consistent quality and service Our programme is underway, a programme plan has been developed, and our initial support requirements have been identified, including an additional 115k in 2015/16. A further value proposition setting out our programme plan, support and financial requirements for 2016/17 will be developed by the beginning of January 2016.
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