TAYSIDE PODIATRY SERVICE IMPROVEMENT WORK

Item Number 6.4 Report Number 22/12 Dundee CHP Committee 14 June 2012 TAYSIDE PODIATRY SERVICE IMPROVEMENT WORK 1. PURPOSE OF THE REPORT To advise the Dundee CHP Committee of NHS Tayside Podiatry Service's strategic improvement work which will reduce variation waste and harm by adopting a single system approach. 2. RECOMMENDATIONS To advise Dundee CHP Committee of the commissioned work to progress the improvement programme. 3. EXECUTIVE SUMMARY Demographics predict that over the next twenty years we will see an aging population, a shift in disease towards long-term conditions and a growing number of older people with complex needs. This will present the service with a significant risk around service delivery and local waiting times as they currently stand. It is therefore important to drive the service forward in order to ensure a podiatry service that is fit for the future and able to address the future population needs within Tayside. 4. REPORT DETAIL Historically podiatry care was provided independently within the three Tayside CHP s, with different management and reporting structures. However in 2009/10 NHS Tayside s AHP review of management saw the creation of a Tayside wide Podiatry Service which is hosted within Perth & Kinross CHP. Work was undertaken to indentify an improved model for service delivery. (Appendix 1) The pathways identified in this model will assist the service to address future challenges in relation to the predicted change in demographics. Following on from this, a review of the podiatry service structure was carried out which involved staff side, podiatry service leads, AHP Director and management. The same rigorous assessment process which was used in the AHP Review (2009) was undertaken and an option appraisal carried out using a recognised evaluation tool. The preferred option for leadership was agreed. NHS Tayside organisational change policy was followed in restructuring the service, to ensure that locality needs and local arrangements will be met, but equally Podiatry have a model that will address the variation, waste and harm across the service. 1

The identified model takes the form of locality leads accountable for strong local operational leadership and Tayside pathway leads. The pathway leads will drive forward improvement work within core, specialist and pre entry services in line with the quality agenda. It should be noted that all leads will also have a significant clinical remit. Core Pathway Lead Core podiatry which includes the nail surgery service, currently makes up the majority of the podiatry caseload. It is delivered by generalist community podiatrists supported by assistant grades. Podiatrists assess, diagnose and treat both common and more complex lower limb pathologies. Focus is on keeping patients mobile and allowing them to retain independence and quality of life. This lead clinician will drive forward substantial and sustainable improvement within core podiatry services. This role will also be responsible for facilitating, directing, advising and supporting clinical teams across the service areas to promote the ethos of person centred, episodic, outcome focused care in line with the quality agenda and NHS Tayside Strategic Aims. Specialist Services Lead - Specialist podiatry services provide podiatry care for priority groups and those eligible for care as part of a specialist service. This incorporates diabetes, wound management, mental health, paediatrics, rheumatology, musculoskeletal, learning disabilities, homeless, prisoner health care and dermatology. This lead clinician will also drive forward practice development within podiatry and ensure robust local networks are in place linking into the relevant MCNs in line with local and national practice development guidelines for AHPs. This role will ensure equity of access and service delivery within the specialist podiatry services and support integration of podiatry within other clinical specialist pathways e.g. orthopaedics. Pre entry pathway lead - This role will collaborate with an extended range of stakeholders, which will include social care, care homes, voluntary sector and communities etc. There will also be opportunities to influence national work streams, with the effect of minimising the number of referrals to the Podiatry service in the future. This role will be pivotal in development and delivery of foot health education; self management models; prevention programs etc as many foot conditions can be appropriately and safely managed by individuals themselves without ever becoming patients if they have the confidence to do this safely and are equipped with the necessary skills and knowledge. Work to date It is important to note that since 2002 podiatry services have established a continual improvement ethos evidenced by previous successful redesign. The Tayside podiatry improvement plan will continue this work and has commenced with the Core Podiatry Pathway. The specialist service pathway will follow and be redesigned using LEAN methodology. A timetable for this is being developed. Running along side this will be the pre entry pathway work which through the promotion of education and enablement will be crucial in managing future demands for the service. For the purposes of this paper the key points of work within the core pathway to date are; Initial Planning 1. LEAN training completed 2. Process mapping for core service undertaken 3. Current state analysis complete 4. Future state identified 5. Project charter completed 6. Driver diagram developed Staff Engagement Formation of Project Group with membership which is inclusive of staff representatives, leads and management. Presentation delivered to all podiatry staff across Tayside. 2

Stakeholder Engagement Informing, Engagement, Consultation Plan completed. Dates arranged with Clinical Governance to undertake Patient Focus Public Involvement activities. Draft service leaflet complete GP/ Primary Care information sheet sent to Local Medical Committee Discussion with Communications Team re press release Improvement paper presented at :- Perth & Kinross SMT meeting Perth & Kinross CHP Committee NHS Tayside Waiting Times Accountability Group NHS Tayside AHP Leads Group Dates arranged to present improvement paper at Dundee & Angus CHP Committees and Tayside Local Medical Committee. Staff Training. Completion of staff training sessions in relation to motivation/behaviour change, Podiatry matrix, episodic care plans. Rolling programme developed to deliver training on improvement methodologies e.g. PDSA with the aim of creating the capacity for continuous improvement within the workforce which will underpin the improvement agenda. Data collection: Risk classification audit. Identifying risk of existing patients within service Monthly/quarterly activity reports from Information and Performance, Differential Access Standards reports new patient referrals triaged in relation to risk, i.e. Urgent seen within 5 working days, Soon seen within 8 weeks, routine put on waiting list - service working towards routine not waiting over 18 weeks. Baseline data collected on podiatry care pathways. Podiatry Assistant caseload information being collected. 5. CONTRIBUTION TO NHS TAYSIDE S STRATEGIC AIMS Improving Health Improving Patient Experience Per Capita Cost Foot and lower limb problems are common and are a significant cause of ill health pain and disability. It is estimated that eighty per cent of older people have foot related problems (Harvey et al., 1997) and in an ageing society the prevalence of chronic foot problems will rise significantly (Levy, 1992). It is also reported that the prevalence of more serious foot pathologies increase with increasing age.(campbell, 2006). We aim to ensure that the Tayside population have timely, equitable access to our podiatry service. Provide robust patient pathways to support patients with long term conditions and support people in self care management. Provide episodic and outcome focused care to enhance quality of life and maintain independence for people with an identified podiatric need. We will continue to promote the ethos of person centred care and strive to deliver a high quality safe and effective service. We aim to improve patient experience by ensuring that the patient is seen by the right clinician at the right time through review of access,skill mix and patient pathways. We will ensure there are robust care pathways between core podiatry, and specialist podiatry/multi disciplinary teams. We propose to empower and increase the confidence of patients and their carers to more effectively manage their own foot care (FOOTSTEP self management programme). Health economic assessments (Donaldson and Mooney, 1991) suggest that the cost effectiveness of podiatry surpasses other intervention (Bryan et al., 1991) Guide to podiatry Society of Pods 2010 Multidisciplinary diabetes foot clinic have been shown to be clinically effective in reducing amputation rates. (Moriarty et al 1993). Review skill mix to ensure most cost effective use of resource. 3

6. MEASURES FOR IMPROVEMENT The service will monitor and report on differential access standards for new patients i.e. referrals triaged in relation to risk, ensure that those with the greatest need are appointed in line with the proposed locally agreed standards. Measure shift from patients on long term podiatry care to episodic care pathway leading to discharge where appropriate. Measuring expected shift in :- return periods, self management referrals, discharges, referral to assistant grades, patients returning to clinic for treatment (previously seen as home visit). Monitoring patient experience through questionnaires, focus groups etc 7. IMPACT ASSESSMENT & INFORMING, ENGAGING & CONSULTING We commit to working in partnership with all stakeholders. Within the podiatry review and subsequent restructure of the service there was extensive consultation with staff via the transition team which included staff side representation. We have developed our Informing, Engaging, Communication and Consultation Plan, in line with CEL 4(2010) supported by Mark Dickson (Clinical Governance Facilitator) and Allyson Angus ( Public Involvement Manager) work in relation to this is in progress. To date activities undertaken include: Formation of The Podiatry Improvement Project Team which is representative of clinicians and Podiatry Leads from each CHP area, with staff side representation as required. Consultation with GPs and Primary care staff via information sheet (Chair of Local Medical Committee, CHP Lead Clinicians) Work still to be completed Publication in local press. Consultation with patient representatives for review of documentation e.g. service leaflet and patient letters. Consultation with: patients and carers via e.g. local groups: focus groups: Advise required re communicating with local MSP s 8. PATIENT EXPERIENCE The streamlining of three services into one creates opportunities for change including the provision of areas of clinical excellence. The patients journey will be enhanced by the service addressing the 6 dimensions of quality (Appendix 2) 9. RESOURCE IMPLICATIONS Financial There is currently no financial outlay to undertake this improvement work. Workforce Podiatry assistants are utilised within the service. There are few trained staff nationally and new posts tend to be trained in-house through the professional body programme. As yet the profession has no Assistant Practitioners posts. Discussion is ongoing nationally and as yet no decision made. Agenda for Change (Annex T) allows the run through of band 5 to Band 6 (assuming 4

competencies are met) this combined with the point above gives the profession a very flat structure. Discussions regarding this are ongoing, but as yet no decision has been made nationally to review this. 10. RISK ASSESSMENT Future demographics for NHS Tayside predict an increase in longevity and complex long term needs. Currently the infrastructure within Podiatry is not in place to support this. If dedicated effort is not directed to this agenda, there is a probable risk that the service will be rendered unable to manage future demand and deliver on NHS Tayside priorities. 11. LEGAL IMPLICATION No implications at this time. 12. INFORMATION TECHNOLOGY IMPLICATIONS Successful measuring of improvement targets is dependant on access to timely verified data 13. HEALTH & SAFETY IMPLICATIONS No implications 14. HEALTHCARE ASSOCIATED INFECTION (HAI) No implications 15. DELEGATION LEVEL AHP Lead, Jane Dernie, Perth & Kinross CHP supported by Tayside Podiatry Service Manager, Lee Sievwright. 16. TIMETABLE FOR IMPLEMENTATION May 2012 17. REPORT SIGN OFF Lee Sievwright Tayside Podiatry Service Manager David W Lynch General Manager Dundee CHP Lynn Baird 7 June 2012 Improvement Project Manager Jane Dernie AHP Lead P&K March 2012 5

Pre Entry Pathway NHS Tayside Podiatry Service Service Model Tayside Population Podiatric Surgery Referral Triage MSK Assistant Clinics Specialist Ser vices Core Serv ices Self Management Programme Patients remaining in service for ongoing care Practice Development 6

APPENDIX 2 PRIMARY DRIVERS SECONDARY DRIVERS AIM To Deliver a high quality, effective, safe and person centred service fit for future demand. Measures % of new patients seen within locally agreed differential waiting times targets. % increase in self management referrals, discharge rates, referral to assistant grade and patients returning to clinic for treatment (previously seen as home visits) % of caseload moving to episodic care pathway. Monitoring patient experience via questionnaires, focus groups etc Safe Equitable Patient Centred Efficient Effective Timely 1.1 Differential waiting times 1.2 Safe working practice 2.1 Equitable access to service 2.2 Access to to specialist services 3.1 Patient/public involvement 3.2 Patient empowerment 4.1 Resources 4.2 Workforce Plan 5.1 Staff engagement & involvement 5.2 Staff development 5.3 Standardisation of practice 5.4 Practice development 6.1 Patients being seen by the right person, in the right place at the right time 7