EPaCCS in Greater Manchester

EPaCCS in Greater Manchester

Developments of integrated End-of-life Care Services/EPaCCS Over the past 8 years the NHS has proactively supported developments in integrated care services across service providers for patients in their end-of-life. As early as 2007, the NHS produced a report Healthcare for London: A framework of Action in which it identified key benefits from establishing and maintaining end-of-life care registers. Supporting this work, the Department of Health in July 2008 produced an End-of-life Care Strategy in which it proposed that local health registers be used as a framework to enhance the communication and co-ordination of care between the numerous care providers delivering endof-life care to patients. The Department of Health was also driving a large scale QIPP (Quality, Innovation, Productivity and Prevention) programme to improve quality of NHS healthcare. Within QUIPP there were a number of national work streams designed to support the NHS to improve care whilst reducing costs. These work streams covered the improvement of provision of care to patients as well as how care organisations were run and managed. QIPP established an additional work stream End-of-life care, specifically aimed at improving the care to end-of-life patients. This work stream recommended the implementation of an Electronic Palliative Care Co-ordination Systems (EPaCCS) that would better manage the early identification of people approaching the end-of-life, as well as how care is collectively delivered by health and social care providers. A Palliative Care Funding Review final report in July 2011, commissioned by the Secretary of State for Health, showed about 20% of the 457,000 patients in England who needed palliative care services every year were not being reached. To improve palliative care, the report recommended that the Clinical Commissioning Groups (CCG) establish operational end-of-life care registers. The Health and Social Act 2012 went further, it required each CCG in England to deploy an EPaCCS solution. It advised that the solution should be delivered through development of integrated working practices between clinicians and support staff across multiple health and social care provider organisations such as general practitioners, hospitals, care homes, out-of-hours and ambulance services. The Care Bill Act 2013-2014 also promoted the integration of care and support between health and social care services. In 2013 a new principle was added to the NHS Information Governance policy further re-enforcing the critical importance of information sharing between care providers. An EPaCCS solution, where effectively deployed, will improve the health and social care given to end-of-life patients, their families and carers. Such systems will allow multidisciplinary care teams to record and communicate patient preferences and wishes to other carers. EPaCCS is a national standard, underpinned by a defined information data set which supports consistent recording of information resulting in improved data accuracy and interpretations across various care providers. Cruarch Associates EPaCCs in Greater Manchester 2

National Progress to date The national programme to deploy EPaCCS solutions is driving improved interoperability between clinical systems, as well as better communications between care professionals. This work is expected to help the NHS save up to 20bn by 2015 through reduced number of unplanned hospital admissions and patient lengths of stay, as well as increased investments to improve community based care and the co-ordination of that care. The Marie Curie Delivering Choice Programme Findings suggested that this improved community and co-ordination of care can lead to increased numbers of patients being supported to die at home, at no extra cost. NHS England reported that by 2012, 24 localities across England had EPaCCS solutions either fully or partially implemented compared with only 8 pilot localities reported in 2010/11. The map shows the known position mid-2012. A year later, it was (Imp. Key: G-Full, O-Partial, B-plan) (Ref: EPaCCS Making the case for change report 2012) reported that out of a total 211 CCGs contacted, 64 had operational EPaCCS, 111 had started planning and 10 had not started. It was also noted that the systems solutions varied widely across these CCGs with most popular being Adastra, followed by SystmOne and EMIS. (Ref - 2011 Greater Manchester Census). Currently in Greater Manchester 2 of the 12 CCGs have implemented EPaCCS. EPaCCS across Greater Manchester Life Expectancy in Greater Manchester The implementation of EPaCCS solutions across Greater Manchester is welcomed, however care providers should recognise they will be working in an environment where the life expectancy of the GM population is rated to be the worst in England. In June 2013, Public Health England published a national league table of early deaths under the age of 75. This report covered the 2009-2011 period across 150 authorities. It showed Manchester leading with 455 premature deaths per 100,000 - more than twice as many as the best performing area. Incidentally, Manchester has also the highest recorded death rate from cancer with152 deaths per 100,000 people) and heart disease and stroke with 116 deaths per 100,000 people. Cruarch Associates EPaCCs in Greater Manchester 3

Implementing EPaCCS across Greater Manchester The planning of EPaCCS across the Greater Manchester s ten localities started in mid-2013. To date Salford and Stockport have deployed EPaCCS solutions and the remaining eight localities are actively working to deliver against the national NHS target of 2015. In October 2014 the Greater Manchester Academic Health & Science Network (GMAHSN) commissioned Cruarch Associates to review and support the GM EPaCCS programme. Terms of reference and work plans were agreed. Cruarch consultants attended stakeholder and project task team meetings. These generated a number of questions and highlighted potential issues with delayed delivery of the EPaCCS programme. These were communicated to GMAHSN together with proposed remedial strategies and plans for discussion and acceptance. Following this an enabling project called the EPaCCS Implementation Dashboard Project was launched to sit alongside the wider GM The Cruarch dashboard has been a real enabler in moving forward with record sharing in Tameside and Glossup, in a much more structured manner than we could have achieved without the Cruarch team. Thank you. Philippa Robinson, Commissioning Development Manager, Tameside and Glossop CCG The Dashboard work carried out by Cruarch has been key to localities being able to grasp the scope and scale of EPaCCS implementations. This has enabled each locality to project manage at a level of detail necessary for such a complex and challenging project. Stephen Burrows, Strategic Clinical Network (SCN) - North West EPaCCS Project Lead EPaCCS programme and provide a number of enabling tools. This included: l Systems thinking workshops to help stakeholders better understand potential benefits arising from EPaCCS deployments as well as impacts to patients, clinicians and business as usual. l Utilising a dashboard with business intelligence and analytics (metrics) to support effective deployments of EPaCCS across the GM localities. Cruarch continued to engage with the EPaCCS stakeholders (clinical and operational) and evaluate the ongoing health of the projects and EPaCCS implementation. Cruarch developed improvement plans which focused support on key management, clinical and operational issues. Cruarch Associates EPaCCs in Greater Manchester 4

Systems Thinking Approach: Introducing new technology does not always result in the desired improvements in healthcare or operational efficiencies. Cruarch delivered Systems thinking workshops that helped delegates better understand the potential benefits arising from deployments of new technical solutions as well as impacts to patients, clinicians and operational staff. Delegates were asked to think of how systems comprising of people, structure and processes influence one another and how they can work The systems thinking workshop gave me a holistic overview of the EPaCCS developments and challenges in Greater Manchester. It helped us identify what our next steps should be as a locality and enabled me to link with wider teams and support networks across GM. Philippa Robinson, Commissioning Development Manager Tameside and Glossop CCG. together to improve how such care organisations perform together. A system is better understood by considering the effects of its combined parts rather than its constituent parts. For example, to fully understand how any individual patient experiences a service is best completed by examining the whole patient journey across the care organisational boundaries rather than efficiencies of individual care organisations. Cruarch Associates EPaCCs in Greater Manchester 5

Key Support included: l Facilitated system thinking workshops for clinical professionals, operations and staff to identify process, system and cultural issues for resolution. See outputs across. l Worked closely with project teams to identify quick wins and long term improvements which result in benefits to patients, clinicians and operations. l Developed improved project metrics (dashboard) to better monitor, report and communicate the progress of EPaCCS deployments against plans. (Dashboard included RAG alerts, clinical benefits, plans, stakeholder engagements, impacted care providers, team resourcing, data sharing agreements, prioritisation of tasks, data flow definitions and testing, GSF/ MDT compliance, process management, staff training, patient communications and project costs). l Utilisation of the dashboard tool across all localities encouraged systematic collection of data, sharing of lessons learned as well as reporting of individual and collective performances. l Provision of hands-on project management training to upskill project managers capabilities. l Direct engagement with stakeholders and project/ programme managers to ensure they understood the visions and challenges as well as adjustments to their roles and responsibilities necessary to fully realise both qualitative and financial benefits of EPaCCS. l Ensured NHS recommendations in their lessons learnedsteps and issues were appropriately considered by project teams. These provide a framework for sustainable change and transformation to deliver real benefits for patients. These were incorporated into the dashboard design. (EPaCCS Making the case for change) l Promoted closer working between the EPaCCS project teams across the conurbation. Helped teams communicate good working practices, successes and lessons learned as well as share their individual and relative performances. l Provided overviews of quality improvement cycles and demonstrated how these processes will lead to further systems improvements. The Dashboard helped us to consider the many aspects of EPaCCS that need attention. Mohammed Abas, Commissioning Manager Central Manchester CCG. Key Outputs of Systems Thinking workshop: l The EoL Care register is owned by the GP and is a central place for beginning to understand the level of Advance Care Planning. l About 0.5% -1% of GP registered patients will be EoL. l Some 80% of EoL patients are not on the EoL register. l Not all identified EoL patients have an Advance Care Plan l Not all Advance Care Plans are available at time of intervention l Discharge summaries may be good place to trigger review or action on EOL planning initiation. l Linking specialist information to GPs or other generalist carers is an issue. l Fax, telephone and verbal communications have significant drawbacks with quality of information sharing in multi-disciplinary teams and increased administration. l OOH or Crisis Intervention is most ripe for improvement l Excessive wastes exist caused by delays, repeat assessments, data searches and poor data. l Good lessons in caring can be shared between care providers. l Many staff do not feel confident in EOL assessment, engagement and care planning. Further training is needed but not always easy in time and cash constrained organisations. l Good lessons in EoL care from Six Steps, GSF and work in MacMillan and Christies should be shared more widely. l Health and social care records are stored in discrete systems across numerous care providers thus preventing a current, shared and integrated view of the patient s health and needs. Cruarch Associates EPaCCs in Greater Manchester 6

C PLAN Continuous Improvements: ACT DO The outputs from the Systems Thinking workshops and the EPaCCS dashboard metric reports are being used by each locality project team to improve EPaCCS project management processes as well as EPACCS system implementations. Project teams, including managers and clinicians, are being encouraged to follow a STUDY PDSA improvement model for developing, testing and implementing system changes that lead to improvement. This model is widely used to deliver improvements in the NHS. PDSA: There are four process steps in this PDSA model plan, do, study, and act, triggered by an idea as shown across. This cycle allows you to develop and test an improvement idea in a controlled way before introducing a change, in doing so reducing your risk of failure. It is an effective and fun tool for involving your team in the creation and validation of suggested ideas. This PDSA cycle is being used to improve our project management processes as well as the EPaCCS deployments with reassuring results. This strategy has already delivered measurable benefits to patients and / or stakeholders. Steps Idea Plan Do Study Act Descriptions Suggest your improvement idea define its aims/success. Explain how the change will result in improvements. Involve management and staff share the idea. Understand benefits to patients, staff, process, systems and costs. Plan how you will test and implement your idea. Describe proposed change - scope, who, when, where and how. Determine how performance data will be collated and reported. Carry out / implement the planned change. Collect and begin to analyse the data. Study the data before and after your change. Complete your analysis of the data. Report observations, results, benefits and lessons learned. When confident, implement recommended change or plan new/ revised change. Qualitative and Quantifiable benefits: It is anticipated that the roll-out of EPaCCS across Greater Manchester will improve the quality and efficiency of EoLC services with the following benefits: Category Description of Benefit 1 Care Provider: Improved productivity of clinicians Improved communication and ease of sharing between professionals involved in person s care, and supporting carers, clinicians, ambulance and out-of-ours services to make appropriate decisions about a person s care 2 Costs: Reduced unnecessary hospital admissions and ambulance journeys. (Estimated savings of 3.6M over 4 years for GM - Refer to calculation and assumptions next page). 3 Patient: Improved EoL care for patients with patient s wishes being fulfilled. More EoL patients dying in preferred place of their choice Improved communications with patients. Reduced complaints more patients contented with EoLC services. 4 Project Teams: Enhanced capabilities of teams increased confidence of EPaCCS projects deploying EPaCCS in line with NHS targets. Improved productivity of project teams Cruarch Associates EPaCCs in Greater Manchester 7

5 Senior/Project Management: Enhanced visibility and control of individual and collective performances of the ten localities. Cruarch Associates EPaCCs in Greater Manchester 8

Manchester Wigan Stockport Bolton Salford Trafford Oldham Tameside Rochdale Bury Totals Financial Benefits Evaluation for Greater Manchester NHS England has carried out a financial benefits evaluation of four EPaCCS sites. It concluded that based on an additional 90 DiUPR (Deaths in Usual Place of Residence which includes homes, extra care or care homes) per 200,000 population pa being achieved this could translate to an estimated (conservative) cumulative net benefit over 4 years of c. 270k for a population of 200,000 people. (Ref- EPaCCS Economic Evaluation Report-May 2013). Based on the above assumptions it is estimated that implementations of EPaCCS across ten GM localities with a total population of cc 2.7M can potentially deliver a cumulative net benefit of 3.6M (see table below). New Benefit Evaluation Manchester Metropolitan Districts Population (x1000) (1*) 503 317 283 277 234 227 225 219 212 185 2682 Cumulative net benefit (Assuming 270k for 200k population over 4 years) (2*) (x 1000) 679 428 382 374 316 306 304 296 286 250 3621 Recommendations/Lessons Learned: 1 This paper provides an overview of the EPaCCS implementation across England and more specifically Greater Manchester. It includes information about the approaches being used and shares the learning and experiences of the GM project teams. 2 EPaCCS implementations are complex projects that aim to support end-of life care across a multitude of different agencies and care providers. For ease of EPaCCS implementations programme/project managers should think very carefully how they will plan, monitor and report the progress of the EPaCCS deployments as well as the resulting benefits. Other areas for consideration include system interoperability/data flows, stakeholder engagements, funding and not forgetting availability of dedicated PM/stakeholders resources. 3 During the EPaCCS planning stage engage with clinicians from all impacted care services so they know how to determine and comply with the end-of-life care needs of patients. 4 During the planning be aware of the requirements for the EPaCCS solution to report on the type of care provided as well as the specified care needs of the patients. 5 Establish mechanisms for providing feedback on current status of EPaCCS implementation from those implementing EPaCCS as well as the additional support they require. 6 For ongoing effective management of the projects and EPaCCS implementations, apply a strategy that supports continuous improvement processes. Cruarch Associates EPaCCs in Greater Manchester 9

Summary Core to the project are the consultations with all the local EPaCCS project teams to verify that the support provided continues to be relevant, understood and agreed. Training and review sessions are also provided to verify the improvement strategies and plans are being fully endorsed. The deployment of EPaCCS across the Greater Manchester conurbation is progressing to plan. It is possible that this project work could be replicated across additional localities in the entire North West in due The Cruarch Dashboard provided us with the necessary Project management and analytical toolset to successfully implement our EPaCCS solution. It also provides a systematic approach to the scoping, planning and dataflow definition, testing and monitoring the progress of collective projects across Greater Manchester. Robert Walters, Wigan IDCR Programme Manager course, and potentially further afield. Core to the success of the project has been a focus on the data required to deliver the benefits set out, and data exchange across different IT systems. This was a key component of the systems thinking workshops and a core element in the development of the EPaCCS dashboard. As the project is currently ongoing, benefits are being tracked and measured as part of the delivery process, and to date all anticipated benefits have been realised. About Cruarch Associates Cruarch Associates is leading consultancy group with offices in Manchester, Belfast and Glasgow providing effective programme and data management solutions focusing business transformation using digital informatics and analytics. If you would like more information or to simply to talk to us please contact us through our website at www.cruarch.com About Greater Manchester AHSN Greater Manchester AHSN is an NHS body established in 2013 to bring together Academia, Health and Small Businesses to create enhanced health, wealth and wellbeing in the Greater Manchester area through development and adoption of innovative technical solutions. GMAHSN commissioned Cruarch Associates to drive the EPaCCS implementation dashboard project in November 2014. For further information please visit our website at www.gmahsn.org Cruarch Associates EPaCCs in Greater Manchester 10

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