The commissioning and provision of neurological services is complex, with responsibilities split across clinical commissioning groups (CCGs), specialist commissioners, community services, acute hospitals, primary care, neuroscience centres and social care. To create alignment in the system across all stakeholders – providers, commissioners and patients – the NHS established Strategic Clinical Networks in England. There are twelve Strategic Clinical Networks (SCNs) and their role is to encourage collaborative working across the boundaries of commissioning and provision, where a whole system, integrated approach is required. One key priority of the Neuroscience SCNs is to raise the profile of neurology by working with commissioners to develop clear pathways of care that identify the following issues:
1. Impact of neurological presentations on acute services.
2. Mapping of funding responsibility for services, NHS England or CCGs.
3. Best practice integrated pathways to reduce delays in diagnosis, treatment and rehabilitation, to reduce mortality and levels of disability.
4. Identify how and where service provision can be improved to free up capacity in the system e.g. through redesign of clinics and improved primary care symptom management.
5. Improve patient related outcomes and experience through care closer to home.
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The Neurology Division of the East Midlands SCN, led by Professor Chris Ward and Helen McCloughry, is currently focusing on two areas where the quality and quantity of services is variable. The first of these is neurological rehabilitation. The Clinical Advisory Group’s agreed priority is to develop commissioning guidance and an exemplar service specification for commissioners. Standards and principles established by the East Midlands Rehabilitation Programme and by the NSF for Long-term Conditions will underpin this work.Coordinated rehabilitation interventions often make the difference between a person being able to remain at home and being admitted to hospital or residential care, and are often essential for continuation of employment and other social and family roles. We distinguish rehabilitation from care, which is required to maintain, rather than to change and improve quality of life.The primary requirement in our model is for service users to have up to date rehabilitation plans alongside their care plans.
The cost savings that rehabilitation can achieve depend on effective co-ordination
The cost savings that rehabilitation can achieve depend on effective co-ordination and we therefore use a precise concept of what constitutes a team. Key performance indicators (KPIs), especially those that reflect outcomes for service users and their families, are central to our work and we are developing regional consensus on a core set of indicators. We are using existing frameworks, including the NSF, the Neurological Alliance and the Rehabilitation programme as a basis for KPIs which will sample the structure, process and outcomes of community neuro-rehabilitation and also track the dimension of prevention, a crucial but often forgotten dimension of rehabilitation.
East of England
Victoria Doyle -Quality Improvement Lead for Neurological Conditions
Dr Max Damian -Neurologist and Clinical Lead for Neurology with the East of England SCN.
Mary Emurla – Network Manager for the Mental Health,Dementia,Neurology,Learning Disability and Autism SCN for the East of England
Since February 2014,The East of England SCN has been focusing on improving the management of people with epilepsy and improving the rehabilitation of people with a neurological condition causing disability. These priorities were developed from a large region wide stakeholder event in November 2013 as well as direction from the National Clinical Director, David Bateman. The SCN also inputs into the national SCN work around neurology standards, community neuro rehab standards and headache management.
In June 2014, the SCN ran a large multi-stakeholder event on improving the care of people with epilepsy which provided an excellent source of information of what people from around the region thought the gaps were. One of the main themes that arose was education especially within primary care. In response to this, the SCN and key stakeholders have developed two epilepsy eLearning modules for primary care which are due to be launched in summer 2015.
Another key theme from the event was improving the management of people within A&E departments.This tied in with the release of the NASH2 study which also highlighted gaps in the treatment of patients withinA&E.The SCN and key stakeholders have developed three epilepsy guidelines for improving the management of people with epilepsy which are entitled “First Adult Seizure in an Emergency Department”, “Management of Status Epilepticus” and “Referral to Specialist Epilepsy Clinics” which were launched in spring 2015.
The SCN is piloting a telecare link between a neuroscience centre and district general hospital for themanagement of peoplepresenting inA&E with severe cluster seizures or status epilepticus to improve access to a Neurologist during this critical time. The results of the pilot will be available in summer 2015.
In October 2014, the SCN ran a region wide stakeholder Master Class on Commissioning and Contracting for High Quality Neuro Rehab to provide stakeholders with tools to aid them in commissioning high quality neuro rehab services which was very well received.
The SCN has engaged all the CCGs within the East of England and has established a region wide advisory group which develop and oversee the work of the SCN. The group consists of commissioners (CCG, local authority and specialised), General Practitioners, Neurologists, Rehabilitation Consultants, Specialist Nurses, voluntary organisations and patients.We would encourage new members to come forward to help us improve the care of people with a neurological condition across the region.
Adam Zermansky -Consultant Neurologist at Greater Manchester Neuroscience Centre.
Julie Rigby -Network Manager with the Greater Manchester, Lancashire & South Cumbria SCN.
Improving the management of headache in primary care
The current model for neurology services is primarily based around out-patient clinics and for the past two years all neurologist services delivered by specialist centres have been commissioned by NHS England. NHS England has highlighted a significant increase in neurology referrals over the past 8 months leading the organisation to embark on a QIPP initiative to drive improvement and efficiencies in this area of care.
Specialised service recommendations to ministers indicate that only 25% of neurology activity is initiated by Consultant-to-Consultant referrals. The remaining activity is initiated from Emergency Departments (EDs) and by GP referrals with up to 33% of patients seeing their GP five or more times about health problems caused by a neurological condition before being referred to a neurological specialist. These data have supported the decision to remove neurology out-patient activity from the service description for adult specialist neurosciences services with the commissioning responsibility for non-specialist neurology to migrate back to CCGs during 2015/16.
Since approximately 25% of referrals to secondary care neurology services are for patients with headache,the Greater Manchester, Lancashire and South Cumbria Strategic Clinical Network (SCN) has refreshed previous work piloted in Salford and shared across Greater Manchester in the spring of 2012. This is an updated algorithm to support GPs in the management of headache in primary care, avoiding unnecessary referrals to secondary care. The algorithm is attuned to the NICE guidelines (CG150) published in September 2012 and the APPG review of headache published in 2014.
The algorithm has been refreshed by a group led by Dr Adam Zermansky from Salford Royal NHS FT with support from GPs and Consultant Neurologists from around the region, including
- Dr Raza Ansari – GPwSI, Lancashire
- Dr Steven Elliot – GPwSI, Greater Manchester
- Dr Hedley Emsley – LTH
- Dr Partha Ganguli – GPwSI, Lancashire
- Siobhan Jones – Specialist Nurse, SRFT
- Dr Jitka Vanderpol – Cumbria Partnership Trust
The next steps for this project are:
- To get comments from GPs across the footprint about the feasibility of implementation, any specific training needs and highlighting any cost implications for commissioners or providers. Training options could include:
- a) Educational roadshows approved for CPD by the RCGP providing an opportunity to explain the detail within the guidelines and its role as a tool for diagnosis and management.
b) Educational videos c) Power-point shared across the patch
- Agree measures of success, potentially: GP satisfaction; patient satisfaction; reduction in referrals to secondary care; decrease in number of rejections at triage. In addition to supporting GPs to manage headaches better in primary care, CCGs are being asked to consider other options which could improve service delivery:
- Creating a cluster of GP’s with an interest in headache e.g. a Headache Club, who are given more time per patient to see headache referrals from local practices
- Identifying GPs from clusters who would like to gain GPwSI accreditation and act as the hub for GP clusters
- Ensuring links with secondary care neurology to support ongoing CPD, including decision support
- Identifying ESP nurses or physiotherapists who could support the management of headache through e.g. delivery of botulinum toxin injections, improving posture and mobility of the neck, acupuncture, mindfulness programmes etc.
- Fostering expert patient groups locally to provide support to patients with chronic migraine etc.
Next steps for the SCN are to share the guidelines via CCGs for sign-off through their internal governance arrangements prior to the guidelines, notes and survey being circulated to GPs.
Michael Oates -Neuroscience Network Manager
The Network held its annual stakeholder event in March 2015 to present and discuss its work programme covering April – March 2014 and intentions for the future.
Dr David Bateman -National Clinical Director for Neurology provided a national picture. He summarised the national priorities for services to address as local, integrated, organised around the patient and accessible. He highlighted the difficulties for district general hospitals, specifically around outpatient access and its case mix,access to acute care,and access to long term care. Neurology was almost absent and a poor relation to other conditions. The presented data highlighted key areas for development.
Most Neurologists were concentrated at neuroscience/neurology centres; only 48% of DGH sites had Neurologists based there and only 13% of those had dedicated neurology beds.
47% of neurology admissions were emergency admissions but only 6.5% were under a Neurologist.The cost of emergency admissions was £975 million out of a £1.4 billion total neurology spend.
Dr Bateman concluded with the opportunities for neurology provided by the five year forward view – multi speciality community provider, primary and acute care systems redesign,urgent and emergency care redesign and changes to neurology commissioning.
The clinical leads for Network’s workstreams presented their progress and future intentions.
- Integrated care: 3 projects. Presented by Bernadette Porter, UCLH.
A team has been working with NW London integratedcareprogrammetopilotaneurological condition -multiple sclerosis (MS). The pilot involves anticipatory care planning by the GP and patient, self-help and case conference by a multi-disciplinary team for complex patients. Educational tools are being developed to support the use of the pathway. Parkinson’s and epilepsy conditions will be added this year.The MS pilot is in Harrow, and 8 GP practices are involved with the care plan available on NHS 111.The self-help element uses a self-test to exclude a urinary tract infection (UTI) with antibiotics available if positive.We are also looking at the benefits of a neurological specialist attending a social care neurology multi-disciplinary team at Enfield – findings and case studies will be published soon.
Finally Bernadette has been working with a North Central London UCL Partner initiative to address causes of emergency admittance for MS – by far the major cause was UTI. The learning from this will inform the NW London programme.
- Shared learning – common neurological conditions. Presented by Dr Bal Athwal, Royal Free Hospital.
The project team identified three common conditions that could be mainly managed in primary care:headache,dizzy spells and transient loss of consciousness (TLC). To support GPs a headache pathway with linked short films at key decision points has been produced. The pilot in Kingston and Barnet CCG is reviewing the educational product which can in its entirety be used as a headache educational tool or be accessed for a specific topic to confirm or support a decision. Dizzy spells and TLC will be developed this year. In addition the team has provided input into a headache referral management QIPP (Quality, Innovation, Productivity and Prevention).
- Acute neurology. Presented by Dr Nick Losseff, Clinical Director of the network.
Acute neurology is the major new workstream this year. It arose out of a neurology organisational audit (Quality & safety workstream) of neuroscience/neurology centres and district general hospitals. It found that no hospital in London had a systematic approach for the emergency admission of patients with neurologic conditions directly under the care of a Neurologist. The programme will cover acute neurology standards, acute models and evaluation. Seven trusts have expressed interest in taking part.
- Borough Based teams (BBTs). Presented by Dr Jenny Vaughan, Ealing Hospital.
One of the roles of the network is to advise commissioners on the development of neurological services. BBTs are our approach to engage with CCGs raising local needs and solutions. Each borough has an identified clinical lead, community rehabilitation lead, and a representative from the third sector.
Available for participants to view were the neurological data profiles for London and each London CCG and the London neurological website – neuro-signpost.
Links to additional information:
Headache educational tool: http://www.londonscn.nhs.uk/publication/london-agreed-headache•pathway-and-podcasts/
London & CCG neurological profiles: www.londonscn.nhs.uk/publication/london-neurology-profiles-by-ccg/
Acute neurology case for change: http://www.londonscn.nhs.uk/publication/acute-neurology-in-london-the-case-for-change/
Update on our workstreams: http://www.londonscn.nhs.uk/publication/london-neuroscience-scn-strategy-update/
Eva Morgan – Quality Improvement Lead for Mental Health, Dementia and Neurological Conditions from April 2013-April 2015.
In 2013, to help develop their work plan, the Thames Valley Mental Health, Dementia and Neurology Network (MHDN) commissioned the Neurological Commissioning Support (NCS) to assess the state of play of neurology in the Thames Valley and identify any gaps and variances in service provision.
Based on the evidence provided by the NCS report and illustrated by the various reports and work undertaken on headaches,the MHDN network proposed a new model for adoption by the CCGs to improve neurological services within Thames Valley,improve patient experience and reduce overall costs to the system. The vision forThamesValley is to empower patients and GPs such that common neurological problems are expertly self-managed, based on the“House of Care” model;that services,where appropriate, are managed in the community and boundaries between primary and secondary care are abolished; that apps are developed and used by both patients and clinicians to manage their condition and integrated pathways are delivered so that care is seamless and based on patient need.
To develop this vision we undertook a number of pilot studies; these included a pilot for developing a GPwSI service in the community and a patient experience survey to understand what blockages exist; Underpinning this work we held our firstThamesValley wide Neurology Strategic Forum with multi-agency stakeholder representation including, CCGs, GPs, Social Care and service users, to provide the strategic direction for the network in 2015/16.
So what have been the outcomes for these specific elements of work?
- Good engagement with CCGs across Thames Valley with all CCGs now having appointed a GP Lead for Neurology or having set up a small but significant neurology review within the planned board programmes of work
- Development of a Parkinson’s pathway with Berkshire East and development of a Neurology Strategy with Berkshire West
- Excellent participation in the strategy forum
with four key areas identified for further work;
– Developing patient centred care based on the“House of Care” model to enable self-management
– Clinical information for patients and clinician to understand their condition -Reducing emergency admissions -Delivering integrated pathways.
Yorkshire & the Humber (Y&H)
Colin Sloane – Quality Improvement Lead
David Broomhead -Consultant Physiotherapist working for Northern Lincolnshire and Goole NHS Foundation Trust.
The current SCN Neurology team includes:
Dr Helen Ford,Consultant Neurologist at Leeds Teaching Hospitals and joint SCN Clinical Lead; David Broomhead, Consultant Physiotherapist at Goole Hospitals and joint Clinical Lead; Alison Bagnall,SCN Manager for Mental Health, Dementia & Neurology; Sherry McKiniry, SCN Quality Improvement Manager; Colin Sloane, SCN Quality Improvement Lead.
The Y&H SCN have prioritised the following projects for Improvement:
- A) Epilepsy management in primary and secondary care
- B) Headache management in primary and secondary care
- Mapping out of headache services
- Headache management audit in the Emergency Dept C) Neuro-rehabilitation
- Current service
- Mapping out to identify gaps and concerns
- Working with NHSE and other stakeholders to formulate a long term plan which aims to improve access to neuro-rehabilitation within acute and community settings.
- D) Defined Neuromuscular pathways.
- E) In conjunction with national leaders and SCNs define neurological service standards.
SCN Neurology Groups
The SCN has had a successful year engaging with clinicians to understand current service delivery processes and barriers to promoting improvements.A number of clinical groups have been established to facilitate a) information sharing both locally and nationally b) identify service gaps c) disseminate good practice d) develop improved pathways of care e) interpret the data from the Neurology Intelligence Network (NIN).
One group instrumental in facilitating service improvement is the Neurology Clinical Expert Group (CEG) chaired by Dr Ford. The aim of this group is to identify areas of good clinical practice, particularly acute presentation and the longer term management of neurological conditions and to facilitate a regional approach to service delivery.
Access to neuro-rehabilitation is vital to promoting better outcomes for patients; currently neuro-rehab in the Y&H is being investigated. Some neuro rehabilitation services, other than stroke appear to have evolved from clinical interest and patient need rather than as a result of direct commissioning. The SCN is working closely with rehab experts, NHS England and CCGs to identify what good neuro•rehab should look like and hopes to develop service models in the future. David Broomhead chairs the neuro-rehab steering group which held its inaugural meeting in July 2014 and meets quarterly.
In partnership with clinical leads from the area the SCN has developed a neuromuscular disease pathway,which has been adopted by the NMD campaign and distributed for comment nationally. Access to the pathway can be found at http://www.yhscn.nhs.uk/mental-health-clinic/neurology-network/work-priorities/Neuro-Muscular-Disease.php
Helped in part by NHS England’s repatriation of specialised outpatient clinics back to CCGs, the Y&H SCN has been fortunate to secure support from commissioning leaders across the three consortia (NorthYorkshire & Humber,West & SouthYorkshire).One challenge is that neurology can struggle to attract attention against all the other commissioning priorities such as cancer, stroke and urgent and emergency care.
The SCN held a Neurology commissioning workshop on 13th Nov 2014, which resulted in delegates agreeing the need for an SCN Neurology Commissioning Group. The first commissioning meeting will be held in Spring 2015. This signifies a positive step towards improving neurology services inY&H through a more formal commissioning structure.