Tuesday 8th November, 8:30am – 1:00pm

Broadway House Conference Centre

Network: Broadway House

Passcode: enjoyBH1!

Agenda Time Topic Lead

8.30 Registration All

9.00 Welcome and Introduction Nick Losseff -Clinical Network Director

Neuroscience

9.15 The Right Care Approach Steve Sparks- Right Care Delivery Partner

9.35 Presentation of Right Care data on

common neurological conditions

Steve Sparks & Mary O’Brien Right Care

Delivery Partners

10.45 Break All

11.15 Solutions:

Enhanced acute neurology service

(EANS)

Community neurology service

Adapting existing service models for

neurological conditions.

Nick Losseff

Dominic Heaney (UCLH)

Jacqui Wakefield (kings) Catherine Atkinson

(Royal Free)

12.30 Summary and questions All

13.00 Close

Right care for neurologic conditions

Dr Nick Losseff

London Neuroscience Clinical Network

November 2016

4

London neuro-context

252,000 people living with a neurological condition in London (excludes migraine

1.7 million) :

33% of the neurology programme budget is spent on unplanned secondary care.

More than half (64%) of neurology admissions to hospital were on an emergency

basis. Neurological conditions account for 17% of all emergency admissions.

London has the highest rate of neurology outpatient consultant appointments

Delayed Transfers of Care (DTOC) in acute hospitals due to waits in accessing

inpatient neuro-rehabilitation.

National Audit Office 2011 – neurology

program budget

• £3 billion + same again in care

• 6 recommendations to improve services

• Mixed progress

5

NAO recommendations

• Appoint NCD / establish clinical network

• Establish data set and quality outcomes

• Appropriate access to services driven though

commissioning outcomes framework / mandated joint

health and care commissioning

6

Problems

• Invisible and apologetic

• No National Strategy

• Commissioning responsibilities inexplicit

• No outcome indicators at CCG level to deliver against

• Hindered by the complexity we have created

7

Progress

• Data

• Right care

• PHE - Fingertips

8

9

Camden / Doncaster CCG (outpatient)

Public Health England – Fingertips Neurological Conditions

10

Camden / Doncaster CCG

(unplanned admissions)

11

Neurology in London Clinical Network Agenda

Developed from consultation and existing priorities

• Common Conditions

• Integrated Care

• Acute Neurology

• Commissioner engagement

12

Redressing the balance

• Out of kilter system

• Moving the expertise to the right place / right time

• Modernising archaic working practices

13

Familiar pattern (e.g. migraine)

• Attendance at GP / A+E

• Often unable to secure responsive assessment by someone

competent

• Admission – CT – LP

• Outcome – a worse headache

14

Partly because …..

• Neurology expertise bogged down in one in one out outpatients

• Not at the front door

• Not in the community

15

Morning summary

• Discuss right care approach

• Data and interpretation

• Solutions

• Common Conditions

• Integrated Care

• Acute Neurology

The NHS RightCare Approach

Steve Sparks, Mary O’Brien

Right Care Delivery Partner 8th November 2016

17

What is RightCare?

NHS RightCare is a programme committed to reducing unwarranted variation to

improve people’s health and outcomes. It ensures that the right person has the right

care, in the right place, at the right time, making the best use of available resources.

NHS RightCare ensures local health economies…..

•make the best use of resources to give better value – better value for patients, the

population and the tax payer.

•understand how they are doing – by identifying variation with demographically

similar populations

•get talking about the same stuff - about population healthcare rather than

organisations

•focus on the areas of greatest opportunity by identifying priority programmes

which offer the best opportunities to improve healthcare for populations

•use tried and tested processes to make sustainable change to care pathways to

reduce unwarranted variation

18

NHS Right Care Principles

19

20

Commissioning for Value Focus Packs

Covering Neurology

• Neurological conditions covered over 3 RightCare focus packs:

• Neurological – major neuromuscular conditions and sudden onset (see stroke), progressive (note dementia), chronic pain

• Mental Health – Dementia

• CVD – Stroke

• All packs provide detail on elective and NEL admissions, LOS, procedures, primary care prescribing

• 26 (out of 65) wave 1 CCGs focussing on neurology in their first cycle of improvement

26

27

• The NHS RightCare team supports local health economies adopt

the NHS RightCare approach as ‘the way we do things around

here.’

• The proven three-phase process provides a more systematic,

evidence-based methodology to service redesign and

prioritisation.

• It is helping many health economies make sustainable change

to improve their population’s health whilst making the best

investment decisions.

28

RightCare wave 1 CCGs in London

29

Our offer to local health economies and national

programmes

• Expertise to support health economies gather and use data to highlight and explain

unwarranted variation, giving you a starting point for transforming the way care is

delivered for patients and populations.

• A range of comprehensive data packs, specific to each health economy, that act as a

source of insight to identify priority areas that offer the best opportunities to improve

healthcare for populations and increase value.

• Access to online tools and optimal value pathways to support the case for change and

evaluate progress.

• Support to interpret intelligence developed by NHS RightCare and from other

sources.

• Access to best practice, real life examples and learning from other health economies

where the RightCare Approach has been adopted.

30

We ask you to:

• Use intelligence to start and drive discussions about how you can improve value, in

particular the data packs provided by NHS RightCare.

• Appreciate that the NHS RightCare data pack data is indicative - a starting point for

action and to stimulate further data analysis.

• Use your local resources, including Commissioning Support Organisations, to delve

further into the intelligence to triangulate with other data sources.

• Proactively work with your local Delivery Partner to understand your health economy’s

data, seeking advice when needed.

• Use the data and tools available, alongside your local insight, to ensure decision-

making and change is based on the right intelligence and with the right buy in.

Neurology in London

A summary of commissioning for value

data

• Person centred service

• Prompt diagnosis, appropriate referral & treatment

• Rehabilitation, adjustment and social integration

• Lifelong care and support for people with long term neurological

conditions, families and carers

DH, 2005. The National Service Framework for Long term Conditions

32

What should good care for neurological

conditions look like?

33

Demographic Summary

Tower Hamlets

City&Hackney

Barking& Dagenham

34

Richmond

Kingston

Overall London has a young age profile… Only a small proportion of its

GP registered population are 75+

Tower Hamlets

Newham

City&Hackney

Islington

Southwark

Lambeth

Wandsworth

35

But for those that are over 75+ there are higher levels of deprivation

compared to other parts of the country

Tower Hamlets

Newham

City&Hackney

Islington

Southwark

Lambeth

Haringey

Specialist provision in London

• Total neurology programme budget spend in London is

£107M

• In London 44,005 patients were admitted to hospital with a

neurological condition in the Neurology Programme

Budget Category who were not cared for by Neurologists.

The total spend for these patients is £82.5m

• The total spend for patients with neurological conditions

cared for by Neurologists is £25.4m

• 30% of spend is covered by consultants within General

Medicine or A&E

Summary Neurology Spend Data

38

Breakdown of highest spending

neurology diagnoses (of £107m total)

Diagnosis Total Spend

R296: Tendency to fall, not elsewhere classified £19.6m

R55X: Syncope and collapse £8.5m

R410: Disorientation, unspecified £5.6m

G35X: Multiple sclerosis £5.4m

G560: Carpal tunnel syndrome £4.6m

R568: Other and unspecified convulsions £4.3m

R42X: Dizziness and giddiness £3.7m

G409: Epilepsy, unspecified £3.4m

R268: Other and unspecified abnormalities of gait and mobility £2.9m

G20X: Parkinson's disease £2.4m

R298: Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems £2.1m

G403: Generalized idiopathic epilepsy and epileptic syndromes £2.0m

G459: Transient cerebral ischaemic attack, unspecified £1.7m

G439: Migraine, unspecified £1.6m

G931: Anoxic brain damage, not elsewhere classified £1.1m

G932: Benign intracranial hypertension £0.89m

G819: Hemiplegia, unspecified £0.88m

G249: Dystonia, unspecified £0.87m

G122: Motor neuron disease £0.84m

G401: Localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures £0.72m

Diagnosis highlighted in yellow are included in Public Health England’s “Defining adult

neurological conditions” briefing document

Hounslow

Sutton

Tower Hamlets

Kingston

Merton

Camden

Barking

Westminster

Bromley

Redbridge

40 England average

Neurology spend only includes programme budget category

Neurological problems (7X). Chronic pain is not included.

Bromley

Islington

Haringey

Sutton

Ealing

Lewisham

Newham

Barking and

Dagenham

Redbridge Tower

Hamlets

Westminster

City and Hackney

41

Tower Hamlets

Hounslow

Sutton

Hammersmith

City and Hackney

Greenwich

Waltham Forest

Kingston

Bromley

Wandsworth

Merton

Camden

Richmond

42

43

Proportion of neurological elective spend by

common conditions

44

Proportion of neurological elective spend by long

term conditions

45

Proportion of neurological elective spend by

other conditions

46

Proportion of neurological non-elective spend by

common conditions

47

Proportion of neurological non-elective spend by

long term conditions

48

Proportion of neurological non-elective spend by

other conditions

There is very little direct

correlation between a

CCG’s spend on elective

admissions and their

spend on non-elective

admissions

49

Neurology Elective vs Non-Elective

Spend

You would perhaps expect to see a negative correlation- if they spend less on elective

then they would spend more on non-elective and vice versa

The London CCGs seem to have a lower elective spend compared to all CCGs, irrelevant

of non-elective spend

• Highest spend excluding falls/dizziness; MS, Carpal Tunnel & Epilepsy

• Approx 40% variation in rate of total neurology spend per 1,000 population across London

• London % elective spend on neurology overall is slightly lower/roughly in line with England average (exception is epilepsy), in line with England average for NEL spend

• No correlation between elective and NEL spend

50

Spend - Summary

51

Common Conditions

Epilepsy

52

….But many CCGs have a high spend rate for elective admissions – all

but a handful spend above the national average

Lewisham

Bexley

Greenwich

Bromley

Lambeth Merton

Ealing

53

54

All London Boroughs have a low recorded prevalence of Epilepsy –

lower than the national average

Westminster

Tower Hamlets

Camden

West London

Newham

Wandsworth

City & Hackney

Lambeth

Sutton

Bexley

55

Virtually all London CCGs spend less than the national average on

emergency admissions. Does this link to low recorded prevalence

rates?

Islington

Sutton

Croydon

Kingston

Bromley

Bexley

Southwark

Richmond

Redbridge

56

London has lots of people admitted for EEG procedures

Lewisham

Bexley

Greenwich

Bromley

Southwark

Lambeth

Sutton

Croydon

57

These rates only

cover inpatient

EEGs

However, London doesn’t typically have better seizure free rates

Richmond

Kingston

Havering

Bexley Tower Hamlets

Islington

58

Spend on hospital admissions for EEGs

by Provider

Provider Name Total Spend Number of admissions

for EEGs

RJ1: Guy's and St Thomas' NHS Foundation Trust £830,000 363

RRV: University College London Hospitals NHS Foundation Trust £510,000 242

RJZ: King's College Hospital NHS Foundation Trust £490,000 208

RP4: Great Ormond Street Hospital For Children NHS Foundation Trust

£230,000 98

RJ7: St George's University Hospitals NHS Foundation Trust £130,000 58

RYJ: Imperial College Healthcare NHS Trust £120,000 52

R1H: Barts Health NHS Trust £100,000 41

RF4: Barking, Havering and Redbridge University Hospitals NHS Trust

£70,000 25

RQM: Chelsea and Westminster Hospital NHS Foundation Trust £40,000 20

RVR: Epsom and St Helier University Hospitals NHS Trust £30,000 *

RAL: Royal Free London NHS Foundation Trust <£5,000 *

RV8: North West London Hospitals NHS Trust <£5,000 *

RHQ: Sheffield Teaching Hospitals NHS Foundation Trust <£5,000 *

RJ2: Lewisham and Greenwich NHS Trust <£5,000 *

∗ Admissions less than or equal to 5

Note that

there is a

children’s

epilepsy unit

at Guy’s and

Thomas’

60

Epilepsy elective admissions (not including day cases) by

length of stay and activity

CCG Name Length of Stay Activity Average LOS Sutton 254 22 11.55

Enfield 202 18 11.22

Barnet 306 33 9.27

Harrow 177 21 8.43

Waltham Forest 294 36 8.17

Kingston 114 18 6.33

Croydon 264 46 5.74

Havering 172 31 5.55

Haringey 186 36 5.17

Hounslow 188 38 4.95

Redbridge 85 18 4.72

Newham 131 28 4.68

Hillingdon 167 38 4.39

Central London (Westminster) 81 19 4.26 Brent 144 35 4.11

West London 96 24 4.00

Hammersmith and Fulham 72 18 4.00

Islington 124 32 3.88

Barking and Dagenham 78 21 3.71

Richmond 63 17 3.71

Ealing 89 27 3.30

City and Hackney 97 30 3.23

Lewisham 126 40 3.15

Bromley 147 52 2.83

Bexley 96 35 2.74

Greenwich 126 47 2.68

Tower Hamlets 80 30 2.67 Southwark 62 29 2.14

Lambeth 86 41 2.10

Merton 16 8 2.00

Camden 70 41 1.71

Wandsworth 44 28 1.57

* Excluded admissions where length of stay is more than 6 months.

Lambeth has the

second highest at

2.73

Lewisham has the

highest LOS for

emergency

admissions at 3.05

61

Average length of stay after an emergency

admission for epilepsy by Provider

* Providers with admissions less than or equal to 5 have been excluded

Epilepsy - Rate of emergency admissions where

patients stayed in hospital for 0 or 1 day and had

no procedure (per 100,000 population) – 2014/15

This is consistent

with generally low

emergency

admission rates in

London

Epilepsy - Rate of elective admissions where

patients stayed in hospital for 2 or more days and

had a procedure (per 100,000 population) – 2014/15

Southwark has the

lowest proportion at

6.98%, and Ealing

has the second

lowest at 7.2%

65

66

Average length of stay after an emergency admission for epilepsy

where patients had CT head scan (by Provider)

* Providers with admissions less than or equal to 5 have been excluded .

• Low recorded prevalence

• Higher than England average elective spend and EEG rate, but seizure free around England average

• Variance in LOS

• Elective

• Short stay emergency admissions with no intervention = appropriate admissions criteria?

• Longer stay emergency admissions with intervention = appropriate admissions criteria?

• Variance in management by Consultant Neurologist

67

Epilepsy - Summary

Migraine and Headaches

68

Islington has the

highest elective

spend at £392 per

1000 pop Hammersmith has

the second highest

at £367 per 1000

pop

69

Hounslow has the

second highest at

1006 per 1000 pop

Sutton has the

highest non-elective

spend at 1026 per

1000 pop

70

Hammersmith and

Fulham has the

second highest at

45 per 100,000 pop

Islington has the

highest number of

day cases at 46 per

100,000 pop

71

• Non elective spend significantly below England average

• Higher rate of day case admissions

72

73

Long term conditions

Parkinson's disease

74

Hounslow has the

highest spend on

elective admissions

at £864 per 1000

pop

Ealing has the

second highest

spend at £751 per

1000 pop

75

Tower Hamlets has

the second highest

at £651 per 1000

pop

Enfield has the

highest non-elective

spend at £675 per

1000 pop

76

Ealing has the

second highest at

51 per 100,000 pop

Hounslow has the

highest admissions

at 74 per 100,000

pop

77

CCG Name Length of Stay Activity Average LOS Bexley 394 18 22 Camden 262 12 22 Kingston 254 12 21 Hounslow 399 20 20 Enfield 705 42 17 Hillingdon 523 32 16 Ealing 520 33 16 Bromley 596 39 15 Greenwich 310 21 15 Brent 371 26 14 Lambeth 524 40 13 Lewisham 350 27 13 Newham 293 23 13 Croydon 535 42 13 Havering 464 38 12 West London 229 19 12 Wandsworth 257 23 11 Harrow 185 17 11 Redbridge 183 17 11 City and Hackney 182 17 11 Southwark 132 13 10 Merton 101 11 9 Waltham Forest 237 26 9 Barnet 225 25 9 Central London (Westminster) 145 17 9

Hammersmith and Fulham 110 13 8

Haringey 177 21 8 Sutton 114 18 6 Islington 72 12 6 Richmond 173 29 6 Barking and Dagenham 89 17 5 Tower Hamlets 78 25 3

78

Parkinsonism and other extrapyramidal emergency

admissions by length of stay and activity

* Excluded admissions where length of stay is more than 6 months.

• Elective and day case spend is higher than England average

with wide pan London variation

• Non elective spend at average level for England with wide pan

London variation

• No CCG has more than 43 non elective admissions

• Bed use for non elective varies between 0.2 (Islington) and 1.9

(Enfield)

79

Parkinson’s summary

Neuromuscular diseases

80

Harrow has the

highest elective

spend at £335 per

1000 pop Havering has the

second highest at

£293 per 1000 pop

81

Greenwich and City

and Hackney have

the highest non-

elective spend at

£393 per 1000 pop

82

Bexley has the

highest number of

day case

admissions at 27

per 100,000 pop

Bromley has the

second highest at

26 per 100,000 pop

83

Greenwich has the

highest number of

bed days at 23

Hillingdon has the

second highest at

20

84

• Day case admissions higher than England average

85

Neuromuscular summary

Motor Neurone Disease

86

Kingston has the

highest spend at

£221 per 1000

pop, and West

London has the

second highest at

£140 per 1000 pop

87

Hammersmith and

Fulham has the

highest spend at

£216 per 1000

pop, and West

Lewisham has the

second highest at

£193 per 1000 pop

88

Multiple Sclerosis

89

Hounslow has the

highest spend at

£791 per 1000

pop, and West

Hillingdon has the

second highest at

£780 per 1000 pop

90

Hammersmith and

Fulham has the

highest spend at

£313 per 1000

pop, and West

Enfield has the

second highest at

£298 per 1000 pop

91

Hillingdon has the

highest number of day

case admissions at

139 per 100,000 pop,

and Hounslow has the

second highest at 136

per 100,000 pop

92

Southwark has the

highest number of

bed days 41, and

Enfield has the

second highest at

20

93

• Elective spend varies from under £250 per 1000 population to

over £750 per 1000 population

94

Multiple Sclerosis summary

Outpatients, primary care prescribing

and diagnostics

95

Camden and Islington

have the highest new

outpatient neurology

appointments at 2470 per

100,000 pop

96

Bexley has the

second highest

spend at £1932 per

1000 pop

Bromley has the

highest spend on

these drugs at

£2220 per 1000 pop

97

98

Enfield has the

highest spend on

these drugs at

£331per 1000 pop

Bexley has the

second highest

spend at £301 per

1000 pop

Croydon

Newham

Tower Hamlets

Sutton

Waltham Forest

Rasagiline Mesilate is an irreversible inhibitor of monoamine oxidase-B used

as a monotherapy to treat symptoms in early Parkinson's disease

99

Tower Hamlets has

the highest spend

on these drugs at

£2924 per 1000 pop

Sutton has the

second highest

spend at £2832 per

1000 pop

Ealing

Merton

Westminster

Kingston

West London

100

Tower Hamlets has

the highest spend

on these drugs at

£6067 per 1000 pop

Hammersmith

and Fulham has

the second

highest spend at

£5554 per 1000

pop

Haringey

Enfield

Camden

Merton

Richmond

Pregabalin is a medication used to treat epilepsy, neuropathic pain,

fibromyalgia, and generalized anxiety disorder

101

Bromley has the

highest spend on

these drugs at

£197per 1000 pop

Camden has the

second highest

spend at £159

per 1000 pop

Haringey

Barking and

Dagenham

Newham

Hillingdon

Hounslow

Rizatriptan is used for the treatment of migraine headaches

Tower Hamlets has

the second highest

spend at £5305 per

1000 pop

Hounslow has the

highest spend at

£5840 per 1000 pop

102

Hounslow again has

a high spend, having

the second highest

at £994 per 1000

pop

Brent has the

highest spend at

£1026 per 1000

pop

103

• London has some of the highest out patient attendance rates in

England (only 2 CCGs below England average)

• There are significant outliers in prescribing spend

• There is significant variation in use of diagnostics

104

Summary for outpatients, primary care

prescribing and diagnostics

Enhanced acute neurology services

Nick Losseff

105

106

Acute Neurology

• London SCN organisational audit of secondary and tertiary care

2014 identified no provider with a systematic mechanism for

admission of patients with a primary neurologic condition under a

neurologist.

[http://www.londonscn.nhs.uk/publications/]

• Aim – to develop proposals for an ownership model.

• Original vision “hyperacute neurology units”

107

Acute neurology

• 4 providers delivering ”HANU” models

• Evaluation by UCLP of 2

108

Implementation

• Suffered from the usual vested interests

• Network provided outside direction

109

Acute neurology

• Huge numbers attending A+E with neurosymptoms

• (Kings / UCH – 1000 per month)

110

Summary of findings

1. Improved Patient Experience - feedback from staff suggested the HANU models resulted in positive outcomes for patients

2. Improved Clinical Outcome and Process-

3. Improved diagnosis- early neurology input showed the benefit of identifying less common or complex disorders frequently not recognised by non-neurological specialists.

4. Readmission reduction- comparative data pre and post HANU shows a reduction in the number of patients who re-attended for headache(13.9% vs 3.8%) and epilepsy (6.1% vs 0%)

5. Reduction of ED visits and unplanned hospital admissions- the findings from the study also suggest additional benefits arising from rapid follow-up in outpatient clinics which might further reduce ED visits and unplanned hospital admissions.

6: Admission avoidance- during the pilot at Kings 19% of admissions avoided from the total number of patients reviewed

111

Models of care

• Greatest benefits were observed secondary to more specialised

input at the A+E level rather than by the “ownership” of

inpatients, as

• Admissions were in any case substantially reduced.

• Need for secondary care level inpatients was small, but

prevented referral to tertiary beds for common problems.

112

113

114

Interlocking models

• Common conditions

• Integrated care

• WONT HAPPEN WITHOUT COMMISSIONER DIRECTION

!!!

115

Thank you

Dr Dominic Heaney FRCP PhD

Consultant Neurologist and Honorary Senior Lecturer

National Hospital for Neurology and Neurosurgery

UCLH NHS Foundation Trust

Community Neurology Service

The Challenge

• Neurological conditions – headache, dizziness and faints and fits

particular prevalent within communities

• Changes in condition e.g. new diagnosis, deterioration, pregnancy,

co-morbidity can require specialist input

• Traditional model of focussing specialist knowledge in secondary

(and tertiary care) cumbersome, expensive and arguably fails to

meet need.

• Secondary care doctors find clinics blocked by “long term follow up”

• Challenge for GPs – short consultation and experience

118

London outpatient

appointments

80,158 £17,314,128

Estimate of common

conditions appointments not

needing neurologist

14,500 £3,160,000

Follow-ups 110,000 £13,580,000

Common conditions data

Admissions

119

Total London neurological admissions 229,355

Total admission spend £107,914,000

Common conditions admissions (14%) 35, 300

Common conditions spend (19%) £20,908,000

Readmissions 2015/16 (SUS) 8,700

Epilepsy total non

elective admissions

6,742 £9,242,808

Headache non elective

admissions

8, 962 £6,036,149

The Approach

• Embed “specialists” within primary setting

• Three tiered approach;

GP

Community based nurse specialist

Neurologist (embedded or hub)

e.g. Camden Integrated Care Service: community-based epilepsy

nurse specialist (1.0 FTE) working closely with consultant (0.2

FTE) delivering care in primary care setting

• Receiving referrals after “advertising” service and also pro-

actively case finding

• Nurse supported by neurologists: options e.g. embedded or

hub

Challenges

• Staff recruitment and retention!

• Information technology

• Pharmacy governance

(“calciumgate”)

• Ownership: CCG or Trust

Outcomes

• Very flexible, now seeing first seizures

• Patient and GP satisfaction high

• Rapidly identify patients with high level of need

• Early data suggests reduction in A&E attendance

• Move of long term follow up patients from hospital to the

community

• Neurologist learning of primary care environment

improves quality of care

Improving the integration and

coordination of neurological care

Adapting existing service models

Jacqui Wakefield/Catherine Atkinson

SCN Integration Workstream Leads Nov 2016

‘As is’ for those with Neurological

LTC • People with neurological conditions often have complex multi

agency support;

• Have the highest levels of pain, anxiety and depression.

• Have the lowest health-related quality of life (EQ5D) of any long-term condition.

• The current system is broken • PAC report findings Feb 2016

• ‘Invisible Patient Report’ Neurological Alliance 2015

• Risks of continuing with the current system are • Unnecessary A&E attendance

• Avoidable occupied bed day use

• Pressure on out-patient neurology and finite medical resources

• Variation and inequalities in health care access

• On-going avoidable spend on secondary care

• Poorer patient outcomes and experience

Integrated care – from the

evidence

• “seeks to improve the quality and cost effectiveness of care for

people and populations by ensuring that services are well

coordinated around their needs – it is by definition both patient

centred and population orientated.”

• “Integration is not about structures organisations or pathways it

is about better outcomes for service users”

• “It allows patients and their carers to navigate the NHS and

social care systems in order to meet their needs

• “It aims to deliver cost efficiency for the system and improve

clinical and wider quality outcomes.

Primary / Secondary Care

Interfaces in practice

What do patients want?

(Neurological Alliance 2015)

• Local services

• Quick and accurate diagnosis

• Rapid access to expert support and treatment

• Self management support

• Reduced admissions and length of stay

Integration from service user perspective

Poor integration leads to:-

• Confusion

• Repetition

• Delay and dissatisfaction

• Duplication, gaps in service delivery

• People getting lost in the system

Integration provides:

• Strengthened preventative services

• Better planning

• Personal involvement of the patient

• Free access to good information

• Reduction in unscheduled care

Overarching framework

SCN agreed core principles of

integrated care for service

providers:

• Case ascertainment

• Care planning

• Risk stratification

• Access to specialist neurology in the community

• Self management support

• Technology

• Specific pathways to manage and treat UTI in the community

– a major cause of unplanned admission for patients with

neurologic disability

Principles of good integrated care

Key principle Delivery method Examples

Case ascertainment:

Knowing the

population;

E.g. Register

SE London, Wandsworth

Barnet hold registers of

patients with LTNC. (Barnet

showed reduction unscheduled care

and unnecessary GP attendance)

Risk stratification-

What do they need ,

when, how and by

who?

Central point of access, risk

management, care pathways

looking at diagnosis to end of

life

In Barnet patients on the

register are aligned to

care pathways indicating

regularity of review and

approach.

Care planning

There is a defined plan in

place.

The patient has been

involved in the plan and

knows who to call/ where to

go.

Care navigator/ case

coordinator/ Specialist

nurse; Shared electronic

patient record; patient

held record. MDT –

Health and social care

joint reviews.

Principles of good integrated

care cont. Principle Method examples

Access to Specialist

expertise

Rapid access to

specialist neuro

knowledge in community

settings;

e.g Specialist nurses

linking in with acute

neurologists

Virtual clinics/ telephone

lines /fast track

appointments

Self management

support

Variety of methods

available to support self

management

Bridges approach;

NWLondon UTI pathway;

peer support groups.

Technology Virtual clinics, self

management support,

Electronic patient

records

NHNN MS triage *Neuro

response ; Self care hub

SCN work stream actions

• Disseminating the core principles to service providers via a

benchmarking tool of key principles with examples practice

exemplars.

• Peer review from SCN group to facilitate service development.

References

• NHS England. GP Patient Survey 2015. http://results.gp-patient.co.uk/report/explanation.aspx

• Neuro Numbers, Neurological Alliance, 2004

• http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data

• 4The Neurological Alliance (2003). Report. Neuro Numbers: A brief review of the numbers of people in the UK with a neurological condition

• Monitor - Enablers and barriers to Integrated Care report June 2012

• Transforming Community Neurology report, Thames Valley SCN 2016

London SCN website – Neuroscience http://www.londonscn.nhs.uk/networks/mental-health-dementia-

neuroscience/