Clinical Governance

1
Clinical Governance Managed Clinical and Care
Networks

• Alison Bramley, MCN Manager
• Coronary Heart Disease, Stroke, and Respiratory
  MCNs

2
Why do we need MCNs?

• What are the problems to which an MCN is the
  answer?
• A. Patients
• perceive service is not joined up
• get conflicting messages
• wait too long
• travel too far

3
Inequity in patient pathway

• Services differ in different areas of Lothian
• Quality improvements in one part of Lothian are
  not spread
• Service improvement is not maintained
• Improvements are not built in to become how we
  do things round here.

4
For example

• Respiratory Healthcare Group has met for several
  years developing a strategy and action plan for
  COPD to move more care into community
• Work on COPD is still fragmented throughout
  Lothian and progress has stagnated
• New driver of HEAT target T6 reduction in
  readmissions and number of bed days
• It now needs leadership and management/admin
  resource to ensure an equitable, evidence-based,
  improved pathway is established
• The Group will become an MCN with funding from
  ABPI for two years and contributions from CHPs
  LTC funding.

5
Lothian Networks

• These vary in history and nature
• Diabetes, CHD Stroke MCNs set up with national
  funding to progress national strategy and
  projects.
• Palliative Care Network not yet fully supported
  as MCN but making local progress on improving
  care.
• Ophthalmology unsupported.
• Respiratory Network becoming an MCN with external
  short term funding.
• Other local networks of clinicians working
  together informally across boundaries aspire to
  MCN status.
• Regional National Networks.

6
NHS Lothian MCNs
7
Managed Clinical Network

• Managed
• Clear purpose
• Structured, organised, supported, monitored
• Clinical
• Good clinical engagement
• Effective Patient involvement
• Evidence-based care
• Network
• Resource to service providers planners
• Role improving whole patient pathway

8
What does an MCN look like?

• linked groups of health professionals and
  organisations from primary, secondary and
  tertiary care, working in a coordinated manner,
  unconstrained by existing professional and health
  board boundaries, to ensure equitable provision
  of high quality clinically effective services
  throughout Scotland
• MEL (1999)10

9
Our aims objectives

• Equity of care
• Dissemination of information and patient focused
  public involvement
• Development of protocols and guidelines
• Improve patient services and patient care
• Increase quality of care through evidence based
  practice, peer review and audit

10
Guidance on MCNs

• Designed to Care (1997)
• Acute Services Review (1998)
• MEL (1999) 10
• NHS HDL (2002) 69
• Building a Health Service Fit for the Future
  (Kerr Report May 2005)
• HDL (2007)21Strengthening the role of managed
  clinical networks

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9 Core Principles

• Clear management arrangements, Lead Clinician is
  responsible for network function Public Annual
  Report to accountable body.

• Journey of care mapped. MCN related to planning
  function
• Annual workplan of service improvements and
  patient benefits

4. Evidence based
5. Multi-disciplinary extend roles
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9 Core Principles (cont)

• Supported service user (patient) and voluntary
  sector involvement Capture service user views
  improve access improve patient information

7. MCN has Quality Assurance Programme approved
by LHB.(NHS QIS guidance awaited) 8. Utilise
education and trainingpotential of network
9. Generate better value for money
13
How MCNs add value

• Co-operate to redesign pathways
• Agree protocols and information for referral and
  discharge
• across boundaries (primary, secondary, tertiary,
  social care)
• equitably across Lothian
• Resolve conflicts of interest across boundaries
• Address inequalities
• Involve patients in redesign of pathways and
  design of patient information
• Monitor service quality against standards
• and much more see market stalls

14
Key achievements Stroke MCN

• Stroke Hotline
• enables a direct phone conversation between GP
  and Consultant for most appropriate referral
  route and immediate booking for neurovascular
  clinic reducing waiting time from over two weeks
  to typically three days.
• Community-based stroke developments
• Continuing multidisciplinary outpatient
  management in Edinburgh Day Centres
• Access to lifestyle self-management programmes
• Development of Phase 4 physical fitness training
  pathway

15
Key achievements Coronary Heart Disease MCN

• Rapid Access Chest Pain Clinics
• reduced waiting times from over 23 weeks totwo
  days or less
• Cardiac Rehabilitation in the Community
• seamless home, community and hospital based
  rehabilitation services tailored to needs of
  thepatient
• Heart Failure nursing service
• clinical care and support of patients in their
  own home reducing hospital readmissions in
  patients gt 65 years of age by 50

16
Key achievements Diabetes MCN

• Integrated diabetes register with shared data
• Roll out of retinopathy screening programme
• Trained staff in each general practice
• Foot screening resource
• Standardised insulin pump training

17
Key achievements Palliative Care MCN

• consistent DNAR information between care settings
  reducing inappropriate resuscitation attempts
• 84 of Practices adopt the Gold Standards
  Framework for improving palliative care
• a single referral form for all palliative care
  services in Lothian.

18
Key achievements Ophthalmology MCCN

• Lothian Orthoptic Optometrist Partnership (LOOP)
• Reduced waiting times, early detection and
  treatment, and reduced surgical intervention for
  children with visual problems
• Vision Support Centre Eye Pavilion
• A unique joined up service of health and social
  care providing support, advice and education to
  staff and patients across Lothian
• Lothian/West Lothian Optometry Cataract
  Initiative (LOCI)
• Successful pilot programme to improve access to
  cataract services, improving quality of referrals
  and waiting times
• Contact Lens Optometry Partnership (CLOP)
• Specialised contact lens service in the community
  for complex long term corneal disease

19
Key achievements Respiratory MCN
Pulmonary rehabilitation in 3 community centres
in Edinburgh and 2 in West Lothian and planned
for East and Mid Lothian Met Office warnings
for COPD patients in East Lothian
20
Principles of accountability and clinical
governance for MCNs

• The general principles of accountability and
  clinical governance will apply to MCNs as they do
  all other work undertaken within the NHS in
  Scotland
• MEL(1999)10

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What does a good qualityMCN look like?

• Clear purpose
• Leadership and enthusiasm
• Good clinical engagement
• Patient involvement
• Effective management
• Quality assurance framework

Diabetes MCN Executive team
22
MCNs Clinical Governance Role

• MCNs are virtual organisations without
  operational responsibility or accountability
• Clinical Governance remains the responsibility of
  operational staff accountable through the
  management line to the Chief Executive
• Operational staff and managers are members of
  MCNs
• MCNs have a role in ensuring safe and effective
  clinical care

23
Current performance mgt of accredited and
supported MCNs

• Accountable to Director of Planning
• Clinical Leads appraised annually by Director of
  Planning and Medical Director
• MCN Workplan signed off by Director of Planning
  and reported to NHSiL Planning Group
• Annual Report
• public document
• for info to HGRM and Service Redesign Committees

24
Performance mgt of redesign and improvement
programmes

• Scottish standards eg NHS QIS Standards, Scottish
  Gold Standard for palliative care
• Standards from national/professional bodies eg
  NICE, British Cardiac Intervention Society etc
• Ensure programme to implement SIGN
  recommendations and is in place for all sectors
• Monitor eg compliance with SIGN, QIS peer reviews
  and national audits
• Identify gaps
• Prioritise Action Plan to meet standards.

25
Monitor and report progress of performance
against standards in new structure

• MCNs an integral part of Clinical Improvement
  Strategy
• Report to HGRM Groups in Primary and Community
  (Mike Winter) and LUHD (Simon Mackenzie), and
  agree Action Plans
• Prioritise work on new SIGN Guideline
  recommendations, NHS QIS reviews and outcomes of
  national audits
• Locally agreed standards incorporated in MCN
  Quality Assurance Frameworks
• Annual (public) Reports with workplans to remedy
  gaps to HGRM Committee.

26
Performance and Clinical Governance of MCNs

• MCNs are accountable to the Board through the
  HGRM Committee for Clinical Governance matters
• It is up to the Board to make sure MCNs are fit
  for purpose when delegating authority to them
• The mechanism for reporting to the committee
  should be clear, agreed and formalised
• NHS QIS advice on local accreditation of MCNs is
  awaited.

27
Examples of good Clinical Governance

• Diabetes MCN Clinical Governance Subgroup
• Stroke MCN action plan to meet NHS QIS and QAF
  standards
• CHD MCN links to Quality Improvement Teams who
  implement SIGN Guidelines

28
Future Developments

• NHSiL Planning Group will agree a strategy and
  criteria for support of future local MCNs
• An advisory check list for any budding MCN
• NHS QIS Guidance on local accreditation will be
  put in place

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MCNs are the answer

• Services are better joined up and equitable
  across Lothian
• Patient information is consistent
• Pathways are implemented and waiting is reduced
• Services are redesigned to be nearer to where the
  patient lives
• Quality improvement principles are used to
  implement and maintain good quality