Improving MSK care with an integrated approach “ MSK Sheffield”

1. Improving MSK care with an integrated approach “MSK Sheffield”

2. Outline – the concept and the reasons • Commissioner view • History of MSK commissioning in Sheffield • What problems we were trying to solve • Conclusions and reflections • What we did – why partnership • Lessons learned and the future

3. History of MSK commissioning in Sheffield • Developed pathways (joint specific & service) • Procedures of Limited Clinical Value • Implementation of surgical thresholds • Developed a community MSK and podiatric surgery services • Developed close and effective partnerships & working relationships with clinical leads across all MSK services

4. What problems we were trying to solve • Concerns that our pathways had created silos and reducing integration frustrating both patients & clinicians • Concerns around variation in GP referral (timing, paper or electronic and relative MSK expertise) • Concerns that our protocols and thresholds had reduced expert clinical autonomy • Concerns of the above reducing flexibility of services to meet patients needs/deliver best outcomes • Concerns for sustainability of services with rising demand

5. Conclusions – recognition that we needed: • A new approach focussing on delivering outcomes through a fully integrated service rather than units of activity within individual directorates • A balance of robust referral pathways but also clinical autonomy and flexibility • To work much more closely with Sheffield’s patients to understand their needs and outcomes required • To address these by harnessing the expertise of local clinical experts those in Primary, Community and Acute care who best know the city and its patients’ needs to redesign MSK services citywide

6. What we did – why partnership? • Significant local assurance process • Hugely complex change – never been tried before in Sheffield • Vast numbers of ‘known unknowns’ & ‘unknown unknowns’ • Recognition that culture and iterative change rather than ‘big bang’ was key to ensuring long term sustainability • Recognition that the clinical expertise to deliver the change successfully was within our core local provider • Potential impact on other critical clinical services such as Sheffield’s regional trauma centre

7. Lessons learned and the future • Takes significant time to build structures, capabilities and trust – this is new for Sheffield • Partnership working has been absolutely key and moved things forward faster and at the same time harnessed fantastic and considered thinking and expertise (clinical and management) • Iterative process but the service is all the better for it • Still masses to do but have we addressed our concerns and are we positive about the future - absolutely!

8. Outline – the changes • Sheffield Context • the beginning • What is the “MSK Sheffield” model? • Operational detail and data so far • What next?

9. The beginning • CCG asked for a outcomes based, integrated MSK service • Sheffield Teaching Hospitals (STH) response • Co-design a model with patients • Single point of access model with aligned services • Re-organising services across whole city for all care • Measuring and reporting on outcomes • Build on what we have already; Spinal pathway, integrated community and hospital service

10. The model design • STH and CCG co-convened 2 large stakeholder events • Patient-centred specification for MSK service for whole city • Clear patient preferences for an integrated and responsive service • choice, information, quality • Model to work across community, secondary care and wider social space for all Sheffield MSK patients • not separate referral management, CATS or community model

11. MSK Managed Clinical Network Innovation Outcomes Shared Decision Making & Self Management Wraparound care Partnership working Prevention & Moving More Engaged and Activated Patients with stakeholder engagement in service design and delivery The Model

12. Decision Making Triage • Treatment Hubs • Wraparound services • Single point of entry with clear referral criteria • Specialist Intervention • GP or other Referrer The referral structure

13. Operational delivery Convene and agree the operational group/delivery team • Single point of access • Triage • Choice • Booking • Service alignment and integration Outcomes • Which ones • Collected how? Continuous evaluation and planning Education and stakeholder engagement programme

14. Operational delivery team • MSK operational group RESOURCED • Weekly meeting (3 line whip!) • CCG-STH collaboration • MSK clinical lead • Programme manager • CCG Commissioning Lead • 2 CCG GP commissioners • Clinical leads ortho, pain, rheum, physio, plastic hands • (GPs, MSK directorate leads, SPA lead) • Patient network • Professional network • Admin staff crucial

15. Single point of access • Electronic referral into ‘MSK Sheffield’ on ERS mandated • by single form (agreed, piloted and now 3rditeration) • GP indicates suggested service • SPA (single point of access) administrative centre • expanded for MSK referrals (44,000 per year) • Send referral on ERS to GP indicated service for initial triage in that service • Triage mechanism agreed amongst senior clinicians • Expert, active triage on ERS with 48 hour turnaround • Agreed ‘triage rules’ to standardise triage destination including reject with advice, move referral to different service

16. Service Alignment – making the pathways smoother and quicker Bringing existing, parallel services into a managed clinical network • STH restructured to create a single MSK directorate and department • Previously, MSK departments over 5 directorates • Independent Sector (IS) sub-contract partners to STH • Orthopaedics plus small element of pain • Worked through service overlaps and gaps to make the patient pathway smoother/quicker • Access to orthotics • Podiatric surgery v orthopaedic foot and ankle • IS to STH transfers • Physio in community, IS and STH

17. Outcomes - What Can We Measure? Process measures • Absolute appointment/procedure numbers, complication rates, proportion of patients with gout getting their uric acid below target etc Patient Reported Outcome Measures (PROMS) • Patients complete sets of questions designed and validated to measure change in specific conditions Patient Reported Experience Measures (PREMS) • Patients asked to report their experience of their treatment Patient activation measures (PAMs) • Report readiness to engage with treatment or change

18. The outcomes ‘how’ • Embed PROM collection into routine clinical care (44,000 new patient referrals each year) • Quickly realised that we couldn’t collect, analyse and report this information on paper without employing a small army of people • Trial IT solution • With commitment to parallel non-IT solution next • Negotiated for this to be properly funded • Designed initial specification for, went to tender

19. My Pathway – ADI: live April 2017 • Web based platform and App • Works on mobile phones, tablets & computers • Interacts with existing hospital systems to know what treatment the patient is receiving and when – ‘pathway’ • Can ask patients PROMs and PREMs at appropriate points in their treatment • Report information to • Patients • Clinicians • The System as a whole

20. 32,000 invitations to July 2018 43% of those invited sign up and are active users 26% of those invited have completed their first Eq5d

21. Change impact

23. Movement in triage between initial triage (where the GP sent it) and the final Triage (where MSK placed it) Note: Orthopaedic (physio triage) plus Orthopaedic together equal Orthopaedic GP ref (first column = 23.06%). In final triage destination (second column), Orthopaedic (physio treatment) remains with Physiotherapy (8.07%) and Orthopaedic remains with Orthopaedics (11.03%). Shown with outline box

24. Patient choice offer - Orthopaedics All patients offered choice of appropriate appointment after clinical triage ‘Appropriate’ = post triage, so only to the right clinic/clinician/provider ‘Choice’ = Time and location (where appropriate)

26. Patients waiting in admin system….

28. Outcome data collection and use of the app • 10,755 MSK new patients new using the MyPathway digital app • Use of outcomes data to change clinical pathways – introduced orthopaedic virtual clinics • Data being collected to establish Sheffield baseline • Eq5d, Back pain ,Pain baseline assessment, Ankylo Spondylitis • 75 more pathways to develop and establish baseline outcomes! • Add self help and information for each patient relevant to their condition

29. Key learning - Positive • Change Process • Clinical leadership and decision making • Putting what is right for the patient first • Resourced properly (clinical leaders, patients and programme management time) • Co-designed with patients with meaningful patient engagement • Test, change, test, change……….. • Cultural collaboration • Within STH, primary care, CCG and IS MSK • Barriers less where outcomes are the focus • Educational gains: across system and across MSK clinicians • Governance • Move from competition to collaboration, better for MSK patient • MSK entire system solution • Better for patient, smoother pathways, can resolve pathway overlaps/variations easier

30. Key learning points – Better if • Set robust base line data first • especially if merging different organisations activity (and data) • Agree plan for evaluation • Prospective/responsive plan to resource shift • More robust communications strategy with stakeholders • Better provision in contract for pump priming • eg. outcomes platform

31. Summary • Described a collaborative, whole system, outcomes-based approach to delivering patient centred, patient focused, integrated MSK care • Described the operational detail and challenges • Described the benefits of clinician led, collaborative CCG-Trust working where every step is co-designed by patients and each part of the process starts with the question of: Right Person, Right Place, Right Time……….