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Planning an effective Change Management Programme appropriate to the NHS. Yi Mien Koh Chief Executive Thursday 2 April 2009. Agenda. Background Hillingdon’s story Strategic objectives Key developments Gaps and challenges Risks The future vision. Background.

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Planning an effective change management programme appropriate to the nhs

Planning an effective Change Management Programme appropriate to the NHS

Yi Mien Koh

Chief Executive

Thursday 2 April 2009


Agenda
Agenda appropriate to the NHS

  • Background

  • Hillingdon’s story

  • Strategic objectives

  • Key developments

  • Gaps and challenges

  • Risks

  • The future vision


Background

Background appropriate to the NHS


Hillingdon health system key facts appropriate to the NHS

PCT 2008/9 budget £330m (before deficit repayment)

Resident population 250,000. Registered population 265,000

49 GP practices with 200 GPs 62 pharmacies

42 dental practices with 150 GDPs 47 Optometric practices

The Hillingdon Hospital NHS Trust (and Mount Vernon Treatment Centre)

Harefield Hospital (Royal Brompton & Harefield NHS Trust)

Mount Vernon Cancer Centre (East & North Herts NHS Trust)

Hayes Cottage Hospital Renal Unit (Imperial Healthcare NHS Trust)

Central & North West London Mental Health FT

BMI Healthcare at Mt Vernon

PCT Provider Services 352 (CATS provider)

ISTC (InHealth and Clinicentre) The Practice plc (CATS)

Hillingdon Health Limited (PBC/Harmoni Joint Venture)

Voluntary sector Health and Social Care


Hillingdon s story

Hillingdon’s story appropriate to the NHS


History
History appropriate to the NHS

  • First wave PCT in country, established Feb 2000

  • Poor commissioning in a monopolistic provider driven system

  • Never in balance, largest deficit in NHS history, Public Interest Report

  • 6 CEs, 3 Chairs, 4 FDs in two years (2005/7)

  • No recognition of health inequalities and investment driven by the articulate

  • Failed Fitness for Purpose and KPIs in 2006/7

  • New CE, new chair, new board - 2007


The story
The story appropriate to the NHS

........ is how we systematically turned around the PCT in a journey of improvement over three years to reach level 2 on WCC competencies

Headline successes:

  • Breakeven (first time in 7 years)

  • Performance on national KPIs - top quartile of PCTs in London

  • Paid off £18m of legacy debt (annual repayment £8m plus £1m interest)

  • On target to clear deficit by 2011

  • FESC procurement

  • Clear strategy


North West London Primary Care Trusts appropriate to the NHS

Spend by PCT 2006/07 (£m)

Sector average 43%

Hillingdon 54%


Nhsl 2007 8 outturn performance on 18 weeks a e mrsa finance
NHSL 2007/8 Outturn Performance on 18 weeks, A&E, MRSA & Finance

19 PCTs achieved 18 weeks admitted;

25 PCTs achieved 18 weeks non-admitted;

15 PCTs achieved A&E (source: weekly sitreps);

9 PCTs (of 27) achieved MRSA trajectories;

21 PCTs achieving finance control total

4 PCTs ‘green’ on all

18 weeks subject to meeting DH data completeness check


Journey to Becoming World Class Finance

2011/12

World Class (self care/ prevention)

Debt free

Strategy implemented

Improvement in health and health outcomes

Focus: continuous quality improvement and innovation

Goal: strong, vibrant local health economy providing high quality care

2009/10

Consolidation (outpatients)

Embedding existing achievements

Maintaining breakeven

Focus: strategy (implementation), contracts (out of hospital), PBC, OD (succession planning), joint working with La and other PCTs

Goal: sustainability

2008/9

Recovery ( high dependency to wards)

Maintaining 07/08 achievements

FOT breakeven

Provider development - FT, APO

Performance (AHC)- top quartile (Q2, NHSL)

Focus: finance, strategy (development), contracts (acute), PBC, market stimulation, PPE

Goal: embeddedness

2007/8

Turnaround (critical care)

Achieved breakeven

Evidence based decisions culture

Substantive chair, CE, FD, new board

ALE score = 2

Performance - top 7 PCTs in London

Focus: finance, controls, relationships, commissioning,

performance

Goal: meeting statutory duty

2006/7

Annus horribilis(Crash)

£53m deficit

Organization failure

public interest report

Interim chair, CE, FD

Incomplete FFP

Poor relationship with stakeholders

Nil credibility

Information free zone

Financial Performance (£)

WCC Competency levels

2002

first reported deficit

Baseline

Budget

-£53M

-£43M

-£19M

-£153k

-£35M

-£27M

£0M

2009/10

2010/11

2011/12

2002

2006/7

2007/8

2008/9



Fundamental strategy
Fundamental strategy Finance

Identifying and tackling underlying reasons for poor

performance and building from clinically-led evidence

base

Enablers

Clear strategy Proactive relationship with opinion formers

New values Embracing and managing GPs and clinicians

Performance management Knowledge based decision making

Systematise processes Strengthening commissioning

Strategic partnership with LA Improvement and innovation

Sustainability


Pct strategy
PCT strategy Finance

Shifting the system towards self care and prevention

Hospital

services

Health &

Wellbeing

Primary &

Community care

Self care

direction of travel for service & resource shifts over next five years


Strategic objectives1
Strategic objectives Finance

  • Sustaining financial balance

  • National priorities and healthcare standards

  • PCT (vital signs) and LSP priorities

  • Pegging hospital activities and investing in out of hospital services

  • Tackling inequalities by investing in south


Csp priorities based on jsna
CSP priorities Finance(based on JSNA)

  • Investments to target families in south of the borough. Progress to be monitored by life expectancy and all age all cause mortality

  • Improve maternity care to improve outcomes for mothers and their babies as measured by birth weight and breast feeding rates

  • Improve health and wellbeing of children, in particular children in need, to reduce teenage pregnancies and to improve educational attainment

  • Obesity care pathways for children and adults

  • CHD prevention, including diabetes, in targeted populations by commissioning preventive services such as smoking cessation and exercise

  • Improve employment opportunities and general healthcare for people with mental ill health



Journey to world class commissioning
Journey to World Class Commissioning Finance

1. Leadership

Problem – nil credibility

Progress - proactive programme of engagement with MPs and LA – honest listening and strategic; involving them along the journey of improvement

2. Partnership

Problem – health not on agenda, little influence on LSP and frozen out of developments in borough

Progress – health number one priority of LSP, excellent joint working, co-location at Civic and joint DPH. Children’s Centres, Building Schools for the Future and integration of services in polyclinics



World class commissioning competencies cont
World Class Commissioning competencies (cont) Finance

3. Patient and public engagement

Problem – little engagement except from the articulate. No strategy and resources

Progress – PPE strategy

4. Clinical engagement

Problem – little clinical engagement, poor relationship with GPs, consultants and predominantly administrative approach

Progress – PEC re-established. PBC initiatives: Urgent Care Centre, Referral Management Centre, PBC Director. Hillingdon Health Ltd.

5a. Needs assessment

Problem – public health not integrated into PCT or LSP

Progress – Joint Strategic Needs Assessment driving LSP and PCT priorities


Figure12 : Index of Multiple Deprivation (2007) by all, children and older people in Hillingdon (Super output area relative to England)


Hillingdon Borough geo-coded crimes between 19/11/2007 and 18/11/2008 (Domestic Violence)

I 50

F 38

F 35


Example of needs assessment and knowledge management coronary heart disease
Example of needs assessment and knowledge management 18/11/2008 (Domestic Violence)Coronary Heart Disease


World class commissioning competencies cont1
World Class Commissioning competencies (cont) 18/11/2008 (Domestic Violence)

5b. Knowledge management

Problem – information and knowledge free zone

Progress – tripled size of analytical team. Care and resource utilisation review ( Department of Health CRU model) including benchmarking.

Internalised BUPA’s clinical insights informing claims management and care pathways. Polyclinic modelling. Modelling impact of tariff reforms.

Key achievements - Demand management initiatives: Rapid Response, Case Management, UCC, RMC, CATS. Performance management and validation routines (13) adopted by all NWL PCTs. Trainers for Healthcare for London polyclinic modelling – training other PCTs. Insights of FESC procurement shared with PCTs around the country



BUPA Clinical Appropriateness Rules Engine 2005-2020

Admission for non-clinical reasons

Incorrect dominant procedure

Invalid dominant diagnosis

Admission of patients who could have been treated without the need for admission to hospital, or within a 4 hour period.

The coding of the incorrect primary procedure based on the care the patient received, causing the wrong HRG to be applied.

The coding of a secondary/ comorbid diagnosis in the primary diagnosis field, causing the wrong HRG to be applied.

Complication of procedures

Inappropriate coding of an admission to hospital, the Primary diagnosis should have been a complication of procedure.

Irrelevant Co-morbidity Coding

Low Priority Procedures

Underlying diagnosis dominant

Coding of co-morbidities that do not impact the clinical management or resource use, artificially inflate the HRG to a more complex level.

The coding of a patients diagnosis leading to admission in a field other than the primary diagnosis, causing the wrong HRG to be applied.

Patients given a treatment contractually identified as Low Priority, without the required pre-approval from the PCT.


World class commissioning competencies cont2
World Class Commissioning competencies (cont) 2005-2020

6. Prioritise investment

Problem – spends not aligned to needs due to lack of strategy

Progress – Commissioning Strategy Plan priorities identified by JSNA and predictive modelling supported by Medium Term Financial Plan

7. Market stimulation

Problem – monopolistic provider

Progress – Provider map. Procurement: FESC, CATS, UCC, RMC, EPIOCS (wheelchairs), diabetic screening, GP-led Health Centre


World class commissioning competencies cont3
World Class Commissioning competencies (cont) 2005-2020

8. Improvement and Innovation

Problem – information and knowledge free zone

Progress – Use of information to inform strategic decision making. Pilot for NHS Institute tool for improvement opportunities, RMC, clinical assessment panel and extended clinical assessment clinics. BUPA care pathway redesign. Benchmarking of programme budgets and outcomes. Advanced data validation of claims management.

Key developments – Contracting with ICHT for packages of care for chronic kidney disease. JV with London Deanery to run masterclasses for GPs on RMC hot topics and developing community specialist workforce. Feedback to GPs from consultant panel on referral quality to support development and improvement, GP balance scorecard includes benchmarking gatekeeper role. Testing of new pathways in community assessment clinics to refine specifications for procurement.


Carpal tunnel how patients funnel down from gps to outpatients and then to inpatients surgery

AS SHOULD BE 2005-2020

AS IS IN

IN HILLINGDON

HILLINGDON

1150

patients a year

turn up at GP Surgeries

6

months wait

1150

patients a year

turn up at GP Surgeries

73

being referred for

Outpatient Care

(+

possible

736

(

64

%)

should require

18

weeks

(

max

)

Nerve Conduction Testing

)

18

weeks

(

max

)

Nerve Conduction Testing

90

+

44

receiving Physio

205

Surgery

(

18

%)

736

Surgery

(

12

%)

?

736

Physio Rehab

205

Physio Rehab

Carpal Tunnel: how patients funnel down from GPs to Outpatients and then to Inpatients/Surgery

The following diagram contrast a years worth of activity and cost associated with ‘as is’ Hillingdon activity (on the left) to ‘ideal – best in class’ activity and costs (on the right)


Analysis of gp referrals april oct 2008 hillingdon pct referral management centre
Analysis of GP referrals April- Oct 2008 2005-2020(Hillingdon PCT Referral Management Centre)


Referral management centre rmc
Referral Management Centre ( RMC) 2005-2020

  • Established Jan 2008 – a PBC initiative

  • Processes 50,000 referrals a year – GP (75%) and non urgent intra-hospital (25%) or C2C referrals

  • Web-based referral tracking system (Amazon style) – paperless via Choose and Book

  • Most referrals triaged by consultants covering 8 highest volume specialities

  • Turnaround max 48 hours

  • Near real time monitoring of referral activity

  • Clinical insights into volume and quality of GP referrals

  • Annual (body shop) running cost: £650,000


Clinical assessment panel
Clinical Assessment Panel 2005-2020

  • PCT employs a panel of NHS consultants (and GPSIs) in twilight years of career covering 8 high volumes specialties

  • Remote working, guaranteed max 48 hours triage. Must agree to be contactable by GPs in office hours. Pay £100/hr

  • Triage options: advice back to GP (5%), referral to consultant community assessment clinics (20%), referral to allied health professionals (5-15%), referral to diagnostics (20%), approval for onward referral to hospital (50%)

  • Community Assessment Clinics in six specialties: musculoskeletal (MSK), dermatology, gynaecology, ophthalmology, cardiology, ENT

  • Example: MSK: Patient satisfaction survey – 100%. Service quadrupled in 4 months due to patient demand. Savings: 250k since July 2008.


World class commissioning competencies cont4
World Class Commissioning competencies 2005-2020(cont)

9. Procurement skills

Problem – poor procurement history due to lack of expertise

Progress – Procurement Strategy. Commercial Director appointed.

NHS London commercial strategy. London clinical and business support

Agency (Hub)

10. Health system management

Problem – ineffectual commissioner in monopolistic provider driven system

Progress – contract management of all types of providers in a well

performing health economy

11. Investment strategy

Problem – short term focus and no financial strategy

Progress – medium term financial plan



Gaps and challenges1
Gaps and challenges 2005-2020

  • Legacy debt

  • Organizational capacity and capabilities

  • Clinical engagement

  • Poor primary care infrastructure

  • Competing (top down) priorities

  • Provider resistance

  • Regulation

  • Flat health budget from 2011

  • Pace of change and execution


Risks

Risks 2005-2020


Risks1
Risks 2005-2020

  • Not breaking even

  • Demand management

  • Clinical engagement

  • Not achieving efficiency targets

  • Relationship with providers

  • Tariff reforms (MFF, HRG4)

  • Succession planning

  • PCT mergers or reconfigurations

  • Strategy execution


Risk mitigations
Risk mitigations 2005-2020

  • Medium term financial plan

  • Robust demand and activity planning including modelling impact of new tariffs and alignment between finance and activity plans

  • Demand management strategies

  • Refreshed PEC and PBC

  • Outer NWL acute commissioning alliance

  • London clinical and business support agency

  • Alignment with WCC principles



What would success look like in 5 years
What would success look like in 5 years ? 2005-2020

  • Investment returns show VFM and improved health outcomes

  • Strong vibrant health economy

  • Reducing health inequalities

  • Plurality of providers and patient choice

  • PCT as health system manager and driver of improvement and innovation

  • Recognized by partners and population as local leader of the NHS

  • Summary of journey of improvement (next page)



Thank you

Thank you 2005-2020


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