Care Pathways and Service Delivery Transformation

Project Lead: Tracy Broom

Project Manager: Claire McCarthy

Purpose

Our team looks at how we currently deliver services to patients and where, when and how we could improve this. We do this by reviewing 'segments' of care delivery, called Care Pathways.

A care pathway is a series of 'things' that happen to a group of people with a particular condition over a period of time. The pathways tend to be condition specific, for example, looking at diabetes or cardiology. Sometimes, people refer to it as a patient journey, where a group of individuals needing similar health or care services move between different teams responsible for providing their care.

Our aim is to design care pathways that are appropriate for the Island, coordinated, best value, based on best practice (i.e. supported by evidence and research), are clinically and financially sustainable and that deliver quality outcomes and experiences for our community.

The types of activity within in a care pathway could include starting with a visit to your GP, referral for tests or treatment at Nobles and perhaps involve a hospital stay or being transferred to the UK for treatment at a specialist centre. Alternatively, the pathway may start when an ambulance is called, followed by a visit to the Emergency Department or the Minor Injuries Unit and complete on discharge home. However it starts, the pathway depicts the whole process through first contact, diagnostics and treatment through to discharge. It may also involve care provided when you are at home such as ongoing follow ups with your GP or optician or a visit from a community nurse or a social worker.

We can’t review all services for the whole of our health and care system at the same time due to the volume of care provided on the Island, so we need to do the reviews in groups. We are guided by Manx Care on the priority of which services they would like us to review and in which order. Each Care Pathway review can take around 4 months to complete, with more complicated pathways taking longer.

Progress

In Phase 1 we looked at 9 service areas and mapped out how we provided health and care, found out how others provided this (international best practice) and then described, at a high level, what an ideal pathway for the Isle of Man community might look like.

These nine areas were: Cardiology, Vascular, Stroke, Diabetes, Children & Young People with Continuing Care Needs (CYPCCN)*, Autism, Cancer, Eyecare and Urgent and Emergency Integrated Care (UEIC).

The process was inclusive, with health and care staff and the Third Sector (voluntary and charity staff) attending sessions and working together to identify and agree issues and opportunities. People who use the services (i.e. patients and carers) were involved through surveys, workshops and individual meetings.

Phase 2 started in autumn 2021 when our work was re-prioritised by Manx Care and we were asked to focus on three of these areas in more detail, developing recommendations with supporting business cases that outlined their feasibility, costs and benefits for service users. These areas were Urgent and Emergency Integrated Care (UEIC), Eyecare and Cancer. For Cancer, we were asked to break down the single, original high level pathway into 12 more detailed, specific tumour site pathways.

Working closely with stakeholders across the system, business cases with proposed recommendations have been completed for UEIC, Eyecare and four of the 12 Cancer Pathways (Skin, Upper Gastrointestinal, Lower Gastrointestinal and Gynaecology). The business cases explain how much it would cost to introduce the recommendations and highlight the benefits that introducing them could bring to patients, carers and providers.

We have added sections at the end of this summary which focus on Eyecare and UEIC, providing you with more detail.

For the six Phase 1 areas not prioritised in Phase 2:

We grouped diabetes, cardiology, vascular and stroke and, working with Public Health, reviewed national screening services provided elsewhere. The purpose of screening is to find people in the community who are at higher risk of a health problem or a condition, so that an early treatment or intervention can be offered. The main outcome of this work is a proposal for a national Diabetic Retinopathy Screening programme for the Island. In addition, we started the next phase of work on the Cardiology pathway
Children with Continuing Care Needs (CYPCCN)* – the team have worked closely with stakeholders across the system to review and update the outputs of the Phase 1 work. They have now developed recommendations to improve this service and completed a draft business case outlining the costs and benefits of introducing these proposals for patients and service users
The next steps for Autism will be developed based on the outcomes of the 2022 DHSC led National Autism Strategy. As Autism is not only supported by health and care services, the decision was taken to wait until the strategy was completed to fully understand the island context for people with Autism and with this information, to then consider how to ensure the numerous Government Departments and other organisations involved in supporting people with Autism might have an holistic, coordinated approach to improve the support offered

The Care Pathways Project has close links with many projects across the HCT Programme, especially the Primary Care at Scale (PCAS) Project, the Workforce and Culture Project, the Manx Care Record Project and the Nursing, Residential and Home Care Project. These project teams frequently collaborate to ensure their work is aligned.

*Please note, this Pathway was previously called 'Children with Complex Needs (CwCN). It was renamed further to feedback from Service Users and Carers.

Update for the next 12 months

The Care Pathways Project temporarily paused at the end of September 2022 to offer resource support to the wider Health and Care system. During this time, a much smaller project team worked with Manx Care, DHSC and Public Health to review the work to date and to agree the most efficient and effective way to undertake future work.

The new agreed approach will expand the scope of the work; looking at ways to support increased self-care and a bigger focus on community services, looking to see if new technology can assist care delivery and working with Manx Care to incorporate more detailed demand and capacity data.

During the pause, the project also worked with DHSC and Manx Care to agree formal Handover and Implementation Monitoring Processes. These will ensure that the agreed recommendations are effectively handed over to Manx Care for implementation and the Implementation Monitoring Process (led by DHSC) ensures that the intended benefits are tracked and delivered.

In September 2023 the Transformation Board requested that the project came off pause and restart its work. A multi-agency group was formed led by Manx Care and DHSC and supported by Public Health and facilitated by the project. Their objective was to agree a Prioritisation Matrix which would then be used to assess the 20 services suggested for inclusion in the next phase of pathway redesign.

The outcome was that the 4 highest scoring services (Urgent and Emergency Integrated Care (UEIC), Respiratory, Cardiology and Diabetes) and the 6 pathways from the previous work which were not fully complete due to being on pause (Children & Young People with Continuing Care Needs (CYPCCN) and Skin, Upper GI, Lower GI, Paediatric and Urology Cancers) were identified to be progressed in the next 12 months of work. This is anticipated to start later in the Spring.

Should you have any feedback, questions or comments regarding the Care Pathways Project or the wider Health and Care Transformation Programme, please contact HealthandCareTransformation@gov.im.

A focus on Eyecare

In September 2022, recommendations for improvement to the Island’s Eyecare Service were approved for implementation and funding was secured by the Health and Care Transformation (HCT) Programme.

This work was the result of a collaborative Care Pathways project involving patients, service users, the Hospital Eye Service staff, a local optician, Manx Care Primary Care and Community team including G.P.’s and a local charity supporting those with visual impairment (Sight Matters). This team worked with stakeholders across the whole Eyecare Pathway to design a more effective, financially sustainable service for patients, carers and those responsible for delivering the service. It sought to address current issues that were identified by the stakeholders and builds on best practise examples taken from the Island, UK and International sources.

There are 3 main initiatives that aim to deliver the following benefits to patients:

Initiative 1. Deliver the right care in the right place by the right person by:

Community optometrists co-delivering care with the Hospital Eye Service (HES)
Community Optometrists commissioned to deliver an expanded scope of clinical care (based on the General Ophthalmic Service model and fee structure in Scotland)
This includes regular Primary Eye Examinations and, when clinically appropriate, Supplementary Eye Examinations, delivered in the community

Benefits of initiative 1

Improvement in patient experience, with screening in the community reducing the risk of false positives and related anxiety around diagnosis and treatment delays
Reduction in patient travel as care is provided closer to home
Reduction in Emergency Department attendances as care for Minor Eye Conditions and ‘unscheduled appointments’ is diverted to community optometrists as appropriate (e.g. the current Minor Eye Conditions Service being piloted by Specsavers and G.P.s on behalf of Manx Care)
Reduction in waiting list for procedures and outpatient appointments as a result of improved diagnostics and advice and guidance provided in the community
Improvement in system resilience to respond to patient needs as and when required
Improved integration of services between the community and the Hospital Eye Service

Initiative 2. Design a sustainable delivery model for the Hospital Eye Service and community optometrists by:

Improved value for money of the on call system
Expand the HES team capacity and expertise
Provide more low complexity work on the island and some paediatric care
Increase throughput of cataract surgery

Benefits of initiative 2

Improvement in resilience of the HES team, with reduced risk of clinics being cancelled and delayed access to care for patients
Improvement in waiting list length as a result of improved workforce resilience and optimising skills of non-consultant staff
Improvement in patient experience as a result of reduced waiting times
Improvement in waiting times and access to care, as HES can complete more procedures in the allotted time and review more patients in the outpatient clinics
Improvement in timely access to tertiary care, with emergencies requiring specialist input directly routed to a specialist centre via the specialist on-call being provided by a tertiary centre versus initially going through two local on-call specialists
Improvement in patient experience and quality of care as issues around off-Island care are alleviated including delays around arranging first and follow-up appointments, elderly patients having to travel off-Island regularly, delayed access to diagnostics and disruption to continuity of care

Initiative 3. Empower patients to live independently, self-care and access appropriate services when required, including individuals with low vision and sight loss by:

Establishing clear criteria and eligibility for 'visually impaired' registration
Embedding an Eye Care Liaison Officer (ECLO) as part of the Eyecare pathway
Delivery of personalised care tailored to individuals (within the HES team
- Improvement in patient experience and quality of care delivered as a result of individuals having access to the appropriate services for their needs early on in their treatment journey
- Improvement in alignment with best practice guidelines to deliver care tailored to individuals with low-vision and sight conditions, thus improving safety and quality of care

Benefits of initiative 3

Improvement in patient experience and quality of care delivered as a result of individuals having access to the appropriate services for their needs early on in their treatment journey
Improvement in alignment with best practice guidelines to deliver care tailored to individuals with low-vision and sight conditions, thus improving safety and quality of care

The Eyecare business case was approved in October 2022. This work has now been handed over to Manx Care to implement the recommendations, with DHSC monitoring progress to ensure that the intended benefits for patients are realised.

A focus on Urgent and Emergency Integrated Care (UEIC)

As the broader UEIC work is on hold whilst the project is on pause, over the past 6 months the project team has been working with Manx Care to progress four priority initiatives within the UEIC recommendations. They are:

Hear & Treat – this involves clinical staff working within the Emergency Service Joint Control Room (ESJCR) to safely assess lower acuity 999 ambulance calls and signpost them to the most appropriate response (instead of all calls receiving an ambulance, when this may not be clinically required). Some calls will receive a higher priority and those that do not require a 999 response will be signposted to alternative, appropriate support. This will allow the Ambulance Service to better deploy its vehicles, according to the callers clinical need. This work has been funded initially for a day time service and started a phased delivery in February (2023) being fully operational in March.

Read BBC's local press coverage.

Read IOM Today's local press coverage.

See, Treat & Leave - this involves 24 hr availability of single crewed rapid response vehicle/s, staffed by Specialist Practitioners, being dispatched to appropriate 999 ambulance calls (instead of all calls receiving a two crewed ambulance). The Specialist Practitioners will have a higher level of training and will undertake an extended role in the patient’s home. This includes immediate treatment, some diagnostics (called 'point of care' testing, which may include ultrasound and blood tests), referral into the hospital teams or transfer to ED, signposting to alternative, appropriate services (for example Hospice, the Intermediate Care Team or the Wellbeing Hubs), the prescribing of medications (including intravenous fluids and antibiotics) and advice /discharge. This will allow the Ambulance Service to better deploy its services according to clinical need, reduce ED attendances and Hospital admissions that are not clinically required and deliver more care in people’s homes. This work has been approved for Transformation funding and will be implemented by Manx Care.

Intermediate Care – this is a 'bridge' between hospital and community care, offering 'step up' care i.e. alternatives to hospital admission (when this is not a clinical need) and support on discharge for patients already in hospital, called 'step down' care. The majority of the Intermediate Care service will be provided in the patient’s home. This includes crisis response (a home assessment done by a clinician within 2 hours, if needed) and reablement (a support package for up to 6 weeks). There is also some bed based care in Ramsey Cottage District Hospital (for patients who need more physiotherapy and occupational therapy support). Social Worker support is also available across the whole Intermediate Care service, wherever you are located. This will support faster recovery from illness, support timely discharge of patients from hospital, reduce ED attendances and Hospital admissions that are not clinically required and deliver more care in people’s homes. This work has been approved for Transformation funding and will be implemented by Manx Care.

Same Day Emergency Care (SDEC) – SDEC will be a dedicated area (close to the Emergency Department, ED) that will specialise in safely seeing and treating adult patients on the same day, allowing them (where clinically appropriate) to return home, reducing admissions into hospital beds when this is not medically needed. It will focus on patients with an illness (as opposed to patients with injuries or those with life threatening presentations, who will be treated in the ED/MIU as normal). This work has been approved for Transformation funding and will be implemented by Manx Care.

All 4 projects above will deliver benefits as standalone schemes but they also interlink and, as each one comes on line, they will increase the impact of the others. When Intermediate Care and SDEC are available as a referral route for the Specialist Practitioners on the Rapid Response Vehicles (for example, an ambulance), benefits are increased (for example, people receive more care in the place and with the staff that can best meet their needs). Or when the Clinical Practitioner in the ESJCR has the option to dispatch a Specialist Practitioner as well as an ambulance, benefits are increased (for example, patients may have all their treatment at home and not require transport to hospital and ambulance response times improve for calls that require a double crew response).

The Care Pathways project team is working on behalf of the Island community and with clinical specialists to support the spread of current good practice and to modernise care delivery where needed, in order to optimise patient outcomes and experience. Aiming for health and care provision to be in the right place, at the right time and delivered by the right person.