>>Stewart Moore: Hi, we're from the Walton Centre Specialist Neuroscience Trust in Liverpool.
I'm Stewart Moore and I'm the Director of Strategy.
We operate all our services across Merseyside and Cheshire, and North Wales on a network
basis, so that's Neurology, Neurosurgery including Spinal Rehabilitation and Pain Services as
well for a population of about three million. Quite a bit of experience of that and it's
highlighted five key obstacles, or to be optimistic critical success factors. Firstly, it's about
the infrastructure to develop and manage that model, it's about the incentives and the disincentives
for partners to be part of it, it's about the money, the financial flows, and it's about
behaviours, organisational and individual. There's lots of fine words about collaboration,
but that can disappear sometimes, our Commissioner's support, especially when the going gets tough.
So in our... we've learned from that in our proposal, we're going to focus on neurology
and spinal services as those are the largest services and have got the greatest opportunities.
Peter Olsen, our Medical Director and Consultant Neurologist will talk about Neurology and
Paul May who's our Clinical Chair Board from the Programme of Care for NHS England and
Divisional Clinical Director Neurosurgery is going to talk about Spinal, and Julia Riley,
Divisional Director, will talk about what a bank card would mean for us.
>>Peter Olsen: Good afternoon, hopefully you can hear me? I'm the Medical Director, but,
more importantly here I'm a Consultant Neurologist still. And importantly, or fortunately, I
don't know, there are less than 600 of people like myself, so there are very few of us;
and yet, there is a huge population of patients with long-term neurological conditions, it
could be eight million depending upon what definition is used in England.
And they need care in the community, and they aren't getting it. Furthermore, they have
crises and exacerbations of their condition as we've heard and this leads to 17% of attendances
at GPs, 10% of attendances at A&E Departments, 20% of acute medical admissions and even if
you take out Stoke that's still 10% of acute medical admissions are neurological.
Now, if you put this together you can see major challenges in terms of access, equity
of access, because although 600, they're lopsided very much towards London and the South East,
so huge problems with equity of access and avoidance of admissions of which there are
250,000 in England alone each year.
So problems... these problems and the inequalities have been documented repeatedly across England
by the National Audit Office, the Neurological Alliance, and, most recently, Public Health
England. So what does The Walton Centre do now? Well, for the last 23 years with this
population of three to 3 million, we've run this hub and spoke model. Now, the strength
of this, or the secret of it is the strength of the spokes, and I would emphasise this,
this isn't about the centre, this is the strength of the spokes. And this is all 14 DGHs in
our patch, the furthest is 93 miles away, or the Isle of Man with a flight and everything
else.
And we provide outpatient clinics, we provide ward referral sessions and we provide input
into the medical assessment unit. We guarantee the clinical governance, the accountability
and the electronic connectivity. Furthermore, we guarantee the supply, and that is the essential
thing; we guarantee the supply, we deliver tertiary level neurological services to our
patients equitably in every DGH three to five days a week.
So what do we want to do? Well, we're already high performing in this in Cheshire and Mersey,
but in short we want to take the services to the DGH seven days a week, and we want
to take our services out into the community. How are we going to do that? Well, [Inaudible]
seven days a week for Acute Services, enhanced medical and neurological advice lines, and
showing implementation in the pathways we've drawn up with our patients, and increasing
the depth and extent of the advanced neurology nurses that we put in between the specialist
care and the community services. So over to Paul May.
>>Paul May: Thanks, Peter. The NHS spends about £2 billion a year on back pain, and
about 300 million on spinal surgery, and there's 7% on year on year increase in activity and
cost. There are considerable variations in practice that many providers of NHS services
are in the private sector without any commitment to audit outcome or quality assurance.
The majority of providers do not... or are not compliable with the 18 week referral to
treatment target, and many patients are waiting for much longer periods than that. If you
can't have equitable care, reputability and reduction of variation unless you've got meaningful,
validated outcome data led by the patient, patient recorded outcome measures. In... for
the last eight years we've had a universal verifiable European based spine [unclear 00:05:35]
patient recorded outcome data search for now a co-ord of 20,000 patients with spinal surgery;
and it's a two year follow up based on patient recorded outcome measures.
For the last two years we've led the National Neurosurgical Audit Programme which has been
adopted by NHS England and gives consultant at unit based mortality rates for elective
and non-elective neurosurgical procedures, and is adopted by all the 24 other neurosurgical
units in England and the six paediatric neurosurgical units.
12 months ago we were asked to support our local district general hospital with a significant
waiting list issue. And we took on 100 patients, many of whom had been waiting for more than
a year for their spinal surgery. We conducted a review and a validation process, and the
outcome of that was only two thirds did not require the original planned surgery, which
has significant benefit... patient significant benefit to NHS.
However, that was a profoundly challenging situation, it was very difficult at all levels
in terms of issues, predatory perception, difficulties and challenging clinical behaviours,
pre-established clinical behaviours without evident space. And, more importantly, the
depth and focus and support required for the patients undergoing these changes, moving
to a different environment, seeing a different surgeon, not having the original surgery that
they thought they were going to be having after one year, really profound changes and
really profound requirements for support of those patients.
However, having been through that we've got a policy of outcome, we've now had a regional
NDT with a district general hospital, we share our work, they all comply, we all comply with
National Neurosurgical Audit and Outcome and spinal data, and we have... we are now engaging
with the other providers in the region. Our experience and lessons learned have been pivotal
in our inclusion in the National Transformation Spinal Programme which NHS England is leading
as one of the four pilot sites for this development of spinal networks. Thank you.
>>Unidentified Male: Thank you very much. Can I have questions for The Walton Centre,
Samantha?
>>Samantha: Thank you, so why do you want to be a Vanguard, what will it actually bring?
>>Unidentified Female: We didn't actually get to that point, did we? Why we want to
be a Vanguard, we want to implement it quicker than what we're already doing, and that will
help us with our double running costs, and it will also help us with the funding mechanisms.
I think, more importantly, for the patient, it will mean a local access to high quality
neurological care, and it would enable us to build on a really good comprehensive neuroscience
service that we've got a track record in delivering.
>>Unidentified Female: So can I just push you again, so why do you really want to be
a Vanguard because that's not about being a Vanguard, you can do that anyway?
>>Unidentified Male: Yes, shall I step up on that one? There's a few particular things,
I think, Vanguard would give us access to some of the project resources I mentioned
we need as a critical success factor. And some of the support around the making it happen
and the changed management, and the financial flows work that I've referred to; I think,
also, the credibility with the stakeholders. We've referred to... Paul referred to the
challenge that we had with the initial Spinal Unit, having a bit of a badge behind us is
going to help us with that and working across the patch.
So there's quite a number of facets, but I think that this would really give us an added
impetus to the project.
>>Unidentified Male: [Inaudible] providers of NHS services who don't currently, unlike
if you... if a patient with a back problem goes to a... one of the specialist centres
or for a complex spinal... for neurosurgery, they're going to be engaging with a unit that
is required and mandated to undertake national audit and outcome programmes. If the patient
is... has... is part of a contract from a CCG within the private sector there is no
requirement for that, and there is no outcome of audit regulation on that exposure, and
we think that's wrong.
>>Unidentified Male: Thank you. I've got a question here and then the one over here next.
>>Unidentified Male: One of the requirements of Vanguard is to demonstrate how you'd improve
the financial sustainability of your healthcare system [Inaudible] that covers nine DGHs,
one of the trust said could you come and run a seven day service for us? And we've managed
to do that with them without the Vanguard process, just by using joint working with
these two organisations; but you asked the question about the financial benefits of your
Vanguard?
>>Unidentified Male: Well, the... I think, from a neurological point of view, I mean,
what we've done is that the pilot that we ran for these advanced neurology nurses, we
did on the Wirral, which is, as some of you may know, it's got water on three sides. It's
a great place to run a pilot, we showed that it reduced the GP contact, it reduced the
admissions and it reduced the A&E attendances. It also was great for patients who voted on
the patient assessment; so, from that point of view, we've demonstrated that part in the
model saves money. We also know that the repeatedly it's been shown that non-specialists, when
these patients are admitted when there isn't availability of neurologists who... to provide
their input, these patients stay in much longer and they have lots of investigations done
which are unnecessary, there have been repeated studies showing that, so, basically it's a
no-brainer from the neurology point of view.
From the neurosurgical point of view I'll let Paul speak, but this particular project
that we did with a certain hospital saved the NHS 154 [Inaudible].
>>Unidentified Male: In general terms, I think, there's large volumes of patients on waiting
lists for spinal surgery that don't need to be on the waiting list, or the original procedure
that was planned or for which they were listed is not necessary, that's going to be a major
challenge to the Spinal Transformation Project. I think, there are large volumes of patients
who are being receiving treatment in the... from private providers on NHS contracts, that
are getting procedures and interventions that are not supported by NICE, and that have a
variable and questionable outcome, and for which there's no assessment of the efficacy
audit and outcome of patient outcome measures. So, I think, there are multiple limbs of significant
financial opportunity in this process.
>>Unidentified Male: Thank you. Question on table number 25.
>>Unidentified Female: [Inaudible] Patient Representative, Nottinghamshire. How are you
going to link up with the private sector and value their inputs as well?
>>Unidentified Male: That's a very good question, and, I think, that we have to engage with
the significant local providers of the... of that service. I know the two largest providers,
not necessarily of surgical procedures, but of interventional spinal procedures nationally
are Ramsey Healthcare and Spire, and that's certainly true in the North West. They provide
a huge volume of service on the basis of CCG contracts.
Now we have to engage through them at the highest level, at a level of the other neurosurgery,
CRG, the complex spine CRG, the local area teams, the Trauma Programme of Care Board
in which spinal surgery, neurosurgery sits through the patient support groups and through
the professional organisations, the Society of British Neurological Surgeons, British
Association of Spinal Surgeons and the British Back Pain Society. We have to address this,
in my opinion.
>>Unidentified Male: This the whole Spinal Transformation Project is a three limbed project,
the key... one of the key elements is the Spinal Pathfinder Project, and a pathfinder
is about the patient journey, the significant number of patients that don't need to get
into secondary or tertiary care in whom the treatment and pathway is so variable from
region to region, from district to district, from local area team to local are team. We
need consistency, we need patient awareness, combined psychological physiotherapy therapy.
We've had a 29 stakeholder engagement led by Charles Green of National Clinical Directive
Spine with all patient groups, professional organisations and providers to devise a pathfinder
project that, hopefully, will divert the... and lead an appropriate pathway for patients
with back pain away from hospital intervention, hospital appointment, inappropriate MRI, unnecessary
or ineffective injection therapy.
>>Unidentified Male: Thank you very much, that's the end of questions. Can I have a
big round of applause for The Walton.