The team have introduced a new model of service delivery for patients with multiple sclerosis, separating the regional pathology-focused diagnostic/early management service from a local community needs-based service where all members of the neurological rehabilitation team are based, including the medical team of consultant physicians and specialist nurses.
The delivery of the new service to patients aligns with the NICE guidance and quality standard for multiple sclerosis which emphasis the need for good coordination of care. Specifically the guideline recommends (1.3.1): Care for people with MS using a coordinated multidisciplinary approach and (1.3.2) Offer the person with MS an appropriate single point of contact to coordinate care and help them access services.
Aims and objectives
The service development aimed at providing a timely, co-ordinated and patient focused service via a single point of contact. The service was established to meet the needs of all patients with long term neurological conditions. Multiple Sclerosis (MS) patients stood out as one of the most important client' group. Despite the apparent homogeneity of this patient group; the clinical presentations and subsequently clinical needs of these patients varied greatly. As MS affects mainly young and middle age individuals; the patients' vocational, psychosocial and emotional needs are often complex and long term. The interplay between the medical and rehabilitation care on one hand and the social and vocational issues warrant a dynamic patient focused philosophy implemented by the managing team.
Our primary objective was to establish a local community based neurological rehabilitation team where patients can access the advice and support of their neurologist, psychologist, physiotherapist, continence adviser etc via one single point of contact and under one roof. The patient's case manager is her/his MS nurse specialist who is able to connect the patient with the appropriate clinician in a seamless manner. The transfer of the MS nurse specialist base from the regional neuroscience centre (where they are traditionally based) to the local facility with the team encouraged and promoted interdisciplinary work and strengthened the professional relationship between all clinicians involved. We wanted to minimise long paper trails allowing the complex issues to be discussed openly within an interdisciplinary team work pattern.
The service development also aimed at reducing duplication of input, establishing a register for MS patients under its care and facilitate / co-ordianate the input of other specialities and agencies involved in the patient's care.
Reasons for implementing your project
Royal Bolton Hospital (RBH) is the provider of secondary care for 265,000 Bolton residents. It previously contracted consultant neurologists sessions from the regional neuroscience centre based in Salford, 10 miles to the south.
In 2005-2006 the UK government adopted two new strategies to improve the quality and productivity of the health services. These were targets-driven service delivery and adoption of the market forces in health economy using 'Adam Smith's invisible hand' to improve productivity and efficiency. RBH struggled to meet the new target of a maximum of 16 weeks waiting for new clinic appointments for neurology patients. They had to postpone or cancel many follow up appointments to meet this target. Unfortunately, this led to huge problems for patients with long-term neurological conditions such as epilepsy, Parkinson's disease (PD) or multiple sclerosis (MS) who needed regular follow ups or occasional prompt consultations.
The community based neurological rehabilitation service found it difficult to access specialist neurology opinion for their patients. To respond to the government's second drive to encourage health market economy, the regional neuroscience service based in Salford launched a new Centre for Assessment and Treatment (CATS) primarily for Salford patients. This new service integrated the work of the neurologists, neurosurgeons and neuroradiologists enabling them to have a standard patient's journey between GP referral and diagnosis of only few weeks. The unacceptable delays for neurology follow up appointments galvanised Bolton PCT to rethink the whole ethos of service delivery.
After wide consultation with the key stakeholders, Bolton PCT decided to commission the diagnostic neurological services to the Centre for Assessment and Treatment (CATS) based in Salford. Management of long-term neurological conditions moved to a new purpose-built community centre where all the members of the neurological rehabilitation team are based, including the medical team of consultant physicians and specialist nurses.
How did you implement the project
The team moved to a new purpose made building in 2009. This new physical environment provided adequate office space, excellent gym facilities and modern clinic spaces within the same building. This allowed the physiotherapists and occupational therapists to access additional facilities and reduced the time wasted moving between clinical and administration facilities. The new facilities could also be used for group therapy or patients' master classes. A clinical neuropsychologist was also recruited in the same year. Negotiations with regional neuroscience to purchase consultant neurology clinic time were successful. The three consultant neurologists doing a minimum of four clinics a week only for patients with long-term conditions, were more than the original neurological input provided in secondary care. These clinics were mainly for patients with complex disabilities or needing single specialist interventions such as chemodenervations. This joint clinic offered the therapists a chance to inform the medical assessment, and the management plan is usually formulated.
The key component of the service however was based on the concept of case management, which is provided by either specialist nurses for conditions such as MS, epilepsy, and Parkinson's disease, or OTs for brain injury (Table 1 in supporting material). This team of specialist nurses / case managers is in the forefront of patient care. Their case load is between 600-1000 per nurse. Easy access to specialist consultant advice or therapist opinion is the main factor enabling the case managers to cope with such a high case load. The concept of case managers also saved significant consultants' time as duplication of efforts was kept to a minimum. The close relationship between the local services and the local patients' support groups was initially instrumental in recognising the scale of the problem. Representatives from the support groups, especially the Neurological Alliance and Parkinson's Society, developed Bolton Neuro Voices (BNV) to act as a partner and supervisory body ensuring an effective way to communicate patients' views and experiences to commissioners and providers. BNV canvasses the views of patients and communicate them to the clinical teams during regular joint meetings. The patients have a single point of contact to access all members of the team.
We believe that our new model of service delivery for patients with long-term neurological conditions is leading to a significant improvement in quality and efficiency. It has allowed the capacity to achieve NICE recommendations including achievement of quality statement 2, which was previously a challenge to the service ‘Adults with MS are offered a face-to-face follow‑up appointment with a healthcare professional with expertise in MS to take place within 6 weeks of diagnosis.’
It has allowed the capacity to achieve NICE recommendations including acheivement of quality statement Unfortunately, we will never be able to verify the amount of monetary savings as the traditional model was so chaotic that knowing the amount of money spent in the past was almost impossible. However, our main objective was and still is to improve the quality of care. Formal audits showed improvements in Did Not Attend (DNA) rates (6.3% in December 2010) and patient satisfaction (100% score service as good or very good). The neurology clinics waiting lists were cut to a maximum of nine weeks. Our service now complies with most of the quality requirements of the National Service Framework for Long-Term Condition.
(NSF/LTC) quality requirement 1. Concepts such as case management, one point of contact, care plans and patient involvement are integral to our service model.
The service model has also allowed for the development of several care pathways which facilitated monitoring and audit on one hand and on the other hand minimised duplication and unnecessary referrals.
Following the government advice to separate commissioning from provider arms, NHS Bolton the provider arm of Bolton PCT joined Royal Bolton Hospital Foundation Trust. Our new employer has expressed their commitment to our service and their desire to expand our model to cover the neighbouring districts.
Key learning points
In the current climate where the concepts of more centralisation of services and more local services nearer home collide and battle. A service like ours provides a fresh perspective for service delivery. Even within a single condition such as MS a diagnostic regional service where rapid access, sophisticated investigations and prompt interventions is needed; can delegate the long term management to a local interdisciplinary service with strong connections with the local services catering for the patient's psychosocial and vocational needs.
-Other organisations interested in following our model need to identify a strong clinical leader who is able to spearhead the development. Our development took place before the split between the Primary Care Trusts (PCTs) commissioning and provider arms. With only 2 partners (PCT and regional neuroscience) the negotiations were complex and protracted. We would expect much more difficult negotiations between the potential 3 partners (2 service providers 'regional and local' and the CCGs).
- Neurologists work both as diagnosticians and managers for clinical cases. The main philosophy of the new service is to separate these two roles. Unsurprisingly, our neurology consultants felt uncomfortable in the initial phases. However, they did recognise that the traditional model was untenable in Bolton. The consultant neurologists should be given credit for eventually supporting the project and spearheading the developments. Other consultants, including elderly care and audiology consultants shared the initial concerns, but again their eventual contribution was immensely valuable.
- Achieving 6 week follow up target – although the model allows the capacity to achieve this we are still reliant on referrals from external diagnostic centres e.g. other neuroscience centres, Private neurologists, independent sectors etc. that can obviously lead to delays.