further reconfiguration in Greater Manchester and sustainability in London
Chapter 13 Lessons from the planning and implementation of further reconfiguration in
Greater Manchester
Overview
What was already known about this subject?
l Service centralisation in GM led to significant reduction in LOS, but not in mortality, compared with in the RoE. Therefore, further reconfiguration of services was planned and implemented.
l There is growing evidence about how approaches to leadership, use of feedback, stakeholder engagement and experience of previous changes influence implementation of MSC in acute stroke services (see Chapters 6, 7 and 10).
What this chapter adds
l The GM acute stroke system– like the rest of the English NHS – faced significant obstacles over the period studied and these affected the time it took to agree a new model, plan it and implement it.
Despite these obstacles, change was implemented.
l Obstacles included turbulence caused by reforms to the NHS and national staffing shortages, which contributed to significant pressures on planning. Post implementation, these factors led to delays in the movement of patients through the system, in finding beds for stroke patients and in discharging stroke patients.
l Issues relating to leadership and governance, and the use of service and process reviews, including the earlier findings from this study (see Chapter 3) were reported as important in enabling implementation.
l Leaders of the GMB reconfiguration‘held the line’ on approaches to implementation (e.g. the timing and degree of phasing of change). A key system enabler post implementation was identified as the Operational Delivery Network (ODN) governance model, funded by the providers, covering the whole stroke pathway. This enabled regular audits and a mechanism to facilitate the system-wide discussions needed to maintain effective system operation. Sources of pressure post implementation included not only staffing but also changes in the nature of workload at CSC, PSCs and DSCs caused by the reconfiguration.
Background
Further reconfiguration of the GM acute stroke pathway (GMB) was implemented from March 2015 (see Chapter 11). This chapter analysed the process of agreeing, planning and implementing this reconfiguration.
The Best et al.5framework of rules for MSC (see Chapter 6110) has been used to explain the previous centralisation of acute stroke services in GM, showing that feedback may need to be combined with other tools, such as financial incentives and engaging a range of stakeholders, not only physicians. Fraser et al.203 explored change management roles in the London reconfiguration, suggesting that evidence from clinical research can be used to frame change in a‘depoliticised’ way. They identified discursive power, emphasising evidence, better patient outcomes and professional support as helpful in generating receptiveness to change.
Many authors have emphasised the importance of context when analysing change, pointing out that much evaluative work seeks to eliminate contextual confounders rather than see context as the state into which change must be integrated215and taken into account.216This chapter explored how an analysis of GMB may further develop the understanding of MSC.
Methods
Design
This chapter presents a single case study, based in GM, as described in Chapter 1. Comparison is made with GMA, reported in Chapters 6 and 7, and is discussed in relation to the quantitative data analysis of GMB (see Chapter 11) and sustainability in London (see Chapter 14).
Data
As detailed in Chapter 2, we conducted interviews with 78 stakeholders (governance and service level) and 59 non-participant observations of relevant meetings and events (approximately 120 hours). We also collected> 100 documents (meeting minutes and papers, key local documents, etc.). Data were collected between December 2013 and March 2017 (see Table 2 and Chapter 2, Understanding development, implementation and sustainability), enabling analysis of the 2-year post-implementation qualitative data.
Analysis
We identified those factors that influenced the decision to change, the planning and the implementation approach of GMB, and GMB post implementation. We combined analyses of interviews, meeting notes and documents in order to develop an understanding of MSC in relation to previous evidence (see Chapter 6).
Results
This section describes the findings in relation to three phases of activity in GM (aligned to the framework described in Chapter 7):
1. the‘to agreement’ phase (decision to change and which model to implement) 2. the‘planning’ phase (implementation approach)
3. the‘post-implementation’ phase (implementation outcome).
Table 27 provides details of the activities undertaken up to the implementation date. Nearly 2 years elapsed between the recommendation for further reconfiguration and the formal agreement to the full implementation of the centralised acute stroke care pathway, and it was a further 18 months before the fully centralised pathway was launched: a total of 3.5 years between decision and implementation. We also studied GMB for 24 months post implementation and highlight here the issues relating to the sustainability of the model, which aligned with those identified in London (see Chapter 14).
To agreement
Activities that were undertaken during the‘to agreement’ phase are outlined, as well as aspects of governance, which influenced the timescale.
The 12-month review
The 12-month review of GMA, which drew heavily on SINAP data, revealed that only 64% of patients presenting within 4 hours of symptom development were transported to a HASU (CSC/PSC).32The review concluded that although progress had been made‘there is further work still to be done in ensuring that all patients have equitable access to the best quality stroke and TIA services’.32
The EAG, established in 2008 to carry out an independent review of plans for GMA and oversee provider selection, reconvened in October 2011 to discuss the GM pathway in the light of the review and recommended that there should be further reconfiguration of acute stroke services, with the 4-hour cut-off for transportation to a CSC/PSC removed.
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TABLE 27 Timeline: planning and implementation of GMB
November 2012 Peer reviews of all
SUs (CSC/PSCs/DSCs)
April 2013 NHS reforms
July 2013 April 2014 proposed for implementation of fully centralised care model.
CSC/PSCs had reservations as they were not due to receive financial go-ahead
Peer reviews
Following the EAG recommendation, peer reviews were carried out in all SUs (HASUs and DSCs) because commissioners were concerned about the variation in services across GM commented on by the EAG, although some felt that this caused delay:
What needs to be done is further centralisation . . . but the immediate response was 12 months of peer reviews.
GM07(2), SCN Governance
The reforms of the NHS following the Health and Social Care Act 2012,34implemented in April 2013, were perceived as resulting in a lack of continuity in leadership, ownership of changes and decision-making, and in the loss of relationships and knowledge. The build-up to this reorganisation, when PCTs were being phased out and CCGs formed (during the‘to agreement’ phase), affected decision-making:
. . . it was kind of difficult for people to make decisions about a GM-wide thing for about an 18-month period, maybe 2 years until things had settled down.
GM07(2), SCN The loss of‘organisational knowledge’ due to impending NHS changes was also noted:
The organisation at the top kept changing and the people changing. So there wasn’t that continual organisation memory you know and that impacted on their ability to make a decision.
GM07(2), SCN Once new NHS structures were introduced in April 2013, it took time before they were functioning
efficiently, contributing to further delays in decision-making. The reconfiguration was finally agreed by the newly formed Greater Manchester Association of Clinical Commissioning Groups Governing Group (AGG)
TABLE 27 Timeline: planning and implementation of GMB (continued )
Date Timescale proposals
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in September 2013, rather than the original plan for agreement in April 2013 by a group disbanded post April. These delays were explained in terms of the‘newness’ of the organisations and the different composition of the new NHS structures:
I don’t think they [newly formed AGG] were intentionally stalling, it was almost as though they couldn’t make a decision . . . they weren't mature as a group together.
GM02(2), SCN . . . most GP chairs in CCGs hadn’t had any exposure to the policy and strategy world of the PCTs.
GM18, service commissioner/Implementation Board Planning
Once agreement was reached in September 2013, formal planning for implementation began, although informal activities had already started. Issues of leadership, governance and feedback were highlighted as influencing process and timescale, with some other specific considerations during planning.
Leadership capacity
Concern was initially expressed about the scale of the changes:
It was kind of assumed that it was a relatively small change, when in fact it was probably as big a change as it had been the first time around.
GM05(3), stroke physician Project management arrangements were put in place just after the start of the‘planning’ phase (November 2013) by the AGG, something viewed as pivotal in moving the work forward:
A huge piece of work, it really does need someone who has experience in programme management full time against it, I think it’s a huge risk to not do that.
GM24, SCN This role was seen as effective and important in supporting the decisions made through the new governance structures, as well as alleviating initial concerns.
Governance
The Stroke Centralisation Implementation Board was established in March 2014, to ensure that the centralisation of acute stroke services was undertaken in line with the agreed timescale and budget. It was accountable through the Chairperson (a new appointment; Senior Responsible Officer for stroke) to the AGG. A Chief Financial Officer was also appointed to act on behalf of all GM CCGs. The Implementation Board was perceived to work well and to involve clinicians in a way that was viewed positively:‘there has been a culture where clinicians have become a bit marginalised and decisions are being made by the managers’ (GM23, stroke physician).
Feedback from external reviews
During the planning period, two reviews of the GM stroke pathways were undertaken, the findings of which were perceived as supporting the plans. A Gateway Review (which examines projects at key decision points in their life cycle to provide assurance that they can progress successfully to the next stage)217in December 2013 made recommendations for governance, which were being planned anyway, and was viewed as helpful
‘. . . because we knew what we wanted to happen but sometimes it's better if it comes from somebody else’
[GM02(2), SCN]. A Clinical Senate Review to provide‘clinical advice with regard to optimising the working of the network model’ (p. 3, reproduced with permission from Greater Manchester, Lancashire and South Cumbria Clinical Senate218) made recommendations regarding the provision of imaging and communication with other change planners, and the review was perceived as lending support to the reconfiguration plans.
Feedback from research findings
The publication of findings of this research (see Chapter 3) was widely attributed as helping to drive the planning of reconfiguration forward in GM and gain agreement on an implementation date:
being able to go to meetings and say to people we’re looking at fifty excess deaths a year . . . because of the publicity . . . because it was a paper and it was a medical journal not just another audit report or just another internal report, I think that has had a significant impact.
GM05(2), stroke physician It would be extremely difficult to argue for e.g. 3–4 months [slippage] in light of the mortality data . . . which indicates that as many as 16 deaths from stroke could be avoided in that period of time if services were centralised.
Stroke Centralisation Implementation Board meeting, 12 September 2014 Other considerations
At one PSC, the ongoing failure to meet A&E waiting time targets led to nervousness about putting more patients through the department when MSC in GMB was being implemented. The same PSC had carried out financial modelling showing that GMB was more costly for them than the CSC and the other PSC.
This led to uncertainty about whether or not this PSC would retain its status as well as to delays in planning by the CSC and other PSC.
The A&E issue was resolved by establishing a‘stroke specific’ bay in the A&E department, staffed by the PSC, thus minimising impact on the wider A&E department. Following discussions between the CSC and PSCs, including input from the Chief Financial Officer, the modelling issue was resolved, but not until late 2014, which led to the GMB‘go live’ date being moved back from January to March 2015. This also led to a loss of staff from the CSC who had been employed assuming the January start but who were not needed until March.
Staff morale was affected during this period, with those at DSCs concerned about the potential impact on their roles following reconfiguration, both in terms of losing their jobs and/or skills in acute stroke care.
Doubt was also expressed about whether or not it would be possible to recruit sufficient staff– doctors, nurses and therapists– to provide the centralised services.
The delays in agreeing the final launch date meant that the CSC and PSCs were well prepared for launch, although the short time frame between the decision to confirm the second PSC and launch meant that there was a lot of preparation needed in just 3 months.
Implementation: a‘big bang’ launch
Implementation of GMB took place on 30 March 2015, as a‘big bang’ rather than a phased launch, as had been the case with GMA (see Chapter 7). Leaders held the line on this approach when phased implementation was proposed, because of the difficulties in phasing presented to the ambulance service and concern about capacity issues if a CSC and one PSC went‘live’ while the second PSC was not fully operational (‘learning from history’).
Post implementation
Findings are presented here using the same framework for analysis as in Chapter 14, enabling us to compare the post-implementation periods in London and GM.
Enablers of governance: system leadership
Following implementation, a stroke ODN219– the first in England – was established to support stroke services, as the clinical network no longer had capacity following the 2013 NHS reforms. The clinical network funded this for the first year, with providers taking over subsequently. Within 6 months of implementation, an ODN manager and project co-ordinator started work, and the newly formed ODN Board met. The ODN’s remit was
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to‘work collaboratively with its stakeholders to develop high-quality services in terms of patient outcomes and experience across the whole care pathway for stroke’ (GM Stroke ODN, Terms of Reference).
Initially, there was confusion over the ODN’s role and there was a perception that because it was hosted at the CSC site that it might be biased. However, over the first year of its work, many of these worries were allayed, with clinicians becoming supportive of the work:
I think the ODN is a really good sort of go-between, and it’s a way of providing an independent interface for everybody.
GMF20, stroke physician Most felt that the ODN, or similar, was necessary for the sustainability of the stroke care pathway, although there was uncertainty about how it linked with the evolving GM governance structures following
devolution,121,122whether or not it had any‘clout’, and whether or not funding would be continued.
Challenges to sustained governance: local and national NHS changes
Changing priorities nationally– ‘stroke isn’t really an NHS priority anymore whereas it clearly was at one time’ [GM05(4), stroke physician] – and locally in GM caused concern. The implications for stroke of ongoing changes to general acute care provision resulting from merger and rationalisation in GM were highlighted, as was the challenge of providing a thrombectomy service in future.
Flow of patients through the hub and spoke model
In order for the stroke pathway to operate optimally, the timely flow of patients through the system is necessary and was a challenge in GMB and London (see Chapter 14).
Transfer of stroke patients to a Comprehensive Stroke Centre/Primary Stroke Centre Prior to GMB, the local ambulance service called ahead to A&E departments when they were bringing in a suspected stroke patient (within 4 hours of symptom onset). Post implementation, patients within 48 hours of symptom onset were brought to CSC/PSCs, leading to a large increase in the volume of alert calls, which A&E departments were unable to handle. The situation, therefore, changed back to the GMA model in which an alert was radioed ahead only for those stroke patients whose symptoms had commenced within 4 hours. Initially, this resulted in stroke patients whose arrival had not been alerted waiting in A&Es without the knowledge of stroke teams. Local solutions were then developed to ensure that stroke teams saw these patients in a timely manner.
Six months after implementation, following advice from the National Clinical Director for Stroke, processes were changed so that only patients presenting within 48 hours of stroke symptoms were transported to a CSC/PSC, rather than all patients, although this change did not receive universal support. A patient presenting at a DSC within 48 hours of commencement of symptoms might be transferred to a CSC/PSC depending on the clinical presentation. After initial challenges, with staff at DSCs reporting that it could be difficult to contact CSC/PSC staff, the process improved, and audit data indicated that patients were being transferred appropriately.
By March 2016, 86% of stroke patients were being treated at a CSC/PSC and a local audit (by the ODN) indicated that the ambulance service was taking patients appropriately to a CSC/PSC.
Repatriation from a Comprehensive Stroke Centre/Primary Stroke Centre to a District Stroke Centre
Repatriation of stroke patients from a CSC/PSC to a DSC was challenging because of‘stroke’ beds being used for other patients, or because of the difficulty of discharging people from hospital. DSCs were notified when one of‘their’ patients was admitted to a CSC/PSC, allowing them to plan to have a bed available, and CSC/PSC staff then contacted DSCs each day with updates, using nhs.net e-mail accounts, supplemented by telephone calls. Responsibility for this contact usually lay with nursing staff, although at the CSC a
repatriation co-ordinator was employed. Such contact led to general improvement in communication and the resultant flow of patients:
. . . lots of networking. I’ve then been going over to [CSC/PSC] as well to say, ‘Hello, you probably speak to me on a daily basis’.
GM25, senior nurse, DSC As timely repatriation from CSC/PSCs was key to maintaining patient flow, a system of financial penalties was instituted: DSCs could be penalised for each day in excess of 72 hours that a patient was unable to move from a CSC/PSC. Some clinicians thought that these penalties were useful as a message to managers about the importance of‘ring fencing’ stroke beds but, in practice, although financial penalty notices were issued, fines were never paid. Instead, a new system was introduced in 2017/18 whereby money would be
‘top-sliced’ from the DSC tariff using the same criteria.
Discharging patients into the community
Discharging patients could be challenging, partly because ESD provision varied across GM, although this was being addressed through a common specification being agreed across GM, facilitated by the ODN.
Also problematic was discharge to social care, as in London:
There are no social care placements, it’s very difficult to get those people out.
GMH12(2), DSC senior nurse Care provision in a Comprehensive Stroke Centre, Primary Stroke Centre and District Stroke Centre services
As outlined in Chapter 11, achievement of evidence-based clinical indicators either stayed the same or
As outlined in Chapter 11, achievement of evidence-based clinical indicators either stayed the same or