Enc 10b  Evalua tion of The Aspiring for Clinical Excellence Programme Author: Specialist Strategic Service Improvement 1 | Page Contents 1.1  Introduction to Aspiring for Clinical Excellence (ACE) .............................................. 7  1.2  ACE Project History and Timeline .......................................................................... 98  1.3  Evaluation Scope and evidence gathering ............................................................. 11  1.3.1  Qualitative Analysis ......................................................................................... 11  1.4  Evaluation Constraints ........................................................................................ 1211  2  Qualitative Evaluation Results ....................................................................................... 12  2.1  ACE group structure ........................................................................................... 1312  2.2  Governance ........................................................................................................ 1413  2.3  Leadership .......................................................................................................... 1615  2.4  Skills ................................................................................................................... 1615  2.5  Communication ................................................................................................... 1716  2.5.1  Birmingham CrossCity CCG ACE Groups/Clinical Dialogue Groups .......... 1817  2.6  Creative solutions ................................................................................................... 19  2.7  Quality focus ....................................................................................................... 2019  2.8  The Patient Perspective ..................................................................................... 2019  2.9  Literature Review ................................................................................................ 2120  3  Quantitative Evaluation Results ..................................................................................... 24  3.1  Data Analysis methods ........................................................................................... 24  3.2  Emergency admissions ...................................................................................... 2524  3.2.1  Birmingham CrossCity compared with regional trends ............................... 2524  3.2.2  Emergency admissions – variation between ACE groups ........................... 2625  3.2.3  Emergency admissions – variation between providers ............................... 3130  3.2.4  Emergency admissions – variation in length of stay ................................... 3433  3.3  Exceptions for all ACE measures by ACE grouping ................ 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Bookmark not defined.34  3.4  Data Analysis methods ....................................................................................... 4039  4  Focused projects – mixed analysis ............................................................................ 4342  4.1  Focused or generic? ........................................................................................... 4342  4.2  Washwood Heath Health Federation – focus on diabetes care ......................... 4342  4.3  Sutton collaborative – over 70s admissions avoidance project .......................... 4443  4.4  Kingstanding and New Oscott – broader project for long-term conditions management ................................................................................................................. 4544  4.5  Transferring Good Practice ................................................................................ 4746  4.6  The Enablers ...................................................................................................... 4948  2 | Page 5  Conclusions ............................................................................................................... 5049  6  Recommendations ..................................................................................................... 5251    3 | Page Executive Summary The Aspiring for Clinical Excellence (ACE) scheme Case for Change1 proposed investing £24.5m over a three year period in order to deliver a step change in the quality and accessibility of primary care for registered patients of NHS Birmingham CrossCity Clinical Commissioning Group (CCG). The Excellence Service Level Framework (ESLF) required specific ‘enablers’ ie spirometry, ECG to be locally provided and asked GP practices to develop proposals for improving primary care delivery under the parameters set of holistic care, integrated care, long-term conditions management and better care for the vulnerable and elderly. The CCG had aspirations to deliver long-term outcomes in terms of higher life expectancy and reduced health inequalities. Over the 3 years of the programme there was the intention to demonstrate a real shift towards comprehensive primary care with reduced use of emergency and outpatient services in secondary care. Objectives for the scheme were to provide greater resources within primary care to prompt creative solutions for GPs to be accountable for the care provided. Objectives for patients were that they received a universal service and were reporting improvements in their experience as a patient and their ability to manage long-term conditions. The Evaluation A mixed method approach using both qualitative and quantitative methods was agreed. In order to carry out this evaluation, the authors looked at a number of data sources: Secondary Uses Service (SUS) data, interviews with the delivery officers and key people within the ACE groups, the delivery plans, GP patient survey and a literature review. Key Results and Conclusions Qualitative findings Qualitative methods were used to identify themes for delivery and to identify the successes of the project. The greatest successes were around improved communication, greater opportunities for collaboration and the opportunity to innovate and identify new ways of working. The general consensus was that the programme had added value and should continue to build on these successes. Some examples of successes included  The ability for the delivery groups such as Washwood Health Federation to be a stronger voice to manage the service received from providers such as community nursing and the use of service level agreements to obtain specific expertise from acute providers;  More structure upskilling of staff for example Tudor Practice Stockland Green were able to recruit a DESMOND nurse to support their diabetes care;                                                              1 Aspiring for Clinical Excellence Programme – Full Case for Change Birmingham CrossCity CCG – June 2014 Governing Body 4 | Page  A focus on quality by Edgbaston and South Birmingham identified that previously appointments were not long enough to provide the service that COPD and Asthma patients required – the aim was to provide a higher standard of care to all their patients;  Innovative communication methods such as the blog from Sutton Collaborative and the use of WhatsApp by Washwood Heath greatly improved communication between staff across the delivery group.  More patient centred care was evident from a four-fold increase in patients of Hall Green collaborative on pre-diabetes registers.  New ways of working were evident for the Sutton Collaborative nursing team who were now directly communicating with named staff working in the wards and frailty units at Good Hope to arrange for early safe discharge for patients.  Some genuine innovation for example in the Ambulance triage project first promoted by Northfield and then introduced in other areas. Some challenges were evident such as  The evaluation has not demonstrated a genuine shift of capacity and resources from secondary care to general practice. Although there have been improvements in for example use of pre-diabetes registers the totality of benefits has not yet been seen  Workforce constraints limited success for some groups  Due to the initial mantra of the project “high trust, low bureaucracy” there are not yet systems in place to fully measure the success of the initiatives with primary care ie the programme structure. The mantra was more of a principle- initially the thinking was that the data packs would be sufficient to measure the impact of provider group level interventions- however the production of the data packs has not enabled the groups to measure their progress real time- the learning is that data extracted from GP clinical systems provides assurance on interventions taking place and therefore provides a measure of quality?  More support for groups on developing real-time data systems is needed. NB These systems were beginning to emerge as the evaluation was being carried out  There were challenging views expressed re data collection and submission and how this has can be used to demonstrate success for example within Return on Investment  Delivery plans were originally used as a vehicle to manage programme deliverables and set aims, objectives and aspirations. However there was limited observation of the plans being used in groups as a document that supports the guiding principles of the programme. Although assurance meetings did take place to discuss and assure these plans there does not seem to be a mechanism in place which continues this on a regular basis. It should also be noted that funding is predicated on the developing of plans Quantitative findings The quantitative analysis focused on the use of secondary care services during the lifetime of the project up to October 2016. An initial focus was on emergency admissions. Birmingham CrossCity CCG has annual growth of 4.7 admissions per 1,000 GP registered patients per year which is higher than the average of all ArdenGEM CCGs (3.7) but lower than the demographically closest 5 | Page comparator in the group, Coventry & Rugby CCG (5.4). However, there is significant variation between ACE groups. While most groups have seen an increase in admissions, Cape Hill, East Birmingham and Tudor Practice Stockland Green have both shown a reduction in emergency admissions. It was also noted that growth by provider site varied significantly with Good Hope seeing highest rates of growth while there is a reduction at City Hospital. In addition, with increasing rates of rates emergency admission overall there has been an overall reduction in length of stay, in line with national expectations. Overall, there was no obvious correlation between changes in primary care inputs as a result of ACE and changes in the use of emergency and outpatient departments. Looking at all the indicators identified for the ACE project the greatest number of cost saving exceptions were for Cape Hill, East Birmingham, Edgbaston and South Birmingham and Tudor Practice Stockland Green. Measures with the greatest variation between ACE groups were excess bed days and cardiology first outpatient appointments. It is noted that there were several service changes introduced by CrossCity and its peers intended to reduce emergency admissions and impact on a number of measures in common with ACE KPIs. In this context it is notable that some ACE groups saw significantly lower rates of growth, and even reductions compared to peers. This indicates that actions in ACE and other initiatives may have differential impact on ACE groups and there is the need to investigate the drivers and mitigations of hospital activity growth at a more local (ACE group) level. Summary & Recommendations While the quantitative data overall did not show an impact it was recognised throughout the evaluation this would be problematic due to the impact of other CCG initiatives and service changes. Despite this at a local level some ACE groups have significantly lower rates of emergency admission growth and the drivers of this local variation should be investigated further. The qualitative analysis shows that many positive factors, including collaboration between practices, the development of a shared clinical agenda, new models of care and development and upskilling of the primary care workforce. It was also noted that ACE projects took longer to establish and make fully interventional This tied with the insight that many ACE schemes focussed on primary and secondary prevention, which may take an extended period of time to impact admission rates, means that subsequent re-analysis may show greater impact of ACE in future years. It is therefore our recommendation that with any further primary care investment more structure is developed around ACE groups to support the demonstration of delivery to all partners involved in the programme. There also needs to be consideration on how data is used to achieve this. Our evaluation has indicated where there may be more support needs and this could be achieved through shared learning. It is likely however that the CCG will need to consider options for supporting groups to upskill their staff. Our evaluation has indicated the value of front-line staff being involved in developing initiatives. The 6 | Page collaborative relationships that have been developed do need to be encouraged to be able to deal with the challenges the CCG will face in future. 1 Introduction 1.1 Introduction to Aspiring for Clinical Excellence (ACE)   When the CCG formed in April 2013, it inherited a number of legacy local enhanced services (LES) from its predecessor organisations (HOB, South and BEN PCTs). A desktop exercise was undertaken to inform future commissioning intentions. The outcomes of the review indicated the following: - Little or no demonstrable impact on secondary care activity - Data collection and analysis was for payment purposes and did not appear to inform commissioning strategy - Enhanced service coverage across the range of LES schemes in operation across the CCG varied at between 19% and 80%. - The schemes all had material variations in both the unit pricing arrangements and also in the service specification of schemes designed to address similar issues. The variations made it very difficult to adopt any of the current arrangements as models for future commissioning. One of the key findings was that an unintended consequence of this approach led to the “cherry picking” of services leading to inequitable provision for patients. In line with the CCG’s strategic vision of developing a model of integrated model care, the agreed strategic approach was to commission enhanced services from general practice under one framework; to ensure that there was a universal offer from general practice to our population. This led to the creation of the Aspiring to Clinical Excellence Programme. The aim of the programme was to reduce the level of variation in general practice and by bringing all practices up to the same standards of primary care. Through programme, the CCG commissioned an enhanced service from general practice to provide universal coverage of services. The Aspiring for Clinical Excellence (ACE): Excellence Level Case for Change proposed investing £24.5m over a three year period in order to deliver a step change in the quality and accessibility of primary care for patients registered with Birmingham CrossCity Clinical Commissioning Group. From the original Case for Change the main aims and objectives for the ACE programme were: 7 | Page Aims:  To deliver significant health impacts for the population in terms of reducing the clear health inequalities that exist  Preventing premature deaths and improving the quality of life for people with long- term health conditions. Objectives:  Support delivery of a model of General Practice that ensures universal coverage across the CCG population;  Provide practices with an overarching framework that allows the freedom to identify creative solutions for how patients receive their care whilst ensuring accountability for care remains with practices;  Support delivery of a patient-centred and integrated approach improving primary care management of long-term conditions;  Up-skill the general practice workforce to deliver services that may have previously been provided by secondary/community providers;  Achieve a genuine shift of capacity and resources from secondary care to general practice;  Bring to life the CCG’s value of “working smarter, not harder” by providing practices with a framework that frees professionals from ticking boxes and, instead, requires them to focus on delivering improved health outcomes for patients;  Support the development of a general practice model that is fit for the future and therefore resilient to future challenges. The programme would run from 2014 to 2017 and the CCG would expect to see demonstrable improvements in the quality of care provided to patients with long-term conditions. The CCG set out the parameters and expectations for delivery of the programme in the Excellence Service Level Framework (ESLF). The main principles were:  GP surgeries were to collaborate with one another, forming ACE groups in a “high trust, low bureaucratic” arrangement  Each GP practice who signed up to the programme (and the principles of collaboration) would be given an additional £12.25 per patient (on the GP’s weighted list) on an annualised basis  Primary care would be supported to deliver a framework of local services tailored to the needs of their patients. This would represent a shift in focus away from the emergency and out-patient departments of secondary care  The ACE groups and subsequent GP practices would provide patients with access to a defined set of ‘enablers’ within primary care (e.g. spirometry and ECGs with appropriately trained staff). Each enabler would be managed through a series of 8 | Page local projects so that outcomes and benefits could be demonstrated and managed across the lifecycle of the ACE programme (ref 1.3.1 for the full list)  Wider programme learning and outputs would form part of the proposed CCG’s universal offer moving forward. It was also envisaged that ACE Groups and affiliated GP Practices ensured that any projects they undertook supported delivery of one or more of the following themes: o Holistic care – person-centred care tailored to the needs of the patient o Integrated care – coordination of services to provide them locally where possible o Long-term conditions management – management of conditions that provides patients with the resources to cope with exacerbations of their illness and reduce the frequency of emergency admissions o Better care for vulnerable and elderly – to consider the particular needs of older patients and for palliative care. Alongside improvements in the patient experience, the CCG also expected to see outputs that showed a shift in activity from secondary care to primary care. This would support the CCGs vision of setting in place a more comprehensive primary care system. All but two practices from across the CCG participated in the ACE programme during the first two years. 1.2 ACE Project History and Timeline In June 2014 GP surgeries were invited to collaborate on the ACE Excellence Programme as part of the CCGs overall objective to strengthen the service to patients in primary care. The first wave groups became known as Pioneers and would act as the test group for programme deliverables, structure and placement of resources. The pioneer phase was initially intended to run for 12 months and the outcomes and learning from this group would be used to further develop the programme and support newly forming ACE groups. A core requirement for Pioneer groups (and subsequent groups) was to undertake projects on so called key ‘enablers’. These enablers were:  Spirometry and interpretation;  ECG and interpretation;  Insulin initiation;  Ambulatory blood pressure monitoring  Wound care management  Phlebotomy These areas were identified as local data showed a high level of variation in the management of these (section 4 shows performance for a number of these areas). Pioneer groups were also required to undertake a number of local projects that focused on one or more of the below: 9 | Page  Holistic care  Integrated care  Long-term conditions management  Care of older and vulnerable patients. There was a real emphasis on group innovating and tailoring solutions to local problems. The groups themselves were recognised as experts in understanding the particular health needs of their population as well as identifying where there may be gaps and shortfalls in services. Groups were advised that they would be expected to review their own data and provide evidence that investment had been targeted to meet the long-term outcomes set for each of the projects. Each group was provided with data packs outlining high level information on patient demographics and activity across each disease area. The data provided was focused on secondary care outcomes and was produced on a quarterly basis. The packs covered the following measures:  Accident and Emergency Attendances and emergency Admissions  Excess Bed Days for Emergency Admissions  Admissions for Ambulatory Care Sensitive Conditions  75 and Over Emergency Readmissions  Admissions for Children with Lower Respiratory Tract Infections  Emergency Admissions for Specific Diseases o Asthma o Chronic Obstructive Pulmonary Disease o Stroke and Transient Ischaemic Attack o Heart Failure o Diabetes o Dementia  Outpatient first attendances  Outpatient follow-up attendances  First to follow-up ratios for specific specialties o Rheumatology o Endocrinology o Respiratory Medicine o Cardiology The 12 month pilot scheme with the Pioneer sites was evaluated by Birmingham University in 20152. This evaluation noted that 35 applications were received from GP practices across the CCG and 6 delivery groups, covering over 200,000 registered patients, were accepted as ‘Pioneers’. Following the pioneer phase, the programme gathered momentum and other GP practices approached the CCG to be part of the programme. From this the CCG established a second                                                              2 ACE Excellence Pioneer Evaluation Pilot – Summary of Evaluation by Health Services Management Centre, Birmingham University for Primary Care Committee Meeting August 2015 10 | Page