Coronary Heart Disease and Stroke: STRATEGY FOR SCOTLAND
3 Managed Clinical Networks for CHD and Stroke
24. The concept of Managed Clinical Networks derives from the work of the Acute Services Review, which was completed in June 1998. The key concepts and core principles of Managed Clinical Networks in Scotland were set out in the Management Executive Letter NHS MEL (1999)10 which was issued in February 1999.
25. The term 'Managed Clinical Network' (MCN) is used to refer to a way of working which relies on clinicians being part of a 'virtual' organisation and which actively involves patients in service design and focus. In essence it comprises clinicians from all backgrounds and sectors in the NHS in a given clinical area, working across the boundaries between the professions, and between primary and secondary care. The concept is therefore fully applicable to both CHD and stroke care, although it is recognised that differences in the organisation of services will arise at the point of delivery, depending on local circumstances.
MCNs FOR CARDIAC SERVICES
26. The CHD and Stroke Task Force was set a number of specific tasks in relation to CHD which included 'to encourage innovative ways of working across the traditional primary/secondary care interface and between different health care professionals'. This is, of course, the prime function of an MCN. In most cases there should be one local cardiac services MCN in each NHS Board area which would include all health professionals in that area dealing with cardiac disease, together with patient representatives (see paragraphs 31 and 32 below for a description of the responsibilities of local MCNs). The arguments in favour of such an arrangement are set out in the Task Force Report. This approach is endorsed by the NHS Plan for Scotland Our National Health, a plan for action a plan for change which states that this is the way forward for cardiac services.
27. Early in the work of the Task Force, the concept emerged of a single, Scottish Cardiac Intervention Network (SCIN) that would be responsible for all invasive cardiac interventions, linked to local cardiac MCNs. (This concept is discussed in detail at paragraphs 84 to 94 and Appendix 3.) SCIN will bring together the existing cardiac surgical, interventional cardiac and all electrophysiology centres.
Dumfries & Galloway Cardiac Services MCN Project
28. While the concept and potential advantages of MCNs for CHD were clear to members of the Task Force, there were many practical issues relating to the function of MCNs that needed clarification before the concept could become a reality. The issues of how to address Clinical Governance across organisations, how to finance and support MCNs, how to manage quality, and how to involve patients in a meaningful way were the most obvious but there were others that needed clarification. Consequently, a pilot project to set up the first local cardiac services MCN and to answer the practical problems, was commissioned by the Chief Medical Officer. The pilot was undertaken in Dumfries & Galloway on behalf of the Task Force.
29. The pilot project has addressed the practical issues in a pragmatic way and produced recommendations of generic value which are contained in an Interim Report available on the project website - www.show.scot.nhs.uk/mcn A local Network has been developed and was formally launched by Professor Ross Lorimer on 20 July 2001. The formal evaluation of the development process and impact of the Network (including health economic evaluation) continues. The local MCN has agreed a Quality Assurance Programme with the Clinical Standards Board for Scotland (CSBS) which covers CHD across primary and secondary care, with primary care standards agreed to match the existing hospital ones.
30. In the short time that the MCN has been in existence, there have been a number of significant and positive outcomes within NHS Dumfries & Galloway. The MCN now has the prime role in strategic thinking, planning and resource prioritisation for cardiac services in the region, with clinicians and patients leading change. A system of pre-hospital thrombolysis now covers the whole region, aimed at all patients who live more than 30 minutes from hospital. There is a chest pain care pathway with supporting protocols used across the local NHS. Patient-held cardiac records are being piloted. Training programmes for patients have been developed, resulting in patient participation at all levels. Quality issues at an out-of-area referral centre have been identified and are being addressed by direct involvement of clinicians. A bid for charitable funding for specialist heart failure nurses has been successful because of the way the Network operates across traditional boundaries. More importantly, there has been an appreciation of empowerment among patients and clinicians, with a positive feeling for the future.
Local Cardiac Services MCNs
31. The role of local cardiac services MCNs will therefore involve undertaking the majority of cardiac service provision in Scotland, from initial diagnosis and investigation through to chronic disease management. Cardiac rehabilitation also comes within the responsibilities of the local networks. The combination of primary care and local DGHs working with patients and local communities means that these Networks are ideally placed to act on primary prevention as well as secondary prevention. A number of clinicians will be working in both their local MCN and SCIN, thereby providing the closest possible link between the Networks.
32. The specific issues which local cardiac services MCNs will wish to address in conjunction with their NHS Board include the following:
the development of Rapid Access Chest Pain Clinics, where these would improve patients' access to services. This work will include the identification of the resources needed (equipment, medical, nursing, technical and secretarial support), along with investigating the possibility of using GP specialists to run the clinics;
setting targets for the secondary prevention of CHD, including rehabilitation, in both primary and secondary care, together with arrangements for annual audit;
the establishment of a Heart Failure group and a local implementation strategy;
developing primary care standards for CHD, based on the Dumfries & Galloway model, linked to the standards in the new contract for general practice and agreed by the Quality Standards Board for Health in Scotland;
developing explicit CHD and stroke prevention strategies which take account of the lessons from 'Have a Heart Paisley', and are in line with the health promotion framework being developed by the Executive. As recommended in paragraph 23, these should link to, and may be an integral part of, more general strategies for primary/secondary prevention/health improvement, such as Joint Health Improvement Plans and local health plans.
where the network covers rural communities, drawing up a written policy for pre-hospital thrombolysis;
developing plans for cardiac rehabilitation, with particular attempts to ensure the participation of excluded groups such as women, older patients and those from areas of socio-economic deprivation;
conducting a needs assessment for CHD services within their deprived and remote communities and, in the light of the findings, agreeing plans to address them;
specifying in the job description of the Lead Clinician and Network Manager of each cardiac services MCN their role as product champions of SCI CHD, in particular the ECCI CHD discharge document; and
considering the creation of consultant therapist and nursing posts, in line with service developments.
33. Some of these developments will already have taken place through existing planning mechanisms, and others will be in hand. Each cardiac services MCN and NHS Board will therefore need to decide, in the light of local circumstances, the degree of priority to be attached to each of these activities. There will be an important role for SCIN in making sure there is uniformity of approach across the country as a whole, and that considerations of equity of access are kept in mind.
MCNs FOR STROKE SERVICES
34. Reports from the demonstration MCN in Neurology with particular reference to stroke (see box below) are now providing experience of a stroke MCN which can be drawn on by others.The wealth of generic information emerging from the Dumfries & Galloway cardiac services MCN has also strengthened the Reference Group's view that MCNs are an appropriate vehicle to drive change and develop stroke services within NHSScotland.
Demonstration MCN in Neurology with Particular Reference to Stroke
NHS Lanarkshire, in partnership with neurologists from the Institute of Neurological Sciences at the South Glasgow Hospitals Trust, is developing an MCN for stroke services. Partner agencies in the MCN Strategy Group are NHS Lanarkshire, Lanarkshire Acute Hospitals Trust, Lanarkshire Primary Care Trust, the University of Glasgow, the South Glasgow Hospitals Trust and Chest Heart and Stroke Scotland.
A multi-professional and multi-agency Stroke Stakeholder Group facilitates collaboration between a wide range of health and social care professionals delivering stroke services across Lanarkshire's three acute hospitals and eight LHCCs. Regular stroke stakeholder meetings provide a forum for consultation in developing and reviewing stroke standards and practice.
Four Stakeholder Working Groups are reviewing and harmonising particular aspects of stroke services:
1. Acute care protocols for physiological monitoring and interventions, including referral criteria for tertiary neurological and neurosurgical expertise, and for 24 hour access to neuro-imaging supported by teleradiology links
2. Multidisciplinary assessment tools, goal setting and documentation
3. Patient and carer information and support
4. Health promotion and secondary prevention for stroke
A draft Quality Assurance Framework has been developed which sets out stroke standards, their rationale and criteria for assessing the MCN's performance in meeting these standards. Lanarkshire's Stroke Audit Group is leading the evaluation of the MCN against combined qualitative and quantitative criteria. The MCN stroke audit database is compatible with the CRAG national dataset. An important aspect of the evaluation will be the impact of protocol-driven referrals to tertiary neurovascular services. There is also ongoing evaluation of the organisational process which underpins the development of the MCN.
Lanarkshire's Stroke MCN contacts are:
Dr A Hendry (Chair), Consultant in Geriatric Medicine, Wishaw General Hospital
Dr H Prempeh, Consultant in Public Health Medicine, NHS Lanarkshire
Dr K Muir, Consultant Neurologist, Institute of Neurological Sciences, Southern General Hospital.
35. Many NHS Boards already have established groups which are developing stroke services. For example, informal networks have been established in NHS Greater Glasgow, Lothian and Highland. Although these have not been 'managed' formally and have not been given budgetary responsibilities, they have clearly demonstrated that services can be improved through networking. MCNs are seen as the logical development of such work, particularly as they have the capacity to work across boundaries and improve access to services which are unavailable in some NHS Boards, for example carotid surgery.
36. The specific issues which stroke MCNs will wish to address in conjunction with their NHS Board include the following:
ensuring that hospitals providing stroke care allow all patients access to stroke unit care (acute and rehabilitation) supported by appropriate neuro-imaging and a trained multidisciplinary team. The bed model developed by the Scottish Borders Stroke Study should be used to calculate the number of beds required (paragraph 109);
making sure hospitals provide specialist rapid access out-patient clinics with appropriate access to neurosurgery and carotid surgery;
providing long-term follow-up for stroke patients, including further development work to establish the feasibility of linking hospital-based data systems with those in primary care, in order to allow capture of information relating to longer-term management of stroke patients and outcome;
developing explicit stroke prevention strategies which take account of the lessons from 'Have a Heart Paisley', and are in line with the health promotion framework being developed by the Executive. As recommended in paragraph 23, these should link to, and may be an integral part of, more general strategies for primary/secondary prevention/health improvement, such as Joint Health Improvement Plans and local health plans.
considering the creation of consultant therapist and nursing posts, in line with service developments.
37. Some of these developments will already have taken place, and others will be in hand. As for CHD, each stroke MCN and NHS Board will therefore need to decide, in the light of local circumstances, the degree of priority to be attached to each of these activities. There will be an important role for the National Advisory Committee on Stroke (see next paragraph) in making sure there is uniformity of approach across the country as a whole, and that considerations of equity of access are kept in mind.
38. The Group believes that a national advisory committee, tasked with maintaining an overview of the development of MCNs and stroke services, will be necessary to drive forward the stroke strategy ( see Appendix 5). The committee's remit should emphasise the need to ensure equity of access to stroke services across the country, and also the need to provide opportunities to share experiences of service redesign.
Modernising Highland Stroke Services
Early in 2001 a Highland Steering Group was set up to lead a review of stroke services across the region, an area of 10,000 square miles. During the winter of 2001 workshops were held across Highland to review stroke services, attended by more than 100 professional staff, voluntary sector representatives, and patients and carers. The priorities identified were:
stroke care co-ordination and communication;
early hospital care and imaging;
post-acute rehabilitation; and
the availability of Allied Health Professions.
Research was also undertaken which identified best practice across the UK in relation to all aspects of stroke services, included interview sessions with patients and carers across Highland, and a study trip to Sweden.
In early 2002 a Highland Stroke Strategy was published which identified the key elements of an effective, quality service as:
working to an agreed protocol;
access to diagnostic imaging;
access to specialist assessment; and
availability of rehabilitation teams.
The Strategy recognised that the commitment during the development phase to improving patient care in terms of quality, access and co-ordination, and the direct involvement of patients and carers in the process, paved the way for the establishment of a Managed Clinical Network for Stroke.
A formal Network is now in the early stages of development and real commitment has been shown already by clinicians and managers. Funding has been provided by the Scottish Executive Health Department to assist with the infrastructure needed to take forward the Managed Clinical Network, including the appointment of a Network Manager, a Network Support Secretary and GP locum cover.
Contact: Ms Susan Eddie, Chair, Highland Stroke Steering Group, Raigmore Hospital, Inverness.
LINKS BETWEEN THE MCNs
39. To optimise the benefits offered by MCNs, whether for cardiac or stroke services, it is essential that the different Networks operate in a co-ordinated way. This will require links - human, administrative and through IT and clinical protocols. There is considerable merit in local MCNs working together to share good practice, protocols, documentation and educational activities. This is especially so where small local MCNs adjoin each other, and in these circumstances joint working on tertiary services has much to offer. Patients living in areas near to the boundaries of local Networks may need to receive services from more than one local MCN. It is important that these Networks ensure that they work together and that one set of boundaries is not replaced by others. Lead clinicians and managers have the key role here in ensuring co-ordination.
40. In the case of CHD, links between the local cardiac services MCNs and SCIN will need to be clear and effective. There are already excellent relationships between cardiologists and surgeons, and many health professionals will be working both in a local network and SCIN. These existing clinical links should be the basis for co-ordination of patient care between the Networks and supported by common protocols for referral to and discharge from SCIN. The Intervention Network will have an important role in education and training, and this role must be linked to the needs of the rest of the service. Circulation or secondment of staff will need to be considered to ensure effective professional development and maintenance of skills for those in remote and rural areas.
41. For both CHD and stroke, local MCNs should become an integral part of the strategic planning processes of NHS Boards and will offer a significant opportunity for local clinicians and patients to contribute to the thinking, planning and commissioning of services. The appropriate lead clinician or manager from each local MCN should attend planning meetings of the Scottish Cardiac Intervention Network or the National Advisory Committee for Stroke as appropriate.
42. The Reference Group recommends that local health plans should, by December 2002, include provision for the development of local MCNs for cardiac services and for stroke. NHS Boards should give consideration to making innovative appointments to MCNs, rather than to institutions. The further development of MCNs is discussed in Chapter 6, 'Next Steps'.