annual report 2015/16 - nwcscnsenate.nhs.uk · health challenges in 2015/16 national support for...
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ANNUAL REPORT & SUMMARY ACCOUNTS 2015/16
P U T T I N G E F F E C T I V E C L I N I C A L
L E A D E R S H I P AT T H E H E A R T O F
T H E N H S
C O N T E N T SForeword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
About Of The Strategic Clinical Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Health Challenges In 2015/16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Acheviements In 2015/16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Embedding Effective Clinical Leadership Locally And Nationally . . . . . 16
Getting serious about prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Shaping evidence-based care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Improving Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Driving Innovation, Efficiency and Productivity . . . . . . . . . . . . . . . . . . . . . . 27
Empowering Patients, Engaging Communities . . . . . . . . . . . . . . . . . . . . . . 28
Future Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Strategic Clinical Networks Clinical Leads . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Financial Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
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FO R E W O R D
Janet RatcliffeAssociate Director
The Strategic Clinical Network is proud of its continuing contribution to improving the health of the people of Greater Manchester, Lancashire and South Cumbria and April 2016 marked the beginning of a new dawn. On 1st April we saw South Cumbria and Lancashire joining with Cheshire and Merseyside Strategic Clinical Network and becoming known as the North West Coast Strategic Clinical Network. At the same time the geography of Greater Manchester encompassed parts of Eastern Cheshire to be known as Greater Manchester and Eastern Cheshire Strategic Clinical Networks (SCNs) as they collaborate with Greater Manchester Academic Health Science Network (AHSN) and forge ahead to support the Greater Manchester Health and Social Care Partnership.
These changes have largely come about as a result of the recommendations in the review of centrally funded improvement and leadership development functions led by Ed Smith, NHS England’s Deputy Chair and published in July 2015.
The review outlined the importance of the role of the Clinical Networks continuing role to support health systems and improve health outcomes of local communities by connecting commissioners, providers, professionals and patients and the public across a pathway of care to share best practice and innovation, measure and benchmark quality and outcomes, and drive improvement.
The review also recommended that AHSNs and SCNs should start to align their business plans aligned.
Despite all the many challenges that the national review brought and a significant cut to the SCNs budget both the clinicians and the managers who work as part of the clinical network support team have worked hard to find innovative ways to improve services for the benefit of patients.
This report outlines much of the work that has been done. We are especially pleased when the Network has achieved ‘cross area working’ such as perinatal mental health, cardiac assessment prior to renal transplantation and end of life care for neurological conditions which have led to improvements in patient care. It is clear that clinicians welcome this cross-disciplinary work that is one of the great strengths of the Clinical Networks.
The SCNs has also forged collaboration with other agencies and groups including Public Health England (PHE), Health Education England (HEE), Manchester Academic Health Science Centre (MAHSC), Healthier Lancashire and the Greater Manchester Cancer Provider Board. The willingness to work with others makes the integration into Greater Manchester Health and Social Care Partnership a natural way forward.
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The 12 Strategic Clinical Network regions in England
Greater Manchester, Lancashire and South Cumbria Strategic Clinical Networks
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GMLSC SCNs is one of 12 SCNs established in England. We work in partnership with commissioners (including local government) to support their decision making and strategic planning. Working across the boundaries of commissioner, provider, and voluntary organisations we bring about the realisation of improvements in the quality and equity of care, reduction in unwarranted variation in care, and improve health outcomes for our patient population.
Led by a Clinical Director and Associate Director, with strong involvement from patients, carers and members of the public, we connect commissioners, providers, professionals, and patients and the public across condition/disease pathways of care to share best practice and innovation, measure and benchmark quality and outcomes, and drive improvement.
We focus on six condition/disease areas of national and local priority including cardiovascular, maternity, children and young people, mental health, dementia and neurological, cancer, and palliative and end of life care services: providing strategic direction, enabling clinical leadership, and bringing the voice of service users, carers and the public to shape evidence based pathways and models of integrated care.
All of our services are free of charge to all health and social care commissioners in Greater Manchester, Lancashire and South Cumbria.
GMLSC SCNs provide clinical leadership and advice to improve health and care services across Greater Manchester, Lancashire and South Cumbria through:
Enabling clinical leadership:
Our Networks include specialist clinicians with links to national leads and experts to help inform decision making around redesign and transformation of services founded upon clinical consensus.
We identify and facilitate the adoption of best practice and innovation in health and social care to inform the development of pathways. Resulting in improved health outcomes and reductions in unwarranted variation in care.
Shaping evidence-based care:
We work collaboratively with health and social care commissioners, providers and voluntary sector organisations to identify common objectives and develop them into strategic commissioning intentions.
We provide evidence and inform the commissioning of health and care services across the NHS. Our whole system view across the boundaries of commissioner, provider and the voluntary sector enables us to examine the full implications of the impact of a service change on other parts of the health and social care system and make subsequent recommendations.
We measure and benchmark quality and outcomes to drive improvement and reduce unwarranted variations in care.
Bringing the voice of service users, carers and the public to shape services:
Our Networks include patients, carers and members of the public whose first-hand experience of care pathways and health and social care services in the region is invaluable in shaping evidence based pathways and models of integrated care.
We deliver educational sessions for patients, carers and members of the public to help develop the skills and confidence needed to successfully contribute to shaping services.
We ensure that the needs of our diverse population is represented within the decision making processes.
Our remit covers six specific disease and condition areas of national and local priority where major health challenges and inequalities exist.
GMLSC SCNs comprises of six Networks (the first four of which are national priorities). These are:
nCancer
n Cardiovascular
n Mental Health, Dementia and Neurological Conditions
n Maternity, Children and Young People
n Patients, Carers and Public
n Palliative and End of Life Care.
A B O U T O F T H E S T R AT E G I C C L I N I C A L N E T W O R K S
A forum where clinicians, healthcare managers, patients, carers, and members of the public work in partnership to improve health outcomes for the population
Greater Manchester, Lancashire and South Cumbria Strategic Clinical Networks (GMLSC SCNs) was established in April 2013 to provide clinical leadership and advice to improve health and care services in the region. Part of NHS England, we are a non-statutory body with offices in Manchester and Preston and are hosted by the Greater Manchester Area Team.
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T H E E D S M I T H R E V I E WHow the role of SCNs is defined
1. Clinical Senates’ roles should be clarified as: Supporting health economies to improve health outcomes of their local communities by providing evidence-based clinical advice to commissioners and providers on major service changes. They should bring together clinicians and managers, from across a defined geography, with patients and the public, to put the needs of patients above those of organisations or professions.
2. SCNs should continue to be Clinical Networks in each of the four current priority areas, however Networks could be established in other local priority areas. Clinical Networks role should be clarified as: Supporting health systems to improve health outcomes of their local communities by connecting commissioners, providers, professionals and patients and the public across a pathway of care to share best practice and innovation, measure and benchmark quality and outcomes, and drive improvement.
3. The 15 AHSNs role should be to: Support health systems to improve the health outcomes of their local communities, and maximise the NHSs contribution to economic growth by enabling and catalysing change through collaboration, and the spread of innovation and best practice.
4. AHSNs and SCNs should streamline their business plans for their member commissioners, providers and professionals. The AHSNs’ work and resources for improvement should be governed by the new Improvement Governing Board.
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H E A LT H C H A L L E N G E S I N 2 0 1 5 / 1 6
N AT I O N A L S U P P O R T FO R P E R I N ATA L M E N TA L H E A LT H S E R V I C E S
In March 2015 Future in Mind published by the Department of Health (DH) prioritised the enhancement of perinatal mental health service as a key step to promoting, protecting and improving our children and young people’s mental health and wellbeing:
The document also outlines that:
“With additional funding, this would be delivered by: enhancing existing maternal, perinatal and early years health services and parenting programmes”.
In support of these recommendations an additional £365 million was identified in 2015 to be allocated over five years up to 2020/21 to improve the care of women who experience mental ill health during the perinatal or antenatal period.
NHS England commissioned the National Collaborating Centre for Mental Health to set up an expert reference group to provide analytical and expert clinical advice. From their analysis the following recommendations were made:
nExpansion of mother and baby unit capacity and a particular focus in three areas of the country where access for women is especially limited - South West, East of England and North West (Lancashire and Cumbria).
nEstablishment of Perinatal Mental Health Networks across the country.
nInvestment in specialist community perinatal mental health services.
This dedicated national funding has been identified to support the development of an eight bedded mother and baby unit and specialist outreach team for Lancashire and Cumbria to address inequality for these women and families. This will be a tertiary service commissioned by the North West Specialised Commissioning Group. A scoping report was produced by the
GMLSC SCNs Maternity, Children and Young Peoples Network and a round table event held alongside the national team with key stakeholders across Lancashire and South Cumbria to identify next steps to drive this project forward.
Improving access for parents to evidence-based programmes of intervention and support to strengthen attachment between parent and child, avoid early trauma, build resilience and improve behaviour.
Map showing the location of mother and baby units across England, highlighting the distance mothers and families have to travel to access services from the Lancashire and Cumbria area
National support for Perinatal Mental Health Services In March 2015 Future in Mind published by the Department of Health prioritised the enhancement of Perinatal Mental Health Service as a key step to promoting, protecting and improving our children and young people’s mental health and well-being: “Improving access for parents to evidence-based programmes of intervention and support to strengthen attachment between parent and child, avoid early trauma, build resilience and improve behaviour.” The document also outlines that: “With additional funding, this would be delivered by: enhancing existing maternal, perinatal and early years health services and parenting programmes” In support of these recommendations an additional £365 million was identified in 2015 to be allocated over five years up to 2020/1 to improve the care of women who experience mental ill health during the perinatal or antenatal period. NHS England commissioned the National Collaborating Centre for Mental Health to set up an Expert Reference Group to provide analytical and expert clinical advice. From their analysis the following recommendations were made:
• Expansion of mother and baby unit capacity and a particular focus inthree areas of the country where access for women is especially limited- South West, East of England and North West (Lancashire andCumbria)
• Establishment of perinatal mental health networks across the country
• Investment in specialist community perinatal mental health service
Map showing the location of mother and baby units across England, highlighting the distance mothers and families have to travel to access services from the Lancashire and Cumbria area.
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D E M E N T I A
In 2012, the Prime Minister identified low dementia diagnosis rates as one of the main health challenges for people living with dementia. It was identified that only about 44% of people will receive a formal diagnosis Alzheimer’s Society.
To this effect, a national ambition was set across England to ensure that at least 67% of people suffering from dementia receive a formal diagnosis by the end of March 2015.
As at the end of March 2015, the north region held the highest diagnosis rates in England at 66.4%. The most recent data indicates that the north still continues to hold the highest diagnosis rate at 72.3 % (an increase of 5.9% from March 2015, as well as achieving the national ambition of 66.7%). This is a reflection of the hard work and commitment by various organisations, including GMLSC SCNs, to sustain diagnosis rates and stretch targets beyond March 2015.
Across the GMLSC SCNs footprint, March 2015 figures were 69% for Greater Manchester, 66.6% for Lancashire, and 61.9% for Cumbria (North and South), with all areas seeing an increase in diagnosis rates. As at the end of January 2016, the figures were 74.3% for Lancashire and Greater Manchester and 73.7% for Cumbria and North East.
In December 2015, the initiative was taken by NHS England’s central team to monitor high risk organisations significantly adrift from achieving the dementia ambition. This includes the group of organisations at highest risk and that merit national level attention, including in the groups of CCGs who have met and exceeded the ambition.
Positively, no CCGs in the north or across the GMLSC SCNs footprint are on the risk register, reflecting the work across the north SCNs maintaining and utilising steering groups and other relevant governance meetings to escalate issues of importance around the diagnosis rates.
What has helped?
nA clear focus on accurate and timely diagnosis within primary care and specialist memory assessment services (MAS). Lancashire developed a dash board for monitoring referral rates to MAS and waiting times, which significantly contributed to the progress seen so far.
nDementia enhanced system and Commissioning for Quality and Innovation (CQUINs) 2015/16.
nCase finding of undiagnosed cases of dementia.
nDementia awareness in communities and localities.
nSupported integrated working in collaboration with commissioners, services providers, voluntary organisations and patient and carer groups to get training and education around dementia on their agendas.
Post Diagnostic Support (PDS)
Current service provision and opportunities within the pathway for support shows that variations still exist across GMLSC SCNs footprint. By focusing on an integrated model of PDS that enhances the involvement from health, social care, and the voluntary and independent sectors collectively with regular community and family/friends support, we anticipate that this variation will become less evident.
Dementia In 2012, the Prime Minister identified low dementia diagnosis rates as one of the main health challenges for people living with dementia. It has been identified that only about 44% of people will receive a formal diagnosis Alzheimer's Society.
To this effect, a national ambition was set across England to ensure that at least 67% of people suffering from Dementia receive a formal diagnosis by the end of March 2015.
As at end March 2015, the North region held the highest diagnosis rates in England at 66.4%. The most recent data indicates that the North still continues to hold the highest diagnosis rate at 72.3 % (an increase of 5.9% (66.4%) from March 2015, as well as achieving the national ambition of 66.7%). This is a reflection of the hard work and commitment by various organisations, including GMLSC, to sustain diagnosis rates and stretch targets beyond March 2015.
Across the GMLSC footprint, March 2015 figures were 69% for GM, 66.6% for Lancashire, and 61.9% for Cumbria (North & South), with all areas seeing an increase in diagnosis rates. As at end January 2016, the recent figures were 74.3% for Lancashire and Greater Manchester and 73.7% for Cumbria & North East.
In December 2015, the initiative was taken by the NHS England central team to monitor high risk organisations significantly adrift from achieving the dementia ambition. This includes group of organisations at highest risk and merit national level attention, including in the group of CCGs who have met and exceeded the ambition.
Positively, no CCG’s in the North or across the GMLSC footprint are on the risk register, reflecting the work across the North SCNs in keeping the momentum and utilising steering group and other relevant governance meetings to escalate issues of importance around the diagnosis rates.
What has helped?
• A clear focus on accurate and timely diagnosis within primary care and specialist memory assessment services (MAS). Lancashire developed a dash board for monitoring referral rates to MAS and waiting times, which significantly contributed to the progress seen so far.
• Dementia Enhanced System and CQUIN 2015/2016 • Case finding of undiagnosed cases of dementia • Dementia awareness in communities and localities • Supported integrated working in collaboration with commissioners,
services providers, voluntary organisations and patient and carer groups to get training and education around dementia on their agendas
Post Diagnostic support (PDS)
Current service provision and opportunities within the pathway for support shows that variations still exist across GMSLC footprint. By focusing on an integrated model of PDS that enhances the involvement from health, social care, and the voluntary and independent sectors collectively with regular community and family/friends support, we anticipate that this variation will become less evident.
CCGNAME
EAS1:DementiaDiagnosisRateJanuary2016comparedtothenationalambitionof67%
NHSBlackburnwithDarwen 83.9%NHSBlackpool 88.6%NHSBolton 75.8%NHSBury 88.6%NHSCentralManchester 90.1%NHSChorleyandSouthRibble 72.4%NHSCumbria 66.9%NHSEastLancashire 67.7%NHSFylde&Wyre 61.0%NHSGreaterPreston 67.8%NHSHeywood,Middleton&Rochdale 68.1%NHSLancashireNorth 72.7%NHSNorthManchester 93.9%NHSOldham 82.4%NHSSalford 85.7%NHSSouthManchester 76.6%NHSStockport 71.8%NHSTamesideandGlossop 70.3%NHSTrafford 69.6%NHSWestLancashire 67.1%NHSWiganBorough 71.0%
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C A N C E R
The new five Year Cancer Strategy identifies that the most critical factor in determining the success of treatment for patients is the prevention and early detection of cancer. From improved access to diagnostic tests, to the education of the public and primary care, to improving the referral relationship between primary and secondary care the SCNs is working hard to improve the stage at which cancer is diagnosed.In GMLSC SCNs survival rates have long been significantly below the England average however one year survival rates in Greater Manchester are nearly 1% better and Lancashire and South Cumbria now have rates equal to the England average. Survival rates, however, in the most deprived areas of the region are unsurprisingly lower than the average with higher rates of diagnosing cancer at Stages 3 and 4 of the disease. Where our CCG areas perform well in terms of survival they also report less cancers diagnosed at later stages of the disease.
CCG One Year Survival Rate Stage 3-4
North Manchester 65.56 38.4%
Oldham 66.15% 36.4%
Blackburn with Darwen 67.29% 40.1%
Blackpool 66.55% 35.6%
East Lancashire 66.67% 36.8%
England (average) 68.2% 31%
Trafford 70.95% 29.3%
Lancashire North 68.5% 31%
I/SCN/Cancer/AnnualReport/HealthchallengeCANCER.docx_150316_jh page1of2
Cancer
Thenew5YearCancerStrategyidentifiesthatthemostcriticalfactorindeterminingthesuccessoftreatmentforpatientsistheearlydiagnosisandtreatmentofanycancer.Fromimprovedaccesstodiagnostictests,totheeducationofthepublicandprimarycare,toimprovingthereferralrelationshipbetweenprimaryandsecondarycaretheSCNisworkinghardtoimprovethestageatwhichcancerisdiagnosed.
CancerSurvivalinEnglandReport–NCIN2012
InGreaterManchester,LancashireandSouthCumbriasurvivalrateshavelongbeensignificantlybelowtheEnglandaveragehoweveroneyearsurvivalratesinGreaterManchesterarenearly1%betterandLancashireandSouthCumbrianowhaveratesequaltotheEnglandaverage.Survivalrates,however,inthemostdeprivedareasoftheregionareunsurprisinglylowerthantheaveragewithhigherratesofdiagnosingcanceratStages3and4ofthedisease.WhereourCCGareasperformwellintermsofsurvivaltheyalsoreportlesscancersdiagnosedatlaterstagesofthedisease.
CCG OneYearSurvivalRate Stage3-4NorthManchester 65.56 38.4%Oldham 66.15% 36.4%BlackburnwithDarwen 67.29% 40.1%
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H E A LT H
It has been reported by PHE that death as a result of cardiovascular disease (CVD) in the North West far exceeds the national average. In Manchester the rate of preventable CVD deaths per 100,000 poulation is 88.6, almost twice the national average of 49.2. Lancashire and Cumbria have 55.8 and 51.3 per 100,000 respectively.With higher than average risk factors too that include; diabetes, depravity, obesity, physical inactivity, and smoking, the SCNs is challenged with both preventing the onset of CVD and improving the early management of the disease(s). Work continues to identify and manage people who are at high risk of developing diabetes and improve information and education for those that have it. Also we continue to improve the early detection of atrial fibrillation and familial hypercholesterolemia and improve access to stroke and renal services.
Preventable CVD deaths (persons <=75yrs)
The palliative and end of life care team’s work programme focuses on the societal change to talking openly about death, dying, enabling end of life care planning and delivering high quality care for those recognised to be dying. Deaths in Usual Place of Residence (DiUPR) is the proxy measure used to determine the quality of care provided and the chart below highlights the SCNs is improving in line with the national average. This has been achieved through the palliative and end of life care team’s work programme and CCG localities.
It is now possible to review the location of the death. Above is shown the location of death for the SCNs broken down by hospital, care home, hospice, home or an communal establishments or elsewhere.
HealthChallenge
It’sbeenreportedbyPublicHealthEnglandthatdeathasaresultofCVDintheNorthWestfarexceedsthenationalaverage.InManchestertherateofpreventableCVDdeathsper100,000is88.6,almosttwicethenationalaverageof49.2.LancashireandCumbriahave55.8and51.3per100,000respectively.Withhigherthanaverageriskfactorstoothatinclude;diabetes,depravity,obesity,physicalinactivity,andsmoking,theSCNischallengedwithbothpreventingtheonsetofCVDandimprovingtheearlymanagementofthediseases(s).Workcontinuestoidentifyandmanagepeoplewhoareathighriskofdevelopingdiabetesandimproveinformationandeducationforthosethathaveit.Alsowecontinuetoimprovetheearlydetectionofatrialfibrillationandfamilialhypercholesterolemiaandimproveaccesstostrokeservicesandrenalservices.
PreventableCVDdeaths(persons<=75yrs)
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HealthChallenge
It’sbeenreportedbyPublicHealthEnglandthatdeathasaresultofCVDintheNorthWestfarexceedsthenationalaverage.InManchestertherateofpreventableCVDdeathsper100,000is88.6,almosttwicethenationalaverageof49.2.LancashireandCumbriahave55.8and51.3per100,000respectively.Withhigherthanaverageriskfactorstoothatinclude;diabetes,depravity,obesity,physicalinactivity,andsmoking,theSCNischallengedwithbothpreventingtheonsetofCVDandimprovingtheearlymanagementofthediseases(s).Workcontinuestoidentifyandmanagepeoplewhoareathighriskofdevelopingdiabetesandimproveinformationandeducationforthosethathaveit.Alsowecontinuetoimprovetheearlydetectionofatrialfibrillationandfamilialhypercholesterolemiaandimproveaccesstostrokeservicesandrenalservices.
PreventableCVDdeaths(persons<=75yrs)
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Attendanceofdiabetesstructurededucation(types
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The palliative and end of life care team’s work programme focuses on the societal change to talking openly about death, dying, enabling end of life care planning and delivering high quality care for those recognised to be dying. Deaths in Usual Place of Residence (DiUPR) is the proxy measure used to determine the quality of care provided and the chart below highlights the SCN is improving in line with the national average. This has been achieved through the palliative and end of life care team’s work programme and CCG localities.
It is now possible to review the location of the death. Below is shown the location of death for all the SCN broken down by Hospital, Care Home, Hospice, Home or an communal establishments or elsewhere.
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2010/11Q4-
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Greater Manchester, Lancashire and South Cumbria (GMLSC) Strategic Clinical Network - Percentage of Death in Usual Place of
ResidenceApriation2015 England GMLSC CumbriaandLancashire GreaterManchester
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50
60
2010/11Q4-
2011/12Q3
2011/12Q1-
2011/12Q4
2011/12Q2-
2012/13Q1
2011/12Q3-
2012/13Q2
2011/12Q4-
2012/13Q3
2012/13Q1-
2012/13Q4
2012/13Q2-
2013/14Q1
2012/13Q3-
2013/14Q2
2012/13Q4-
2013/14Q3
2013/14Q1-
2013/14Q4
2013/14Q2-
2014/15Q1
2013/14Q3-
2014/15Q2
Q42013/14-2014/15
Q3
2014/15Q1to
2013/14Q4
2014/15Q2to
2015/16Q1
GMSCLSCN- PercentageofDeathsinLocationsHome Hospital CareHome Hospice OCEorelsewhere
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H E A LT H C H A L L E N G E - N E U R O LO G Y
Neurological services continue to face a number of challenges across the SCNs footprint. It is estimated around 4-5% of people present to their GP with headaches and a significant number of people are inappropriately referred to secondary care neurology services. The Network area has the third highest recorded prevalence of epilepsy in adults in England and an increasing number of people experiencing neurological disease or injury. In addition there is a high demand across the Network area for neuro-rehabilitation services.To address these challenges, a headache pathway has been developed and the Network is supporting its adoption in primary care. The SCNs has worked with Epilepsy Action, Epilepsy Society and CCGs to create a single access point for resources to support effective commissioning of services:
The SCNs continues to work with the Greater Manchester Neuro-Rehabilitation Operational Delivery Network to develop a service model fit for purpose and with commissioners in Lancashire to undertake a review of neuro-rehabilitation services which will support the development of a new model for neuro-rehabilitation.
Update on last year’s priorities:
nStrategy for neurosciences: this work has been started but given the changing footprint for the SCNs it has been agreed that two separate strategies should be progressed for Greater Manchester and Lancashire / South Cumbria. This work is underway and will be supported by audit data based on the standards from the Association of British Neurologists.
nReview of community neuro-rehabilitation services in Lancashire: this work is underway and has been expanded to address patients who are admitted to hospital with acute episodes of neurological disease or injury. The review has been supported by a clinical workshop which was held in January (see report item 2 below). Further work is underway to survey staff to understand the demand and capacity within services.
nReducing unnecessary and avoidable hospital admissions for epilepsy: this work has not been progressed locally but the SCNs has worked on a best practice document and supported the development of the epilepsy commissioning toolkit (see item 4 below).
Neurology assets available on GMLSC SCNs website
1. CVT Guidelines
2. Lancashire Neuro-rehabilitation workshop report
3. Headache guidelines and notes
4. Epilepsy commissioning toolkit
Recorded prevalence on epilepsy >=18 yrs per 100,000
Headaches and migraine emergency admissions >=20 yrs per 100,000
Healthchallenge-Neurology
NeurologicalservicescontinuetofaceanumberofchallengesacrosstheSCNfootprint.Itisestimatedaround4-5%ofpeoplepresenttotheirGPwithheadaches1andasignificantnumberofpeopleareinappropriatelyreferredtosecondarycareneurologyservices.Thenetworkareahasthe3rdhighestrecordedprevalenceofepilepsyinadultsinEngland2andanincreasingnumberofpeopleexperiencingneurologicaldiseaseorinjury.Inadditionthereisahighdemandacrossthenetworkareaforneuro-rehabilitationservices.
Toaddressthesechallenges,aheadachepathwayhasbeendevelopedandthenetworkissupportingitsadoptioninprimarycare.TheSCNhasworkedwithEpilepsyAction,EpilepsySocietyandCCG’stocreateasingleaccesspointforresourcestosupporteffectivecommissioningofservices:http://www.epilepsytoolkit.org.uk/
TheSCNcontinuestoworkwiththeGMNeuro-rehabilitationOperationalDeliveryNetworktodevelopaservicemodelfitforpurposeandwithcommissionersinLancashiretoundertakeareviewofneuro-rehabilitationserviceswhichwillsupportthedevelopmentofanewmodelforneuro-rehabilitation.
Recordedprevalenceonepilepsy>=18yrsper100,000
Headachesandmigraineemergencyadmissions>=20yrsper100,000
1Steineretal,Cephalalgia,20032http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data#page/6/gid/1938132725/pat/112/par/N51/ati/19/are/E38000014/iid/91597/age/278/sex/4
Healthchallenge-Neurology
NeurologicalservicescontinuetofaceanumberofchallengesacrosstheSCNfootprint.Itisestimatedaround4-5%ofpeoplepresenttotheirGPwithheadaches1andasignificantnumberofpeopleareinappropriatelyreferredtosecondarycareneurologyservices.Thenetworkareahasthe3rdhighestrecordedprevalenceofepilepsyinadultsinEngland2andanincreasingnumberofpeopleexperiencingneurologicaldiseaseorinjury.Inadditionthereisahighdemandacrossthenetworkareaforneuro-rehabilitationservices.
Toaddressthesechallenges,aheadachepathwayhasbeendevelopedandthenetworkissupportingitsadoptioninprimarycare.TheSCNhasworkedwithEpilepsyAction,EpilepsySocietyandCCG’stocreateasingleaccesspointforresourcestosupporteffectivecommissioningofservices:http://www.epilepsytoolkit.org.uk/
TheSCNcontinuestoworkwiththeGMNeuro-rehabilitationOperationalDeliveryNetworktodevelopaservicemodelfitforpurposeandwithcommissionersinLancashiretoundertakeareviewofneuro-rehabilitationserviceswhichwillsupportthedevelopmentofanewmodelforneuro-rehabilitation.
Recordedprevalenceonepilepsy>=18yrsper100,000
Headachesandmigraineemergencyadmissions>=20yrsper100,000
1Steineretal,Cephalalgia,20032http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data#page/6/gid/1938132725/pat/112/par/N51/ati/19/are/E38000014/iid/91597/age/278/sex/4
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A C H E V I E M E N T S I N 2 0 1 5 / 1 6
Palliative and End of Life Care Network: Several publications of guidance around palliative and end of life care have been reviewed and updated, including the Just in Case Medication for last weeks/days of life guidance providing a consolidation of the list of subcutaneous drug, doses and frequency of administration that localities use for local advice. Also reviewed and updated in 2015 were the North West End of Life Care Model 2015, Pain and Symptom Control Guidelines and Dying Person in the Last Days and Hours of Life Guidelines.
Palliative and End of Life Special Interest Groups: Four specialist interest groups were successfully established, each producing a programme of work, these being: education and training, research and audit, care coordination,transforming care. The special interest groups have been embedded in the work of the SCNs and they are a standing item on the advisory group.
Electronic Palliative Care Co-ordination Systems (EPaCCS): A growing number of all our localities are live with some form of EPaCCS. Working with GMAHSN, we supported the delivery of NHS England’s objective to have a 70% rollout of EPaCCS across England by August 2015.
NICE and Education Programme: Using GP strategic leads the SCNs supported implementation of the NICE guideline on ‘suspected cancer: recognition and referral’ (June 2015) across the region.
We produced the following practical resources that are now available on our website:
• An education package for GPs that includes videos, quizzes, case scenarios and slides containing the NICE recommendations. This is currently being used by Macmillan GPs to deliver training about the NICE guideline to their GP colleagues.
• Best practice advice for GPs, written by one of the GP leads, that outlines the practical actions that GPs should take to ensure that the NICE guideline is effectively put into practice.
• Guideline summary posters, that act as an easy reference guide to the NICE guideline for GPs.
We also held a NICE guideline implementation event in Lancashire and South Cumbria for cancer managers, cancer nurses, Macmillan GPs and CCG cancer leads, which achieved the following:
• We provided practical guidance and support for the main implementation challenges.
• We facilitated discussions with each locality to help them develop an implementation plan. Each locality produced a plan to show how they will implement the guideline in terms of: demand modelling, creating referral forms, capacity increase and primary care education.
In addition, we produced two week wait referral forms based on the NICE guideline that could then be adapted by each locality to reflect their pathways.
Peer Review: The SCNs has continued to support the Lancashire and South Cumbria Clinical Network groups in responding to the annual national cancer peer review process. Working closely with the Chairs of the Clinical Network groups and other members, levels of compliance have been maintained year on year, thereby ensuring that all cancer services across the Network footprint are working to the same standards.
Improving Outcomes Guidance (IOG): The SCNs continues to support commissioners to develop and achieve IOG compliant services in Greater Manchester, Lancashire and South Cumbria. Increased levels of IOG compliance in haematology services, for instance, are increasing patient safety and improving clinical delivery. We are also improving the clinical delivery of head and neck services by centralising the most specialist functions and future work will involve specialised urology surgery centralising onto one site within the Network.
Psychology - Macmillan Paper, Lancashire and South Cumbria Work: The Greater Manchester psycho-oncology pathway group and the Lancashire and South Cumbria psycho-oncology network group have agreed to work together as a group of clinicians. This work has been facilitated by the Network alongside Manchester Cancer. As well as sharing good practice in regard to the treatment of mental health problems for people with a cancer diagnosis, they will also be looking at developing guidance which will support commissioners in decision making when commissioning these services in the future.
Vocational Rehabilitation: In collaboration with Lancashire Teaching Hospitals NHS Foundation Trust, a vocational rehabilitation project has been established in Lancashire and South Cumbria which aims to develop an evidence base for commissioners on the types of services that best support cancer patients in securing employment. Once developed, this evidence base will support commissioners in implementing services which improve employability and quality of life for cancer patients. The project will initially run as a two year pilot through Lancashire County Council Employment Support, Skills, Learning and Development Service.
Accelerate Coordinate & Evaluate (ACE) Wave 2 - Greater Manchester/Lancashire: In Greater Manchester the SCNs worked in partnership with commissioners and providers on a proposal to the ACE Team to pilot the delivery of multi-diagnostic centres across the region. The Greater Manchester pilot was identified as one of five national sites for 2016/17 and will be delivered in Oldham and South Manchester in the first phase.
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Supporting Greater Manchester’s new Cancer Vanguard: The Christie in partnership with Manchester Cancer and NHS Trafford CCG successfully bid to develop a new Cancer Vanguard whose aim is to establish a single system provider for Greater Manchester cancer services. The focus will be on driving improvements in clinical outcomes and patient experience across the entire patient journey including health promotion, diagnosis and care. The SCNs will work in partnership with the new Vanguard in 2016/17 strengthening relationships and adding value in areas where large numbers of stakeholders across a variety of organisations are required to work together to imrpove cancer outcomes.
Breaking Down Barriers to Services: We know many communities experience barriers to services. The team attended an awareness session particularly focusing on the needs of trans people regarding early diagnosis. For example looking at what can be done to inform and encourage trans men to attend cervical screening if they have a cervix, and how we can increase awareness of prostate cancer for trans women. This year we have been working to develop plans for both community awareness and support for clinicians to be educated to meet the needs of trans people.
Cancer Champions: Following on from the success of Cancer Champion work in Greater Manchester last year a similar project was rolled out across Lancashire. The SCNs liaised between PHE and Community CVS in Blackburn with Darwen to deliver an awareness session aimed at increasing screening uptake in each CCG. Following on from the training session 16 organisation will receive a small contribution towards delivering interventions to communities who we know experience additional barriers to services e.g. black and minority ethnic (BME) people and trans people. A session in Barrow in Furness is also booked in for early April.
Oncology and Acute Oncology Review – Development of a Future Model of Care: The SCNs, in collaboration with CCG and Acute Trust stakeholders, developed a project to review and make best evidence recommendations in regard to the provision of an oncology and acute oncology service model across Lancashire and South Cumbria.
Network Clinical Groups: The SCNs continue to support and administer a range of clinical network groups in Lancashire and South Cumbria enabling them to meet, develop network-wide clinical guidelines and audits, work plans and hold annual education events. This also contributes towards improved compliance with national peer review quality standards.
Masterclass Education Series: In collaboration with Lancashire Teaching Hospitals NHS Foundation Trust, the SCNs provides support to the successful masterclass series. The masterclasses are tumour specific or cross-cutting themed events aimed at healthcare professionals with an interest in oncology. The series focus on the breadth of understanding of a specific tumour site. These events are extremely popular with healthcare professionals and attract a regular attendance of over 160 delegates.
Best Practice Follow-up Research Project: The SCNs completed a study on oncology patient follow-up, and to gain perspectives from NHS staff about alternative models. The study comprised of a literature review, a qualitative interview study and a synthesis of the findings to produce preliminary recommendations for the future implementation of alternative follow-up models that can improve patient experience and outcomes while also reducing cost.
Development of the Cancer Dashboard Toolkit: A comprehensive cancer data toolkit has been developed for stakeholders which provides information on prevalence, incidence, mortality, screening, one year survival, routes to diagnosis, cancer waiting times and patient experience. The toolkit is available on-line on the SCNs website.
Be Clear on Cancer: The SCNs supports the national Be Clear On Cancer (BCOC) campaigns which are led by PHE in partnership with NHS England and Cancer Research UK. The campaigns aim to increase awareness of the signs and symptoms of cancer and improve survival outcomes through earlier detection. GP strategic leads and cancer champions are utilised to deliver key messages from the BCOC campaigns. The SCNs has also engaged with local media to ensure that BCOC campaign messages are delivered locally alongside the national BCOC campaigns.
Cancer Research UK Bowel Screening Campaign: The SCNs has helped to promote the Cancer Research UK Bowel Screening Campaign, which aims to raise awareness of the NHS Bowel Cancer Screening Programme (benefits/eligibility) and encourage participation (particularly among 60 - 74 year olds).
Vascular: A pathway for critical limb ischaemia (CLI) has been developed and adopted by local services across the network area. Local training has also been provided on the identification and management of CLI.
A guideline for swollen legs; in particular deep vein thrombosis has been adopted by Greater Manchester providers.
A community model of care has been developed to improve access to vascular services in Lancashire. This has been now approved by Lancashire commissioners.
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Diabetes Toolkit: A toolkit for diabetes has been developed, fronted by a set of recommendations that propose to local commissioners and providers ways to improve information and structured education for people with diabetes. The toolkit includes the minimum standard of information to be provided, how to re-enforce the information, how to review structured education and improve referral, awareness, attendance, recording and support from family. The recommendations and toolkit have recently been approved by local commissioners.
Cardiac: A working group supported piloting early access to acute interventional cardiology (within 24hrs of admission) for patients with high-risk acute coronary syndrome. We had success with widening access to acute interventional cardiology 24/7 for patients with high-risk acute coronary syndrome. The functional imaging, stable angina pathway and ‘chest pain of possible cardiac origin’ pathways have been developed.
Improving Cardiac Services: We have supported improved services in Lancashire and South Cumbria, working with the newly appointed clinical lead. A clinical lead was appointed in Lancashire and South Cumbria to progress work in the areas of familial hypercholesterolaemia and out of hospital cardiac arrests. There has been further joint working across stroke and cardiac on atrial fibrillation/stroke prevention work.
Stroke: In Lancashire and South Cumbria, the SCNs in collaboration with NHS Midlands and Lancashire Commissioning Support Unit, has undertaken a stroke review, looking at current service provision and a gap analysis and workforce analysis for Lancashire and South Cumbria. Following this, an end-to-end stoke service specification - an aspirational specification - was produced and there has been agreement by all CCGs that this is the model of care that should be adopted.
Stroke Operational Delivery Network in Greater Manchester: The SCNs has supported the implementation of the first Stroke Operational Delivery Network in Greater Manchester. This went live in July 2015.
Atrial Fibrillation (AF) (stroke prevention) Commissioning Toolkit: In collaboration with GM AHSN, North West Coast AHSN, PHE, Local Authority and GMLSC SCNs we have developed an AF (stroke prevention) commissioning toolkit. This is being disseminated with other AF initiatives at three events taking place in Cumbria, Haydock and Manchester. This toolkit is the framework for commissioning all elements involved with AF (stroke prevention).
Both the events at Winterbourne View and the Confidential inquiry into the premature deaths of people with learning disabilities (CIPOLD) inquiry highlight the importance of action to: ‘rapidly expand and improve community provision for people with learning disabilities and/or autism who display - or are at risk of displaying behaviour that challenges’ and ‘supporting people to access health services’ through ‘providing expert advice, support and training to health and social care providers; providing individual assessment, care coordination and therapeutic interventions for people with learning disabilities; offering advice and support for the provision of reasonable adjustments for people with learning disabilities, including the provision of easy read information.’
The Mental Health Network has established a learning disabilities clinical advisory groups as a sub group of the mental health steering group. The cinical advisory group has representation from all professional groups from across the Network to achieve four key objectives:
1. 60% reduction in non-secure beds – this will see a reduction in the number of beds from 82 to 30 by 2020 (equivalent to 10.7 non-secure beds per 1 million of the population). These 30 beds will be comprised of 6 crisis or acute inpatient beds for stays of up to 6 months and 24 continuing care/ rehabilitation / forensic beds for longer stays up to 24 months (with a small number that may be longer term)
2. 34% Reduction in the number of low secure commissioned beds although the requirements of low secure in-patient beds are more difficult to forecast we are aiming to achieve a minimum 34% reduction in the number of beds with the potential to achieve a greater reduction through improved use of forensic out- reach support to avoid admissions. This further reduction would see the need for low secure commissioned beds reduce from 56 to 35 by 2020 (equivalent to 12.5 beds per 1 million population)
3. Improving in / out reach intensive support – this will ensure greater support within a community based setting (including more crisis support options) and enable the reduction in the number of beds required. Our redesigned / re-profiled community services will adopt principles of positive behaviour support which will filter through into commissioned contracts and workforce development programmes.
4. Expansion of community based accommodation - This work will be made possible with an accompanying expansion in the specialist residential flat models in Greater Manchester providing additional supported home placements.
FOCUS ON LEARNING DISABILITIES
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Implementation of an Electronic Communication System for Renal: In 2014/15 clinicians agreed that an electronic communication system would improve management of acute kidney injury (AKI). NORSe (National On Call Referral System) has since been adopted after exploration of the same system used by Birmingham. Education sessions have been run by the SCNs AKI clinical leads for sites that will use the system and NORSe is planned to be rolled out across Greater Manchester, Lancashire and South Cumbria from March 2016.
Pre-emptive Transplant Pathway: A project is underway to refine and optimise the pre-emptive transplant pathway, specifically the cardiac work up element. The aim is to create a common pathway to be adopted by Central Manchester University Hospitals NHS Foundation Trust, Salford Royal NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust. After much discussion around the pathway and current ways of working, all three centres are in the process of finalising their internal process pathways accordingly.
Improving Access and Waiting Times for Mental Health: The SCNs is working to improve early intervention in psychosis (EIP) and improving access to psychological therapies (IAPT) NICE access rates and waiting time targets. We have supported the Northern mental health operations steering group, worked in partnership with the North West Psychological Practitioners Network (PPN North West) and delivered workshops and presentations to Heads of Commissioning, providers and the Regional Medical Director. Continuing the sharing of good practice and service improvement, the SCNs has established an IAPT steering group representing local areas across Greater Manchester and delivered EIP masterclasses.
Supporting Liaison Mental Health: The SCNs has worked in partnership with providers to establish a liaison mental health advisory panel, engaging with clinical lead professionals to provide expert advice and information on the national objective of establishing Core24 liaison mental health services in all acute hospitals by 2020.
Supporting Commissioning Leadership: The SCNs was joined by over 70 organisations at the Alliance Manchester Business School to participate in the first Mental Health Leadership Programme. Designed for the voluntary sector and organisations working with seldom heard groups, the event supported the 5 Year Forward View and national mental health priorities to develop voluntary sector leaders, not just at a national level, but also locally.
Support for Greater Manchester Devolution: To support Greater Manchester Devolution, the SCNs has facilitated a consultation to understand health challenges across Greater Manchester, and using our strong links and networks with voluntary and community organisations we ran a workshop to understand the issues and challenges the community faces. We also facilitated an equality impact analysis (EIA) to identify within the plans for devolution across Greater Manchester that the changes do not exclude or disadvantage any individual or groups including those with ‘protected characteristic’.
PAT I E N T S , C A R E R S , P U B L I C
A DV I S O RY G R O U P DAY
Attended by a wide selection of patients, carers, members of the public (PCP) and professionals, the SCNs advisory group gathered for a day of insight and shared experience.The Associate Director, Janet Ratcliffe chaired the day sharing her powerful own story as well as providing an overview of the current position of SCNs and Senates. This was followed by Professor Donal O’Donoghue, Senate Chair and Juliette Kumar, Senate Manager providing group members with an overview of the work of the Senate and the role of patients, carers and the public within the Senate.
A thought provoking and passionate presentation was delivered by Trustee, National Council for Palliative Care Tony Bonser and Dr Susan Salt, Consultant in Palliative Medicine. Workshop sessions followed on (mental health, dementia, neurological conditions, CVD, cancer, maternity and children) focusing on their priorities and progress to date.
Early afternoon saw the sharing of PCP experience on Alzheimer’s research from Derek Whitehead, Stroke Carer. Mohammed Sarwar, Chief Executive Officer, Multicultural Arts & Media Centre (MAMC) spoke about engaging the BME communities and there was an introduction to Healthwatch from Paul Carroll, Director of Healthwatch Wigan. Afternoon workshops followed on Academic Health Science Networks, Greater Manchester Health and Social Care Devolution, Healthier Lancashire and SCNs and Senate Communications.
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C L I N I C A L P R O F I L E
Dr Amanda Thornton Dementia Clinical LeadSCN Dementia Clinical Lead and Clinical Director of Adult Community Services, Lancashire Care NHS Foundation Trust.
I had worked in my own area as a Clinical Lead on large-scale transformation of the dementia clinical pathway. The Dementia SCN Clinical Lead offered an opportunity to collaborate with people by experience, providers and commissioners across an even wider footprint and was too good an opportunity to miss!
I have worked with some amazing people within the SCN - especially the Quality Improvement Leads - so have learnt quickly about how the SCN works and what it stands for. The role has given me an independent voice as a clinical expert – a chance to be heard without any organisation loyalties, which has allowed my contribution to be truly heard in the way it was intended - as someone able to advise on how best to deliver services to a population I am truly passionate about serving.
My greatest achievement has been to connect to people and to help connect people to other people…! The dementia pathway involves the person, their family and carers, the community, those that commission services and those that deliver them, statutory or not. It has been a privilege to be part of a social movement and a leadership team aiming to facilitate people being at the centre of their own decision making and future. I am clear though that we still have some way to go.
The SCN offers ‘all of the above’ stakeholders an independent, informed team of people to work towards the best offer for their community, with the involvement of their community. The SCN has a clear role to play in trying to reduce unwarranted variation and provide assurance to people by experience that we continue to work towards the provision of evidence based, inclusive networks of services in their region to help them live well.
New Learning Disabilities Clinical Advisory Group Established: We are supporting work across Greater Manchester and Lancashire CCGs to scope existing learning disability provision, access and capacity across Greater Manchester to prevent and better respond to crisis presentations locally and address health inequalities and premature death. Greater Manchester and Lancashire were identified as fast track areas and successfully bid for matched funding from a national £10 million fund. Each area developed a Transforming Care Project Plan and is now working towards implementation. This work is led by the Greater Manchester Commissioners Network and the Lancashire and South Cumbria Commissioners Network which are supported by the SCNs. To support this work the SCNs hosted two successful community learning disabilities teams workshops.
Our Work on Dementia: We have been working with schools on dementia awareness among young people, supporting Lancashire Dementia Voices within Lancashire, to continue to raise awareness around dementia from a dementia person’s perspective and what matters to them. We held a consultation on the newly proposed NHS England Well Pathway for Dementia in November 2015 and from this have worked on Dementia awareness in black, asian and minority ethnic (BAME) communities and we are working on the development of an integrated and holistic dementia care pathway.
Faith Champions Project: The faith champions project is specifically targeted to identify and train members of the faith community to help further develop and support the mental health agenda. This group was specifically chosen to provide support and services to those more vulnerable members of the community who usually do not engage with the services and authorities. Working with these organisations we are engaging with hard to reach groups to reduce the level of health inequality across GMLSC SCNs. The aim is to train up to 120 individuals who are already embedded as community leaders or members of faith groups who can provide support and guidance as well act as a signpost to further services and treatments should they be required.
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E M B E D D I N G E F F E C T I V E C L I N I C A L L E A D E R S H I P LO C A L LY A N D N AT I O N A L LY
CancerGP Strategic Leads
The SCNs in partnership with Cancer Research UK employed three GP strategic leads to work across Greater Manchester, Lancashire and South Cumbria. Embedding this clinical leadership within the region has enabled the Network to support local CCGs and providers in embedding the new National Institute for Health and Care Excellence (NICE) guidance for Cancer referrals. A number of products have been produced from this partnership including education materials for GPs and resources to enable commissioners and providers to be able to carefully plan the implementation of the guidance in their area.
Network Site Specific Groups (NSSGs)
The SCNs continues to support clinical leadership across Lancashire and South Cumbria in bringing together network groups in secondary and tertiary care around the tumour sites they work on. These network groups are led by clinicians and address risks on pathways and develop work plans to improve services for patients across the region.
Maternity
Saving Babies Lives in North of England (SaBiNE)
Reducing stillbirth is a priority for the NHS:
nReducing stillbirth is a mandate objective from the government to NHS England.
nIt is in the NHS England Business Plan 2015-16.
nReducing deaths in babies and young children, specifically neonatal mortality and stillbirths is a key indicator in the NHS Outcomes Framework.
Last November the Secretary of State announced a national ambition to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2030, with a 20% reduction by 2020. This announcement was followed by ‘Spotlight on Maternity’ which sets out how this ambition can be achieved. Similarly, The National Maternity Review, led by Baroness Julia Cumberlege, sets the strategy for improving maternity care and services over the next five years.
NHS England Central Policy Team have led on the development of the Saving Babies Lives - Care Bundle and asked the SCNs to take the lead within each area. There are four elements to the care bundle (smoking cessation, reduced fetal movement, small for gestational age (SGA) and fetal monitoring) with each element having a task and finish group, GMLSC SCNs is part of the SGA group. The project started in June 2015 and has been adopted in 38 Trusts across the North East, North West and Yorkshire and Humber.
GMLSC SCNs had seven early implementer providers within the footprint:
nCentral Manchester University Hospitals NHS Foundation Trust
nStockport NHS Foundation Trust
nWrightington, Wigan & Leigh NHS Trust
nPennine Acute Hospitals NHS Foundation Trust
nLancashire Teaching Hospitals NHS Foundation Trust
nUniversity Hospitals of Morecombe Bay NHS Foundation Trust
nEast Lancashire Hospitals NHS Trust
Each early implementer had designated clinical midwives seconded for 18 days to support the implementation and intensive ‘train the trainer’ workshops held for midwives, obstetricians and sonographers. A discussion forum was established with weekly WebEx question and answer follow up sessions. The organisations were asked to regularly complete a national survey on each element. An SCNs WebEx learning event was held in December to share experiences and best practice. The Saving Babies Lives: A care bundle for reducing stillbirth was formerly launched nationally in March following feedback from the SCNs and early implementer sites.
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RenalEstablishing NORSe
When the need for provision and implementation of an electronic communication system for AKI in the three renal tertiary centres, Royal Preston, Salford Royal and Central Manchester, was identified to standardise the referral pathway to a nephrologist, clinical consensus on the most effective electronic communication system led the Network to acquire a National On call Referral System (NORSe). The system aims to enable renal services across Greater Manchester, Lancashire and South Cumbria to provide high-quality, seamless care between hub and spoke centres, with the three renal hub centres accepting referrals for advice or transfer from satellite spoke hospitals, thus improving safety and appropriateness of AKI transfers to hubs, improved audit trail for the management of AKI and ultimately reduction in AKI 3. Along with the communication system, training and awareness has been provided for all sites to use the system along with selection of AKI champions to promote and support the adoption of NORSe at their local sites. NORSe has been rigorously tested by the AKI working group and AKI champions to ensure that the system is fit for purpose when it is rolled out as live. The go live date for this system to become fully operational is Thursday 28th April 2016.
CardiovascularFamilial Hypercholesterolaemia (FH) Screening
FH affects around 1 in 500 people in the UK population and is associated with premature morbidity and mortality from coronary heart disease. Fewer than 25% people with FH are diagnosed and the majority remain untreated or improperly treated.
We aimed to promote and support a cascade screening service for Lancashire and South Cumbria working with the Greater Manchester Academic Health Science Network to ensure early identification and appropriate management of this high-risk group of patients and their families.
In Greater Manchester a stakeholder event took place on Thursday 11th February 2016, in collaboration with GM AHSN, where proposed models were discussed and agreed. A business case with service specification is being developed.
Papers have been taken to Lancashire Collaborative Commissioning Board regarding screening and management of people with FH, including costings. The work is to be incorporated into the Healthier Lancashire, prevention work-stream and will be taken forward in the future.
AF (Stroke Prevention) Commissioning Toolkit
People who suffer from AF have an increased risk of having a serious disabling stroke. Early detection, diagnosis and treatment is essential and it is on the agenda of CCGs, PHE, Local Authorities, AHSNs and the GMLSC SCNs.
We worked collaboratively to develop an evidence based commissioning toolkit that informs all commissioners what is available and recommended to commission in stages of detection, treatment and management. This includes all standards, NICE guidance, medical devices, medicines management guidance etc.
An AF (stroke prevention) commissioning toolkit has now been completed, with input from all organisations and the SCNs AF clinical leads have formulated a web based tool that contains links to all information.
The roll out of the toolkit on a wider footprint is in the process of being facilitated, there are three events being delivered by the end of April, in Cumbria, Haydock and Bury. The events are aimed at all commissioners of services in PHE, CCGs and any providers.
CancerCancer Champions
In Greater Manchester the SCNs delivered a cancer champion programme and from this experience have developed a strategy for the recruitment of cancer champions across the city to support the development of the Cancer Vanguard and its prevention workstream in 2016/17.
In Lancashire and South Cumbria the SCNs have worked in partnership with PHE and the third sector to deliver a cancer champions programme focussed upon improving screening rates amongst people who find services hard to reach.
G E T T I N G S E R I O U S A B O U T P R E V E N T I O N
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C L I N I C A L P R O F I L E
Dr Prathiba Chitsabesan works as a Consultant Child and Adolescent Psychiatrist in Stockport, Manchester (Pennine Care NHS Foundation Trust) and has a special interest in working with young people with neurodevelopmental disorders (directorate Attention Deficit Hyperactivity Disorder Lead).
As the local lead consultant for 10 years, she has been involved in strategic management and service development. An Honorary Research Fellow for the Offender Health Research Network (The University of Manchester), she has helped to lead on the development of the Comprehensive Health Assessment Tool (2013) for the Department of Health. She has also contributed towards reports for the Youth Justice Board (Mental Health Needs and Effectiveness of Provision for Young People in the Youth Justice System, 2005) and Office of the Children’s Commissioner (Nobody Made the Connection: the Prevalence of Neurodisability in Young People who Offend, 2012) on the needs of young people in the criminal justice system.
More recently she has taken on the role of Clinical Director for the child and adolescent mental health services (CAMHS) directorate (Pennine Care NHS Foundation Trust) and as a clinical advisor for the Strategic Clinical Networks (CAMHS Advisory Group) she has led on the ADHD SCNs Guidance (Delivering Effective Services for Children and Young People with ADHD) which was launched last year. She is keen to promote multi-agency partnerships and believes there are exciting opportunities with Greater Manchester Devolution in improving children’s mental health and wellbeing through closer partnership working.
Be Clear on Cancer (BCOC)
Across the region the SCNs supported the ‘Blood in Pee - Be Clear on Cancer Campaign’ with advertising using bus banners and social media.
Maternity, Children and Young PeopleProfile of Need
The National Child and Maternal Health Intelligence Network, (CHiMat) developed and produced a Profile of Need report for Greater Manchester, Lancashire and South Cumbria to help the Network understand the needs of the population (children and young people). The report used only published data available in the public domain. It presents data from across the life cycle from birth through childhood and into adolescence and also includes focus sections on long term conditions: asthma, diabetes and epilepsy. The report has been circulated widely to inform future planning and is available on the SCNs website. It has also been shared with SCNs nationally and the document can be easily reproduced for any SCNs by CHiMat as all data definitions are available. While the full report will help to inform the SCNs wider work programmes, the ‘Focus on Asthma’ section will provide some useful comparisons for CCGs to support the wider asthma agenda. The north west has 17 of the 21 CCGs falling into the top 25 of CCGs nationally with the highest emergency admission rates for children and young people (CYP) with asthma. The narrative in the document also has examples of translating the data into an economic value for commissioners to consider.
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S C N s E V E N T S
Palliative and End of Life Care Summit Wednesday 1st April this attracted around 100 delegates including patients and carers, community leaders, commissioners and managers and was run in collaboration with Stories to Change.
Time to Act!! Improving Transition and Healthcare for Young People Monday 20th April attracting 70 delegates, focused on gathering local stakeholders involved and interested in the ‘transition’ of services from adolescence to adult service.
CAMHS, It’s Time to be Seen and Heard! Thursday 14th May attracting 85 delegates, again a clinically focused event also successfully engaged with members of Youthforia and Manchester Youth Council who presented on the day.
CCG (CAMHS) Masterclass (2 Day Programme) Thursday 26th March & Monday 18th May assisted the clinical lead on the second day to ensure smooth running of the masterclass together with leading the Kahoot.it.
NHS Confederation Wednesday 3rd – Friday 5th June. Over the three day event we enaged with hundreds of colleagues from accross the health system to promote the work of SCNs.
Commissioning 2015 Wednesday 24th – Thursday 25th June Managed the delivery of the north region SCNs, Senates and AHSNs attendance at this event and was actively involved in the national SCNs and Senates stand.
The SCNs is involved in the organisation of many events throughout the year.
National CCG Mental Health Leadership Programme SeminarFriday 26th June of behalf of the National Clinical Director, Geraldine Strathdee – attendance was nationwide with approximately 120 delegates onsite.
Health and Care Innovation Expo 2015 Wednesday 2nd – Thursday 3rd September a further successful exhibition managed for and on behalf of the 12 SCNs and Senates. Our stand also incorporated the delivery of a full 2 day seminar programme involving 3 NCDs – one of whom presented via the exhibitions ‘Camp Expo’.
Engagement Event to Explore Setting up a Clinical Respiratory Network Wednesday 16th September saw us involved in setting up this inaugural session to ascertain the appetite for a Respiratory Network in Lancashire.
NCIN Cancer Roadshow Friday 18th September in collaboration with NCIN (PHE) we ran a 2 half day local roadshow which attracted around 90 delegates giving them the opportunity to attend three cancer data café sessions.
Patients, Carers and Public Advisory Group Seminar (PCP)Wednesday 23rd September attracted around 75 patients, carers and members of the public who had the opportunity to engage with SCN staff around specific disease areas together with hearing from our two local AHSNs, Greater Manchester Health and Social Care Devolution team and Healthier Lancashire. We also initiated discussed with interested parties to get involved with our communications from a PCP perspective.
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Eating Disorders Workshop in Collaboration with Cheshire and Merseyside Attracting 65 delegates on Friday 2nd October. Delegates heard from service users around their journey and its highs and lows and their hopes for the future. The day also encompassed a number of national speakers who covered issues around understanding guidance, commissioning rules and the assurance process.
Parity of Esteem Conference “Improving Physical Health” attracted around 100 delegates and took place on Wednesday 21st October – we had involvement from Geraldine Strathdee and Mike Prentice. Delegates were able to attend a range of workshops.
Time to Act!!! Taking Transition to the Next Level with Ready Steady Go Training! attracted around 80 delegates and took place on Thursday 22nd October – delegates heard from RSG developer Dr Arvind Nagra.
Palliative and End of Life Care Showcase Event Attracted around 100 delegates and took place on Wednesday 4th November. Throughout the day, delegates heard from the special interest groups (education and training, transform, research and audit and care coordination) who presented their locality showcases.
ADHD Education Event attracted around 100 delegates and took place on Thursday 5th November. Delegates were able to attend a variety of workshops as well as having the opportunity to hear from a service user.
Improving Care in Acute Kidney Injury: Sharing Best Practice Event attracted twice as many delegates as originally anticipated with around 160 colleagues predominantly from our local health economy although
a number of attendees travelled further (from South West London up to Healthcare Improvement Scotland). A full day programme including Richard Fluck, plus many more nationwide speakers. Abstract competition with prizes and a choice of 8 sessions. The day also attracted 6 RCP CPD points.
Community Learning Disability Teams GM Fast Track Workshop Attracted around 80 delegates on Wednesday 2nd December. The main purpose of the day was to deliver the current fast track plans for Greater Manchester (a further session organised for Lancashire), to clearly understand the GM population and key services, aims and objectives in reducing variation throughout the footprint, creating a cross-sector alliance of organisations from social care to clinical providers.
Prevention and Optimal Management in Stillbirth Attracted around 90 delegates and took place on Friday 4th December. The event consisted of a range of presentations and café style breakout sessions allowing attendance at all six sessions.
The 2nd National CAMHS SCNs Event Attracted around 100 delegates in London at the Royal College of General Practitioners. Delegates heard from Karen Turner, Jacqueline Cornish and Kathryn Pugh on the National Update and how pivotal the CAMHS agenda is. AYPH presented ‘What role does the VCS play in supporting CYP mental health?’ and SCN colleagues heard from Paul Farmer who gave an overview of people’s views on priority areas for change. We heard from Sarah Khan who gave an overview of the adult mental health programme and were presented with a modelling tool commissioned from South, Central and West CSU in partnership with HCD Economics Ltd. The day closed with the Rt Hon Alistair Burt MP supporting the CAMHS agenda.
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RenalCardiac Investigations for Renal Transplant
The three renal hubs for Greater Manchester, Lancashire and South Cumbria - Manchester Royal, Royal Preston and Salford Royal - offer renal pre-emptive transplant work up procedures. The pathway for pre-emptive transplant varied at each centre, specifically the cardiac assessments carried out.
The project aimed to deliver a standardised cardiac assessment pathway, applicable to all three renal hubs, with consensus from all nephrologists and cardiologists at these hubs. The delivery of the cardiac pathway planned to reduce length of time of the pre emptive renal pathway and increase the number of transplants carried out across Greater Manchester, Lancashire and South Cumbria.
After a consultation period with input from cardiologists, nephrologists and anaesthetists at the three renal hubs, it was decided that Royal Preston would revise their cardiac work up along the lines suggested by the new European guidelines. A revised transplant assessment protocol has been issued to Lancashire Teaching Hospitals NHS Foundation Trust by Royal Preston.
A meeting to finalise the Greater Manchester pathway for Manchester Royal and Royal Salford will took place in May where the draft pathway will be scrutinised and then taken forward as their revised transplant assessment.
CardiovascularEnd-to-End Stroke Service Specification
Lancashire Collaborative Commissioning Groups requested that the GMLSC SCNs and NHS Midland and Lancashire Commissioning Support Unit (LCSU) undertake a review of stroke services across Lancashire and South Cumbria. This was facilitated in a phased approach.
Phase 1: concluded with a review of current stroke services, gap analysis against current stroke standards and a workforce analysis.
Phase 2: concluded with the development of an end-to-end stroke service specification. Each element of the specification was developed by clinical lead experts in their field; it is evidence based, standard and outcome based.
All CCGs have signed up to the service specification; the providers are in the process of pulling together a collaborative business case for its implementation, which will include an options appraisal and costs.
Neuro-RehabilitationThe SCNs have supported the Greater Manchester Neuro-Rehabilitation Operational Delivery Network in reviewing good practice in the delivery of neuro-rehabilitation to develop a revised model of care which is fit for purpose over the coming years. The current service model which has been in operation for the past 15 years does not cater well for four key groups of patients who require in-patient rehabilitation:
nPatients with tracheostomies.
nPatients with prolonged disorders of consciousness.
nPatients displaying severe challenging behaviour.
nPatients with slow-stream rehabilitation needs.
At present there are no directly commissioned in-patient services for patients with severe challenging behaviour and those with slow-stream rehabilitation needs. Patients who require these services are considered on a case by case basis through individual funding requests which can lead to prolonged waits in NHS beds whilst a package of care in the independent sector is commissioned and arranged. Generally, patient flow through neuro-rehabilitation services is poor, leading to sub-optimal care, blocked access to neurosurgery and is having a significant impact on the major trauma collaborative.
The proposed model is to manage the relatively small numbers of patients with tracheostomies and/or prolonged disorders of consciousness in a post-acute setting at the Neurosciences Centre to allow access to specialist equipment e.g. MR scanner and neuro-anaesthetists. These beds will be found from a re-organisation of existing beds and will ensure that care is delivered in line with evidence and will reduce variation in management of this group of patients across the conurbation.
S H A P I N G E V I D E N C E - B A S E D C A R E
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Through our Eyes DVDThe Palliative and End of Life Care Network undertook a project themed ‘Through Our Eyes’. The project was delivered in two phases in partnership with an independent organisation Stories to Change who worked alongside the SCNs.
Families from BAME communities who have experienced the death of a loved-one shared their stories to help improve end of life care.
As part of the initiative their stories have been captured on camera and a special film produced which includes excerpts of interviews with volunteers from Afro Caribbean, Hindu, Jewish, and Muslim communities talking about their experiences.
On 1st April, 2015, a region-wide ‘Through Our Eyes’ stakeholder working summit was held with around 100 delegates across the geography in attendance. This included a mixture of delegates including commissioners, care staff, community members and participants.
The aim was to develop guidance to accompany the DVD, with the expectation of having access to a continuing network of people dedicated to taking the work forward. The delegates viewed the film and participated in facilitated workshops to reflect, consider and recommend strategic priorities moving forward.
Following this the DVDs were sent out to interested stakeholders across the SCNs. This has been followed up with a full evaluation and has had very positive feedback including Care Quality Commission (CQC). Since the launch of this project a number of localities have held local workshops/seminars specifically for BAME communities.
North West End of Life Care ModelThe north west end of life care model sets out best practice in the care and support from diagnosis of a life-limiting illness through to death, and includes bereavement support. The model, which has five phases, was revised and re-published with update to reflect spiritual care.
ADHD GuidelineThe Delivering Effective Services for Children and Young People with ADHD Guideline was launched in November 2015 and is a key deliverable for the Maternity, Children and Young People’s Network. ADHD was highlighted as an area of concern for our stakeholders and agreed to be taken forward by the SCNs CAMHS advisory group. A small multi-disciplinary team led by clinicains have worked together to produce a guideline with recommendations and pathways for commissioners and providers to improve the care and service for children and young people with ADHD.
Rosemere Research ProjectThe Rosemere Cancer Foundation supported a literature review of the best evidence which supported stratified approaches to managing patients following cancer treatment. The SCNs supported the steering group and ensured commissioners were involved alongside providers in driving the paper. This evidence has been shared across the region to inform commissioners and providers of some of the approaches used which enable a more holistic approach to care whilst also reducing costs in the system.
Vocational Rehabilitation ProjectIn Lancashire and South Cumbria the SCNs supported a bid to the Rosemere Cancer Foundation for a two year pilot testing how best to deliver vocational rehabilitation for cancer patients. The Network has agreed a provider of this service to start in April 2016 (Lancashire County Council) and chairs the steering group who are overseeing the work, developing the evidence base and planning commissioning beyond the pilot period.
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I M P R O V I N G PAT I E N T S A F E T Y
StrokeThe Neurosciences SCNs supported the development of guidelines for clinical guidelines for the assessment and management of adults with cerebral venous thrombosis with support from a wide range of specialists in the field.
The guidelines were developed in response to a coroner’s report into the death of a patient in Greater Manchester which highlighted the need for all patients with proven cerebral venous thrombosis to be referred to and, where safe and appropriate, managed in a regional neurosciences centre.
The guidelines provide details of relevant assessments and treatment options with the overall recommendation that all patients with a new diagnosis of cerebral venous thrombosis should be referred to and, where safe and appropriate, managed in the regional neurosciences centre at Salford Royal NHS Foundation Trust for Greater Manchester and in the regional neurosciences centre at Lancashire Teaching Hospitals NHS Foundation Trust for Lancashire and South Cumbria or, if there is no appropriate, available neurosciences bed, in an acute stroke unit.
CancerEducation
The SCNs has written a strategy for the cancer education of primary care under the Cancer Education Board in Greater Manchester. The aim is to support primary care in ensuring patients are referred in line with the NICE Guidance so that cancers are identified earlier and that the wider staff groups beyond GPs are supported to spot signs and symptoms in patients. The roll out of this education programme will be delivered in 2016/17.
Video Conferencing
Video conferencing has become an important enabler for clinicians in meeting as multi-disciplinary teams across large geographies. The SCNs has supported Lancashire and South Cumbria clinicians in improving their contract with their provider and ensuring that important multi-disciplinary team meetings are taking place with a quorate membership which ensures that patient safety and delivery of excellent treatment is embedded in multi-disciplinary discussion.
Palliative CareLancashire ‘Just in Case’ medication for last weeks/days of life guidelines
Guidelines were produce to consolidate the list of subcutaneous drug, doses and frequency of administration that localities use for local advice. The purpose of the document is to improve the safety and quality of care at end of life of patient and reduce variation across Lancashire. It is also hoped that the guidelines will reduce the risk of medication errors particularly where there is cross boundary working and help support out of hours colleagues working across localities.
Greater Manchester Strategic Clinical Networks Pain and Symptom Control GuidelinesThe fourth edition of the SCNs Pain and Symptom Control Guidelines in Palliative Care for multi-professional healthcare teams involved in prescribing, advising, and administering therapies across all care settings including primary care, hospital, hospice and nursing homes was produced. The guidelines cover pain and symptom control in specific situations and end of life care in the management of patients with an advanced progressive illness.
MaternityStillbirth Guideline and Integrated Care Pathway
Following on from the success of Version 1 of the Stillbirth Guideline and Integrated Care Pathway (ICP) 2014/15, the Maternity, Children and Young People’s Network special interest group made additional changes based on feedback from its use in practice and recent clinical guidance. Version 2 of the Stillbirth Guideline and ICP was launched in December 2015. The guidance and ICP are now embedded into local providers and has also been adopted by other SCNs and gained national and international interest. This is again a key deliverable for the Maternity Network, involving strong clinical collaboration, clinical leadership and network wide engagement and has been well received by clinicians and families alike.
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Maternity Quality Improvement DashboardThe SCNs Maternity, Children and Young Peoples’ Network prioritised a project to specifically develop and analyse a network-wide maternity data set as part of its work programme. Over the past 12 months this has been developed and refined with all the Trusts in the GMLSC SCNs footprint now providing data on the suggested list of outcome measures agreed on by the maternity quality improvement data special interest group. The Trusts are completing and submitting monthly returns to the Network, who are collating and analysing the reports along with special interest group to identify areas of best practice and areas for improvement. The completion of which is a key performance indicator included within the Greater Manchester Maternity Specification as is provider representation at the group. The agreement of a set of indicators that should be developed to help local maternity systems to track, benchmark and improve the quality of maternity services is a key recommendation from the National Maternity Review – Better Births published in March this year.
C L I N I C A L P R O F I L E
Dr. Naresh Kanumilli
SCNs Diabetes Clinical Lead Having worked in diabetes for many years, and looking at the changes that are happening in the NHS, I felt that I wanted to ensure that the best is being done for the person with diabetes.
I have been part of various service and pathway designs and felt the need to ensure best practice is shared. Another frustration of mine was that there didn’t seem to be any strategic planning in the management of diabetes. There seemed to be a lot of people doing some good work, in silos and with no support.
The most rewarding aspect of working for the SCNs is coming into contact with various groups of very enthusiastic and keen healthcare professionals and people with diabetes. All of whom were keen to make a difference and wanted to be heard.
The ability to bring together these people and provide them with a platform to raise concerns and express their opinions, to improve diabetes care, has been the highlight. This could not have been possible without the support of SCNs and a highly-motivated team.
We have set up specialist interest groups and looked into various aspects of the management of diabetes. Following on from the abysmal results of the National Diabetes Audit, showing very poor uptake of structured education, we have produced a document on structured education and disseminated it to the CCGs for approval and adoption. This has been successful and we hope this will improve the management of diabetes and empower the person with diabetes to take control of their condition.
The SCNs as an organisation is invaluable in supporting the clinician, the commissioners and the person with diabetes in achieving the best outcomes for the individual. The SCNs has a role in developing strategies and ensuring that the NHS and its partners are ready to deal with the rising tide of diabetes and helping to link various organisations together for a common goal.
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D R I V I N G I N N O VAT I O N , E F F I C I E N C Y A N D P R O D U C T I V I T Y
RenalImproving AKI Care and Physician Education: AKIcare© ‘app’ development
AKI is a common problem amongst hospitalised patients, in particular the elderly population and these patients are usually under the care of doctors practicing in specialties other than nephrology. It is estimated that one in five emergency admissions into hospital are associated with AKI. The AKI working group identified the need for a multi-faceted approach to education and management of AKI, providing clinicians with easily accessible information and clinical guidelines as well as traditional face-to -face or web-based education. The working group developed a partnership with Extravision Ltd and have delivered a web-based ‘app’ which enables clinicians to access the SCNs AKI guidelines on any platform (e.g. desktop, smartphones, tablets): AKIcare© . The AKIcare© app is now being joined by Cheshire and Merseyside and after undergoing some superficial alterations will be used across both patches.
CancerCancer Data Toolkit
Accessing and understanding data has often been a challenge for clinicians, managers, patients and commissioners. The SCNs has produced a cancer data toolkit which enables key stakeholders to view important information in regard to cancer outcomes which enables them to be more informed about the efficiency and productivity issues that are occurring across the cancer pathway. The data is transparent so all stakeholders see the same information enabling the community focussed upon cancer to be equally informed and able to contribute to the debate on improvement.
PalliativeElectronic Palliative Care Co-ordination Systems (EPaCCS)
EPaCCS enable the recording and sharing of people’s care preferences and key details about their care at the end of life. The SCNs is involved in co-ordinating and support the deployment of EPaCCS in 13 localities. During 2015 the number of localities with an EPaCCS system increased from 1 to 8.
MaternityGreater Manchester Maternity Services Specification
A draft Greater Manchester Maternity Services Specification has been produced in collaboration with a number of clinicians and commissioners. This is based on best practice, national guidance and recommendations and includes the following key performance indicators.
OUTCOME KEY PERFORMANCE INDICATORS
1. You as a provider contribute to the national data set on a monthly basis
2. You as a provider contribute to the GMLSC SCNs quality improvement maternity dashboard on a monthly basis
3. You as a provider will actively participate in the quality improvement and benchmarking of the GMLSC SCNs data. This focuses on reducing variation and improving outcomes
4. You as a provider will contribute to the two yearly national survey patient experience questionnaire (Picker Institute) survey and share an action plan with CCGs
PROCESS KEY PERFORMANCE INDICATORS
1. Captured as part of the GMLSC SCNs quality improvement maternity dashboard
Some aspects of the specification will need to be discussed and agreed locally as they fall outside the current national payment tariff.
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The SCNs are committed to ensuring that patients, carers and members of the public are genuinely involved in shaping their work.
The SCNs have pledged to:
nMeaningfully involve patients, carers and members of the public and clinicians in everything they do.
nDevelop, support and train patients, carers, public, staff and clinicians on patient care and public engagement (PCPE)
nPromote PCPE and NHS England’s commitments on meaningful engagement in the priority areas of the SCNs.
nAdvance equality and work towards reducing inequalities.
We continue to successfully implement our Patients, Carers and Public (PCP) Strategy which comprises of supporting advisory group members which meet regularly. Each meeting is chaired by a PCP member from the SCNs and Senate Oversight and Planning Group (OPG). The aim of the meeting is to:
nSupport steering group patients, carers and members of the public.
nTake issues that arise from the meeting back to the OPG.
nProvide an opportunity for personal development and to become effective members of the steering groups.
nShare crosscutting themes with the SCNs areas of work and priorities.
nProvide feedback from OPG meetings to the PCP steering group members.
nDevelop staff on how to engage with patients, carers and members of the public from diverse backgrounds and minority groups and to ensure the SCNs staff know how to sensitively work with these different groups.
PalliativeThrough Our Eyes
We have developed the use of the ‘Through Our Eyes’ film resource to train staff and engage BAME communities in conversations about end of life care. An event was held to launch the ‘Though Our Eyes’ DVD.
Dying MattersThe SCNs supported the National Dying Matters week in May 2015. The SCNs provided localities with materials and supported local events. There was active patient, carer participation in the delivery of this. Leaflets were also purchased in a number of languages to reach people from BAME communities about the key messages of advance care planning.
CancerDevelopment of eBooks
We supported the development of a suite of cancer patient eBooks with the Lancashire Teaching Hospitals NHS Foundation Trust. There will be at least 40 different eBooks covering most of the main cancer procedures. They are designed to explain to patients the procedure they will be undergoing in an accessible and interactive manner. These were only available in one format and we linked the authors with external experts who will develop cross-platform resources and we supported the Trust with business development and project management advice. In this way we were able to develop a plan for a product that could be made available to other Trusts in the Lancashire and South Cumbria area, and more widely, while the Trust retained the intellectual property rights. We also ensured that the system would allow for regular updating to ensure that the products would not become outdated. This project has and will contribute to better patient information and improved support on their cancer journey.
E M P O W E R I N G PAT I E N T S , E N G A G I N G C O M M U N I T I E S
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National Cancer Patient Conference
The SCNs delivered the national cancer patient conference in 2015 at Manchester Central. The conference was the first of its kind for many years and attracted patients and those working closely in patient involvement from across the country. The conference enabled patients to learn about what was taking place in cancer nationally, to offer their views and opinions on developing areas and to discuss patient involvement initiatives that had worked well. Plans are now afoot for a conference in 2016 and the SCNs have put in plans for this to happen in the autumn.
DiabetesDiabetes Patient Information and Structured Education
According to the National Diabetes Prevention Programme, 4 million people will be living with diabetes in England by 2025. Diabetes is a national priority and the SCNs has continued to support the commissioning of behavioural change interventions.
At present, it is clear there is significant variation in the information provided following diagnosis and recorded attendance at structured education programmes is far lower than expected. This means many people are not provided with sufficient information to enable them to understand their diabetes, how to manage it in a way that reduces the risk of complications and the choices and services available to them. It was agreed by GMLSC SCNs diabetes specialist interest group that there needed to be improvement in enabling effective self-management and these issues needed to be addressed.
Two separate but inter-related projects began in 2015; developing a minimum standard of information provided to adults following diagnosis and; developing a toolkit to enable commissioners and providers to review their structured education programmes.
The primary aims were to; recommend a minimum standard of information is provided to adults following diagnosis; state the way the messages should be delivered to have a broader and clearer impact; highlight areas of good practice; suggest ways the messages could be re-enforced; identify reasons why people do not currently attend structured education programmes and possible solutions and provide a menu of options for other structured education programmes.
The outputs of the project were combined in a toolkit fronted by a set of recommendation entitled; Improving Information and Education for People with Type 1 or Type 2 Diabetes Across Greater Manchester, Lancashire and South Cumbria. These recommendations were endorsed by the Clinical Commissioning Board in Lancashire in March and have been put to the Heads of Commissioning in Greater Manchester and Commissioners in Cumbria for adoption.
Mental HealthChild and Adolescent Mental Health Services (CAMHS) Transformational Plans
The Department of Health and NHS England have outlined a major service transformation programme that is intended to significantly reshape the way services for children and young people with mental health needs are commissioned and delivered across all agencies over the next five years, in line with proposals put forward in Future in Mind. These include prioritising investment in those areas that can demonstrate strong leadership and ownership at local level through robust action planning and the development of publicly available local transformation plans for children and young people’s mental health and wellbeing. The initial programme funding was dependent on the development of a Transformation Plan for each local area aligning with the overarching principles and ambition set out in Future in Mind. CCGs are encouraged to develop their plans with their multi-agency partners (e.g. Local Authorities, Education, and Justice) and these are available on the CCGs websites. The GMLSC SCNs Maternity, Children and Young People’s Network supported CCGs through this process and has also supported Midlands and Lancashire Commissioning Support Unit in establishing Lancashire children’s and young people’s emotional wellbeing and mental health service transformation programme.
The Network is leading nationally on CAMHS and coordinating a monthly virtual SCNs CAMHS forum to share best practice. In December 2015 the SCNs hosted a national SCNs event Its transformational time – children will be seen and heard, key note speaker was the Rt Hon Alistair Burt MP, Minister of State for Community and Social Care, DH who assured the audience by his clear and enthusiastic commitment to children and young people’s mental health that CAMHS was an important part of the governments agenda.
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F U T U R E P R I O R I T I E S
Mental HealthWe are supporting commissioners and providers to deliver against the Five Year Forward View for Mental Health and the Taking Charge Strategy from the Greater Manchester Health and Social Care Partnership. This involves:
nContinued work on early intervention for people experiencing psychosis.
nWorking towards 24/7 access to mental health care for people facing a crisis.
nEnsuring good liaison mental health care is provided 24/7 in all acute hospitals by 2021.
We will support the regional NHS England office and Greater Manchester commissioners and providers on improving IAPT and EIP (50% of people experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral. 75% of people referred to the IAPT programme treated within six weeks of referral, and 95% treated within 18 weeks of referral) and liaison mental health.
We will continue to support NHS partners on the Greater Manchester Devolution Mental Health Strategic Partnership Board and Executive Group to share good practice and implement the crisis care concordat priorities.
We will continue to develop commissioners and providers including the voluntary sector skills and acknowledge as leaders of mental health and wellbeing through the national (subject to the view of the new Clinical Director for NHS England) and Greater Manchester Commissioners and Providers Network.
Parity of esteem: We will improve staff education and promotion of clinical competencies including the promotion of remote smoking cessation in mental health organisations, promoting weight reduction and exercise in mental health patients.
We have several priorities around mental health liaison, including:
nEmbed and ensure coherence of the liaison psychiatry services with the mental health programme and Devolution Manchester agenda.
nProduce a liaison mental health advisory group strategy to guide the actions to achieve Core24 status of Greater Manchester Acute Trusts by 2020.
nTo liaise with central commissioning groups to provide guidance on commissioning of services to achieve Core24 status by 2020.
nTo deliver professional training for healthcare professionals to drive forward the liaison psychiatry and mental health agenda and identify pathways for health professionals to reduce unnecessary hospital admissions.
nTo continue to build capacity within communities to support liaison mental health and mental health services.
Learning DisabilitiesOur support for the Transforming Care Programme and fast track plans and support for the implementation of the Greater Manchester strategy and national priorities from NHS England regional office will continue.
We will continue to build on the good relationship with the voluntary sector, patients, carers and families including supporting seldom heard groups tackling health inequalities.
We will continue to support the Greater Manchester Devolution, commissioners and providers priorities on learning disabilities including fast track.
DementiaContinued support will be offered to commissioners and providers to increase the rate of timely and accurate diagnosis across the SCNs footprint and reduce the local variation.
Work will also continue with stakeholders to ensure there is a consistent standard of support offered to those newly diagnosed and their families across Greater Manchester and Eastern Cheshire. Joint efforts will be made to establish dementia friendly communities and links will be made to aid research on patient and carers’ experiences.
Dementia individual clinical pathway: We will help to deliver work around an agreed clinical care pathway in delivering an individualised care plan, with best practice pathways able to flex to local population needs and commissioning intentions. Work is currently ongoing to populate a toolkit developed by the SCNs to reflect the well pathway domains, whilst drawing on local, regional and national priorities.
We will support a clear strategic approach to dementia in ensuring that the appropriate range of services is commissioned. Information is currently being pulled together with regards to CCGs having a named dementia lead (or not) and whether or not they have a standalone dementia strategy or one embedded within the broader CCG strategy. This agenda is currently being looked into by Dementia United prior to the formal launch in 2016/17.
We will promote and facilitate access to research for people with dementia, their carers and communities. This is currently being led by the GMLSC SCNs clinical lead and it is anticipated that a resource/toolkit which provides a seamless route into research participation will be made available at the end of the project. We are currently working in collaboration with join Dementia Research to promote and facilitate this, as well as produce a resource that could be utilised across the boundaries of care.
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We will promote and facilitate well trained staff to deliver on dementia priorities locally and across the boundaries of health and social care, with the SCNs supporting a collaborative approach to education and training alongside key stakeholders. The education and training guidance is being developed with already existing information partner SCNs, relevant guidance from Health Education Northwest and other readily available guidance.
We will support the national ambition for CCGs to achieve and sustain nationally mandated dementia diagnosis target rates beyond 66.7%.
We will support the most recent NHS England dementia diagnosis rates risk register of high risk organisations not achieving the national ambition
We will provide continuous support to the roll out of the student and young people engagement project themed ‘Dementia Matters’ delivered by the Central Manchester Public Programmes Team.
Other Dementia Priorities Include:
nSupporting and facilitating the Dementia United agenda and locality meetings across Greater Manchester.
nSupporting and enabling the NHS England resilience in care homes agenda.
nEnable and support consistent approaches to dementia education and training through ongoing promotion and facilitation of workforce and education developments.
nEnable and support consistent approaches to participation in research across the boundaries of health and social care by way of ongoing promotion and facilitation of existing tools, guidelines, resources and expertise input through our dementia steering group.
nContinuing to work in partnership with commissioners to set priorities for models of post diagnostic support, based on the NHS England Well Pathway for Dementia.
nSupport the National Dementia Awareness week (15th – 21st May 2016).
nSupporting and promoting NHS England Transformation Framework’s ‘The Well Pathway for Dementia’ via our 2015/16 work programme and dementia clinical pathway development.
nSupporting the Dementia United Pledges, with reference to the key worker model whilst the testing out of the most effective delivery model is being piloted in 2016/17.
nEnhancing and supporting the Prime Ministers Challenge around explicit leadership and the development of a Dementia Strategy through our 2015/16 work programme.
nContinuing to support the partnership working with BAME communities through voluntary groups.
CancerWe plan to redevelop the cancer awareness toolkit to increase the resources available through it and the number of users it can support. In particular, we aim to develop it as a comprehensive portal for linking (both clinical and non-clinical) staff and volunteers with training and education opportunities. Our priority will be to create a system that is accessible and inclusive and which raises awareness of cancer signs and symptoms but also supports people in raising these issues with patients, family, carers and friends.
We will support the establishment of a new Cancer Education Network in Greater Manchester operating as a sub-group of Cancer Education Manchester. Working with stakeholders in the Cancer Vanguard, CCGs and in the third sector we will aim to ensure that strategic cross-sector working education services are strongly aligned with national priorities, regional service delivery and local priorities.
We will work with a broad range of stakeholders to continue the development of a Lancashire and South Cumbria area-wide network to promote and support the development of cancer education services. Working with clinical and non-clinical partners to develop and deliver a range of education designed to improve patient experience and outcomes, we will confirm the make-up and remit of the group and provide leadership and servicing support.
We aim to secure external funding to support the establishment and initial operation of an education and training hub - Rosemere Cancer Education Hub - to improve the quality and increase the delivery of cancer education and training in Lancashire and South Cumbria. Providing education and training services in all four Trust areas of the Lancashire and South Cumbria footprint, the key aim of the project will be to deliver a range of projects which will improve the welfare of cancer patients, their families and carers.
We will redevelop the cancer awareness toolkit to increase the resources available through it and the number of users it can support. In particular, we aim to develop it as a comprehensive portal for linking (both clinical and non-clinical) staff and volunteers with training and education opportunities. Our priority will be to create a system that is accessible and inclusive and which raises awareness of cancer signs and symptoms but also supports people in raising these issues with patients, family, carers and friends.
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DiabetesFor 2016/17 the SCNs will focus on the same priorities for diabetes outlined by the National Clinical Director. These are:
nType 2 prevention.
nImproving structured education for those newly diagnosed.
nImproving the management of diabetic foot.
nImproving performance against the three NICE targets (blood glucose levels, cholesterol and blood pressure).
Work will consist of helping providers identify and manage people suitable for the National Diabetes Prevention Programme (NDPP) and working with commissioners to review education programmes and the management of diabetic foot.
CardiacWe plan to help widen access to acute interventional cardiology 24/7 for patients with high risk acute coronary syndrome.
Further work will take place on the development of the functional imaging and the stable angina pathway.
We will assist in the improvement of services in Lancashire and South Cumbria, working with the newly-appointed clinical lead.
There will be further joint working across stroke and cardiac on AF/stroke prevention work.
We will support a working group to pilot early access to acute interventional cardiology (within 24 hours of admission) for patients with high-risk acute coronary syndrome, in collaboration with Manchester Academic Health Science Centre.
We will further develop chest pain of possible cardiac origin pathways.
A clinical lead will be appointed in Lancashire and South Cumbria progressing work on FH and out of hospital cardiac arrests.
An AF stroke prevention commissioning toolkit for commissioners will be developed.
There will be a project to refine and optimise the pre-emptive transplant pathway, specifically, cardiac work up aimed to create one pathway planned to be adopted by Central Manchester University Hospitals NHS Foundation Trust, Salford Royal NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust. After much discussion around the pathway and current ways of working, LTHTR revised their cardiac work up along the lines suggested by new European guidelines and a revised transplant assessment protocol has been submitted to their Trust. CMFT and SRFT are in the process of finalising their pathway and this is expected to be adopted presently.
Maternity, Children and Young PeopleWe will be supporting commissioners and providers to deliver against the National Maternity Review: Better Births and implementing the Saving Babies Lives care bundle.
The National Maternity Review has made 24 recommendations to inform system transformation and have identified key themes which are fundamental to creating a system that properly supports improving safety of care and empowering women.
Nine work streams have been identified:
n Supporting local transformation.
n Promoting good practice for safer care.
n Increasing choice and personalisation.
n Improving access to perinatal mental health services.
n Transforming the workforce.
n Sharing data and information sharing.
n Harnessing technology.
n Reforming the payment system.
n Improving prevention.
The SCN will also be supporting the Maternity Choice and Personalisation Pioneer programme pilot sites within Greater Manchester.
Perinatal Mental Health
We will be establishing and developing a Perinatal Mental Health Network in line with good practice. To enable us to:
n Continue to engage and collaborate with CCGs and providers to deliver best practice and reduce fragmentation in service provision.
n Identify and assess baseline positions in terms of availability and access to specialist perinatal mental health services (gap analysis in line with NICE guidance) in order to determine strategic plans for coming years and respond to availability of new funding.
n Ensure that a broad range of perinatal mental health support is available locally, with clear pathways available for identification and timely access to psychological therapies and specialist perinatal services in line with NICE guidance.
n Establish local workforce strategies.
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Children and Young Persons’ Emotional Well-Being and Mental HealthWe will be supporting commissioners and providers to deliver against the Children and Young People’s Mental Health Taskforce paper - ‘Future in Mind’.
Future in Mind made 49 recommendations to inform system transformation and identified five key themes fundamental to creating a system that properly supports the emotional wellbeing and mental health of CYP:
n Promoting resilience, prevention and early intervention.
n Improving access to effective support – a system without tiers.
n Care for the most vulnerable.
n Accountability and transparency including the development of effective patient engagement/participation.
n Developing the workforce.
In light of the recommendations the SCNs will be focussing on 6 key areas of work:
n Implementation of Greater Manchester ADHD guidance.
n Community Eating Disorders (3 new services for GM).
n Workforce Development/Thrive - new model of provision.
n Tier 4 inpatient reconfiguration.
n Mental Health Liaison and Crisis Care.
n Leading and/or supporting system transformation change including patient participation.
In addition the SCNs will continue to support and facilitate clinical and commissioning groups responsible for delivering Future in Mind across Greater Manchester and Eastern Cheshire
Palliative and End Of Life CareFour specialist interest groups were successfully established across Greater Manchester, Lancashire and South Cumbria, each producing a programme of work, these being, education and training, research and audit, care coordination and transforming care.
n The special interest groups have been embedded in the work of the SCNs and they are a standing item on the advisory group.
n A Showcase Event took place on the 4th November 2015 to present best practice from the Greater Manchester localities and we have presentation and photos from this event.
n BAME event to launch the ‘Though Our Eyes’ DVD.
n The CQC has taken this work as an example of best practice.
n Localities are engaged with this agenda through the advisory groups, Dying Matters Awareness Week, and various other opportunities at a local level, e.g radio interviews.
n Audit is currently in progress against the five priorities of care for the dying person being undertaken by the research and audit special interest group.
n 50% of all our localities are live with some form of EPaCCS system.
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S T R AT E G I C C L I N I C A L N E T W O R K S C L I N I C A L L E A D S
Dr Farzin Fath-Ordoubadi Central Manchester University Hospitals NHS Foundation Trust
Consultant Cardiologist
n Leading on Cardiac
Dr Khalil Kawafi The Pennine Acute Hospitals NHS Trust
Consultant Stroke Physician and Clinical Lead
n Leading on Stroke
Dr Michael Picton Central Manchester University Hospitals NHS Foundation Trust
Consultant Renal Physician and Clinical Director for Renal Medicine
n Leading on Renal
Mr Simon Hardy East Lancashire Hospitals NHS Trust
Consultant General and Vascular Surgeon
n Leading on Vascular
Dr Mark Kellett Salford Royal NHS Foundation Trust
Clinical Director for Medical Neurosciences
n Leading on Neurological Conditions
Dr Sandeep Ranote 5 Boroughs Partnership NHS Foundation Trust
Consultant Child and Adolescent Psychiatrist
n Leading on Child and Adolescent Mental Health
Miss Karen Bancroft Bolton NHS Foundation Trust
Associate Medical Director/ Head of Family Care Division and Consultant Obstetrician and Gynaecologist - Women’s Healthcare
n Leading on Maternity
Dr Geraldine Skailes Lancashire Teaching Hospitals NHS Foundation Trust
Consultant Clinical Oncologist
n Leading on Cancer
Dr Susan Salt Trinity Hospice
Consultant in Palliative Medicine
n Leading Palliative and End of Life Care, Lancashire and South Cumbria
Dr Sara Shackleton NHS Chorley and South Ribble Clinical Commissioning GroupGPn GP Clinical Lead for Palliative and End of Life Care
Dr Mark Robinson Wrightington, Wigan and Leigh NHS Foundation Trust Consultant Paediatrician and Clinical Director Child Health
n Leading on Children
Dr Naresh Kanumilli NHS South Manchester Clinical Commissioning Group
GP
n Leading on Diabetes
Dr Amanda Thornton Lancashire Care NHS Foundation Trust
Clinical Director
n Leading on Dementia
Dr Dave WatermanStockport NHS Foundation Trust and St Ann’s Hospice Consultant in Palliative Medicine
n Consultant Physician in Palliative Medicine
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S T R AT E G I C C L I N I C A L N E T W O R K S C L I N I C A L L E A D S
Julie CheethamDeputy to Associate Director
Strategic Clinical Network Managers
John HerringStrategic Clinical Network Manager
Maqsood Ahmad OBEStrategic Clinical Network Manager
Programme Clinical Leads for SCNs areas also include:Dr Carol Ewing, Clinical Advisor, Children and Young People
Mr James Bruce, Paediatric Surgery, Children and Young People
Dr Christian DeGoede, Health Transition, Children and Young
People
Dr Leonard Ebah, AKI Education
Dr Jonas Eichhöfer, Cardiac Lead (Lancashire)
Julie Flaherty, Children and Young People
Jean Hayhurst, Stroke/AF
Dr Mammen Ninan, Stroke/AF
Dr Dimitrios Poulikakos, AKI Education
Dr Nick Roberts, Stroke (Lancashire)
Dr Dare Seriki, CLI Vascular
Tracy Walker, Stroke Rehabilitation
Joanne Whitmore, Stroke/AF
Dr Paul Wright, Stroke/AF (Greater Manchester)
Dr Neil Davidson, AF
In addition the SCNs would like to acknowledge the following clinicians and advisors, who are leaving the Network, for their valued contribution during the last year:
n Dr Stephanie Gomm Clinical Lead for Palliative and End of Life Care
n Dr Chrissie Hunt Clinical Lead for Cancer
n Dr Neil Smith Clinical Lead for Cancer
n Dr Sarah Taylor Clinical Lead for Cancer
Julie RigbyStrategic Clinical Network [email protected]
Janet Ratcliffe is retiring having formed and led
the Network for over three years following her
leadership of the Greater Manchester Cardiac
and Stroke Network. Janet’s ability to focus on
the needs for staff and clinicians to concentrate
on what will improve their health brings out
the best in all. She supports the staff not only
as resources for the service but because they
are people she cares about. Janet is astute and
sensitive in dealing with others to ensure that
the advice of the Network is taken fully into
account when decisions are made. We wish
her well in her retirement as she will be much
missed.
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F I N A N C I A L S U M M A R YThe SCNs budgets were reduced by £1m in 2015/16 compared with 2014/15 annual allocation. The admin budgets suffered a cut of 15% as part of the Organisation Alignment Capacity Programme (OACP) which was consistent with all other corporate and admin budgets for 2015/16. The programme budgets however suffered deeper cuts of 22% compared with previous year’s allocation together with 34% cut in income for end of life care from Health Education North West. A breakdown of the annual budgets for SCNs is as follows:
2014/15 2015/16
Increase/ Increase/ Budget Area Annual Budget Annual Budget (Decrease) (Decrease) (£ millions) (£ millions) (£ millions) %
SCNs Admin 0.81 0.71 0.11 13%
SCNs Programme 2.61 2.04 0.57 22%
Subtotal 3.42 2.75 0.68
SCNs Income/Rechargers 0.20 0.30 -0.10 -49%
End of Life Care 1.24 0.81 0.42 34%
Subtotal 1.44 1.11 0.32
Total Available Resources 4.86 3.86 1.00
The SCNs admin and programme budgets closed with a balanced year-end position as forecast throughout the year, within this position are the following main categories of expenditure:
SCNs – Clinical LeadsThe SCNs employed a number of clinical leads in 2015/16 to provide clinical advice for each of the Network area. These clinical leads were appointed from local Trusts on a sessional basis and have proved very effective in the delivery of the improved patient outcomes across different Networks. A summary of the clinical leads in each SCNs area and their costs are as follows:
No. of Clinical Leads Sum of 2015/16 Costs (£’000s)
SCNs Network Programme Clinical Leads Costs (£’000s)
Cancer 4 76
CVD 11 117
End of Life 3 25
Maternity 9 134
Senate 1 38
Grand Total 28 390
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Staff Mix by Grade - 2015/16
0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00
DirectorBand 9
Band 8cBand 8d
Band 8bBand 8a
Band 7Band 6Band 5Band 4
SCNs Programme Budgets – Investment PlanHaving engaged with a number of stakeholder groups, SCNs developed a coherent investment plan to deliver a number of priorities in the five Networks (Cancer, CVD, Maternity and Children, Mental Health and Dementia and End ofLife Care) to deliver improved outcomes through collaborative working with a number of NHS, voluntary and third sector organisations. These initiatives were carefully selected with key selection criteria being the strategic alignment with SCNs objectives. The total investment amounts to just under £0.51m with projects ranging from as little as £1k to £50k. All the investment projects were delivered and accounted for in 2015/16.
SCNs – End of Life Care ProgrammeFunding for the Palliative and End of Life Care team comes via the 12 Greater Manchester CCGs. In addition to this Health Education North West, awarded £670k for education and training across the SCN. This was divided by CCG based on the weighted average population for delivery against an agreed set of priorities.
SCNs Staff Structure and Skill MixThe SCNs has a diverse workforce with skills ranging from clinicians to project managers and highly skilled admin staff. £2.01m of investment on staffing resources enabled SCNs to employ an average of 36.8 staff throughout 2015/16. The below chart shows the skill mix of employed SCNs staff at different Agenda for Change band levels
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N O T E S :
www.gmlscscn.nhs.uk @GMLSC_SCNs
Greater Manchester, Lancashire and South Cumbria Strategic Clinical Networks
Manchester Office:4th Floor, 3 Piccadilly Place
Manchester M1 3BNTel: 0113 825 5228
Preston Office:Room 176, Watling Street,
Preston PR2 8DYTel. 0113 825 3121