healthier together - pat

1 Healthier Together The Greater Manchester Case for Change

The Greater Manchester

Case for Change


Document History:

Date Version Author Details

06/08/12 V1 Alex Heritage

Sue Wallis

Initial Draft incorporating Clinical Workstream Cases for Change. Issue for comments

15/08/12 V2 Alex Heritage Amendments following review from Warren Heppolette & Andrew Burridge.

16/08/12 V3 Jennifer Platt Amendments following review from Jess Williams, Janet Ratcliffe, Nicola Baker, Anne Talbot.

17/08/12 Final Alex Heritage Approved by A. Talbot. Submission to Clinical Strategy Board

30/08/12 Final Jennifer Platt Addition of Foreword from GM Authorities

30/08/12 Final Alex Heritage Textual Amendments. Endorsed by Large Scale Change Board

04/09/12 Final Alex Heritage Textual Amendments. Endorsed by Clinical Strategy Board.

Approved by: A. Talbot (17-Aug-12)

Title Healthier Together - The Greater Manchester Case for Change

Author Alex Heritage & Sue Wallis

Target Audience Clinical Strategy Board / NHS Greater Manchester Board

Version Final

HTP Reference HTP- 009

Created - date 6th July 2012

Date of Issue 26th September 2012

Document Status Final

File name and path

Q:\SERVICE TRANSFORMATION\Healthier Together\Clinical Workstreams\Case For Change\Greater Manchester Case For Change\2012 08 06 The Greater Manchester Case For Change - FINAL.Docx


Contents

Foreword by Greater Manchester CCG Chairs ................................................................................. 5

Foreword by Association of Greater Manchester Authorities .......................................................... 6

Introduction ................................................................................................................................... 7

An Introduction to the Greater Manchester health and care system .................................................. 8

Population ........................................................................................................................................... 11

Health and Care inequalities............................................................................................................... 13

Transport ............................................................................................................................................ 16

An understanding of why Greater Manchester’s Health and care system needs to change ............ 18

Three Key Messages to our patients and citizens .......................................................................... 21

Exploring Variation across Greater Manchester ............................................................................ 23

Mortality ............................................................................................................................................. 25

Quality and Safety ............................................................................................................................... 28

Finance and Workforce ....................................................................................................................... 30

Summary of Clinical Cases for Change ............................................................................................... 32

Conclusion ................................................................................................................................... 47


Table of Figures

Fig 1.1 Location of Greater Manchester ............................................................................................................... 11

Fig 1.2: Population profile, 2010 ........................................................................................................................... 12

Fig 1.3 Indices of Multiple Deprivation ................................................................................................................. 13

Fig 1.4 Greater Manchester Local Health Profiles compared to England Average ............................................... 14

Fig 1.5: Traffic Flows (Motorways, A & B Roads) .................................................................................................. 16

Fig 1.6: Core Bus Network ..................................................................................................................................... 17

Fig 1.7: Greater Manchester Metrolink and Rail Network .................................................................................... 17

Fig 1.8: Key health inequalities identified in the Local health Profiles ................................................................. 18

Fig 1.9 Greater Manchester Local Health Profiles: Children ................................................................................. 19

Fig 1.10: How satisfied or dissatisfied would you say you are with the way in which the NHS runs nowadays. . 19

Fig 1.11: Greater Manchester NHS Secondary Care Providers ............................................................................. 23

Fig 1.12: Greater Manchester NHS Secondary Care Providers Map and PCT boundaries .................................... 23

Fig 1.13: Greater Manchester CCG PCTs to CCG ................................................................................................... 24

Fig 1.14: Greater Manchester Local Authority Social Care commissioners .......................................................... 24

Fig 1.15: Number of deaths, all causes, 1993-2009, all persons aged under 75 .................................................. 25

Fig 1.16: Standardised mortality rates, all causes, 1993-2009, all persons aged under 75 .................................. 25

Fig 1.17: Potential years of life lost from all causes of mortality, Number of deaths, all causes, 2006-2009, all

persons aged under 75.......................................................................................................................................... 26

Fig 1.18: % change in number of deaths, all causes, all persons, aged <75.......................................................... 26

Fig 1.19: Summary Hospital-level Mortality Indicator (SHMI), April 2010 – March 2011 .................................... 27

Fig 1.20 AQuA Acute Trust Quality Dashboard Q1 12/13 ..................................................................................... 29

Fig 1.21 NHS Greater Manchester Financial Challenge 2011-15 .......................................................................... 30

Fig 1.22: Greater Manchester Provider Establishment ......................................................................................... 30


Foreword by Greater Manchester CCG Chairs

As clinical leaders of Greater Manchester it is our passion and aim to provide the very best of health

and care to our patients and communities. Greater Manchester is changing with vibrant

communities growing with many people living longer. However, more people are living longer with

multiple long term conditions such as diabetes and COPD which increases the demand on the NHS

and social care services. In response to the wider economic climate, our public services in Greater

Manchester face unprecedented pressures to ensure that every pound is spent efficiently to provide

the best outcomes for every patient.

Greater Manchester has a good record of changing to meet these extra demands with many

improvements in outcomes for patients. However, parts of our current system were designed for the

last century which relies heavily on our hospital services. Building on our previous achievements we

believe that our current system can be changed to ensure that people are cared for in the most

appropriate place. Care might be delivered in primary and community care settings or even in our

patient’s own homes, whilst freeing up specialist care in hospitals for those who really need it.

Local health communities of Greater Manchester have made good progress in responding to local

pressures, however it is recognised that in some cases the local system may achieve greater

outcomes for patients by working with wider partners across Greater Manchester.

In Summary:

Demands on the NHS and Social Care are growing... So the NHS is changing to meet these extra demands and improve the care it provides... But even more change is needed.

We are fully committed to leading the Healthier Together programme which will be the catalyst to change the way health and care is provided to ensure high quality services are safe, accessible and sustainable for our future patients and communities.

Dr. Wirin Bhatiani NHS Bolton CCG

Dr. Kirian Patel NHS Bury CCG

Dr. Mike Eeckelaers NHS Central Manchester CCG

Dr. Chris Duffy NHS Heywood, Middleton & Rochdale CCG

Dr. Martin Whiting NHS North Manchester CCG

Dr. Ian Wilkinson NHS Oldham CCG

Dr. Hamish Steadman NHS Salford CCG

Dr. Bill Tamkin NHS South Manchester CCG

Dr. Ranjit Gill NHS Stockport CCG

Dr. Raj Patel NHS Tameside & Glossop CCG

Dr. Nigel Guest NHS Trafford CCG

Dr. Tim Dalton Wigan Borough CCG


Foreword by Association of Greater Manchester Authorities

In Greater Manchester local government is leading collective efforts to deliver an ambitious public

service reform agenda and secure economic growth. We want Greater Manchester to be known as a

city region where all people benefit from increasing prosperity and opportunity.

We know health and social care expenditure accounts for £6bn (nearly one third) of public sector

expenditure in GM. This scale of spending is unsustainable given the financial challenges to the NHS

and local authorities in the light of demographic change and reducing budgets. Too great a

proportion of these resources are currently focused in response to acute need and avoidable crises.

Hospital and local social care services have in the past faced criticism due to a perceived failing to

integrate. Acute hospital care is generally not provided in a vacuum but incorporates a wide range of

issues across organisations including community services, avoidance of inappropriate admissions, and

discharge into home or other care settings. More broadly, our requirements for a safe and

sustainable hospital system need to understand the pressures upon an interdependent care system,

and our collective intentions for prevention, independence and wellbeing. Local government has a

crucial role to play supporting the NHS to understand the relationship with housing and transport.

Local elected politicians need to be engaged throughout the programme, given the importance of

these proposals to their local communities.

We recognise that the scale of the challenge facing social and health care requires system leadership

that works across organisational boundaries. Healthier Together provides a major opportunity for us

to change our services to meet the needs of GM residents, under the direction of a GM Health

Commission (soon to be reconvened as a GM Health & Wellbeing Board). AGMA is keen to

participate within Healthier Together and looks forward to working closely with NHS GM, GM Clinical

Commissioning Groups, and the acute sector in GM.

Steven Pleasant

Chief Executive – Tameside Council

Lead Chief Executive for Health

On behalf of AGMA


Introduction

The Greater Manchester Case for Change seeks to provide an overview of the Greater Manchester

health and care economy whilst identifying strategic areas for change. This document supported by

eight separate clinical work streams for change provides the foundation and first step of the

Healthier Together programme. The document is structured to provide an overview of Greater

Manchester including:

An Introduction to the Greater Manchester health and care system;

An understanding of why Greater Manchester’s Health and care system needs to change;

The exploration of the variation across Greater Manchester;

A summary of the Clinical Cases for Change.

The Greater Manchester Case for Change has been developed in conjunction with other key

programmes and aligns with other important strategy documents including the Greater Manchester

City Region Community Budget Pilot, Greater Manchester Joint Strategic Needs Assessment and

Greater Manchester’s Local Transport Plan.

The Healthier Together programme has developed strong partnerships with a number of

organisations that have been utilised to support the cases for change.

http://www.agma.gov.uk/

http://www.agma.gov.uk/

http://www.mottmac.com/

http://www.gmpublichealthpracticeunit.nhs.uk/


An Introduction to the Greater Manchester health and care system

It is estimated that across England the NHS treats 1 million people every 36 hours. Many of these people have their lives saved or improved because of the care they receive from dedicated NHS staff. The NHS is there when we need it most, providing round the clock, compassionate care and comfort. It plays a vital role in ensuring that as many of us as possible can enjoy good health for as long as possible – a matter of fundamental importance to us, our family and friends.

Greater Manchester is a vibrant and dynamic conurbation with great potential for economic growth and prosperity. However, the population of Greater Manchester has traditionally suffered some of the poorest health in England. Good progress has been made in addressing the health challenges posed by the burden of disease associated with social deprivation, poor mental health, cancers, cardiovascular disease and poor lifestyle choices leading to problems of obesity, alcohol related morbidity and smoking related disease, however further focus to reduce health inequalities is essential.

The current organisation of health services in Greater Manchester was designed to meet the needs of

the last century. Today, the greatest requirement is the ongoing care of people with multiple long

term conditions and, to meet these needs, the NHS needs to take a more strategic approach to

shifting the balance of care from hospital to community, primary, social and self care. It is also

recognised that access to specialist care needs to be improved across Greater Manchester. The

presence of leading international institutes within Greater Manchester should ensure that all national

quality standards are met ensuring current inequalities of access and related outcomes for patients

are improved.

A further challenge is that the current organisation of hospital services in Greater Manchester is not

financially sustainable. Over recent years, despite achieving planned cost savings, a number of Trusts

in Greater Manchester are facing challenging financial difficulties. This situation must be addressed

to ensure high quality services are consistently provided.

The Greater Manchester Health and Social Care system faces a significant challenge in making changes whilst still maintaining a service 24 hours a day, 7 days a week and seeking to deliver against the five NHS Outcome domains: 1. Preventing people from dying prematurely; 2. Enhancing quality of life for people with long-term conditions; 3. Helping people to recover from episodes of ill health or following injury; 4. Ensuring that people have a positive experience of care; 5. Treating and caring for people in a safe environment and protecting them from avoidable harm. (Department of Health (2011) The Operating Framework for the NHS in England 2012-13)

The Greater Manchester case for change supported by 8 clinical work streams and aims to provide

the foundation for achieving the programmes vision and outcomes.


Healthier Together Vision:

For Greater Manchester to have the best health and care in the country

Outcomes:

Improve the health and wellbeing of people in Greater Manchester

- safe services based on best practice, clinical standards and better specialist care in our hospitals

Improve equality of access to high quality care

- improved, timely access to appropriate staff, facilities and equipment across the whole of Greater Manchester

Improve people’s experience of healthcare service

- integrated care provided in the most appropriate setting to provide better outcomes and experience for patients

Make better use of healthcare resources

- care provided by sustainable organisations that allow best possible use of the total resource available to the health and social care system in Greater Manchester.


The Healthier Together programme is one element of a wider public sector reform agenda that seeks

to improve outcomes for all Greater Manchester residents. With the publication of the Greater

Manchester Strategy in 2009, Greater Manchester set itself an ambitious vision for 2020 to secure

long-term growth and enable the city region to fulfil its economic potential, whilst ensuring that our

residents are able to share in and contribute to that prosperity. The last two years have seen

governance arrangements in Greater Manchester become more robust and mature, enabling us to

secure a range of bespoke agreements with Government in our recently agreed City Deal, helping to

empower us to make our own decisions about what is needed to support growth. Our unique

governance arrangements are supported by an increasingly streamlined set of delivery structures and

a new cross partner focus on public service reform.

Our current models of public services are not fit for the coming challenge of delivering growth,

particularly given the scale of planned reductions in public spending. We need a transformational

reduction in demand and dependency, with people and places becoming more resilient and self-

reliant. Greater Manchester therefore needs a radical programme of public service reform over the

next three to five years which will both reduce high levels of dependency and demand for a range of

public services and support our growth plans, by helping connect people to opportunities, reduce

worklessness, improve skills and workforce productivity.

The 2010 Spending review set out plans for Community Budgets which would enable partners to

redesign public services in their areas, agreeing outcomes and allocating resources across different

organisations.

The Greater Manchester proposal for a Community Budget covers a wide range of themes. It

addresses the current service response to troubled families, offenders and children. There is a health

and social care strand running through all of them, reflecting the case for a greater integration of

response including integrated commissioning across the public sector.


Population

Greater Manchester is a metropolitan county in North West England, with a population of 2.6 million. It encompasses one of the largest metropolitan areas in the United Kingdom and comprises ten metropolitan boroughs: Bolton, Bury, Oldham, Rochdale, Stockport, Tameside, Trafford, Wigan, and the cities of Manchester and Salford.

Greater Manchester spans 493 square miles (1,277 km2). It is landlocked and borders Cheshire (to the south-west and south), Derbyshire (to the south-east), West Yorkshire (to the north-east), Lancashire (to the north) and Merseyside (to the west). There is a mix of high density urban areas, suburbs, semi-rural and rural locations in Greater Manchester, but overwhelmingly the land use is urban.

Fig 1.1 Location of Greater Manchester

Source: Greater Manchester Local Transport Plan 2011-16 p.7

It has a focused central business district, formed by Manchester city centre and the adjoining parts of Salford and Trafford, but Greater Manchester is also a polycentric county with ten metropolitan districts, each of which has at least one major town centre and outlying suburbs. The Greater Manchester Urban Area is the third most populous conurbation in the UK, and spans across most of the county’s territory which presents a significant challenge to public services.

Number of people per hectare: 19.5 (E&W avg: 3.4) Households without car / van: 32.8% (E&W avg: 26.8%) Lone parent households (with dependent children): 8.0% (E&W avg: 6.5%) Ethnicity: White 91.1%; Pakistani 3%; Indian 1.5% Limiting long-term illness: 20.4% (E&W avg: 18.2%) General health ‘not good’: 11.1% (E&W avg: 9.2%)

(Source: Greater Manchester Joint Strategic Needs Assessment)

http://www.gmpublichealthpracticeunit.nhs.uk/greater-manchester-joint-strategic-needs-assessment-gm-jsna/gm-places/gm-population-profile-and-demographics/


Greater Manchester has a younger population structure than the national average with lower proportions aged over 45 than across the North West and England (Figure 1.2).

Fig 1.2: Population profile, 2010

Source: ONS/ NHSIC

This population profile emphasises Greater Manchester as a growing and vibrant conurbation that continues to see a rising demand on health and care services. Furthermore, this younger population structure will have an impact upon the annual birth rate with many new communities forming around economic hubs (Manchester City Centre, Media City UK) with expectations of a modern health and care system providing the right care at the right place and right time.


Health and Care inequalities

Significant inequalities in health are present within Greater Manchester. Recent analysis taken from the Local Health Profiles suggests that not only do gaps in health outcomes exist between the most and least deprived populations within the Greater Manchester area, the population is generally deprived (Figure 1.3).

Fig 1.3 Indices of Multiple Deprivation


Greater Manchester comparators: 7 of the 10 Greater Manchester PCTs have significantly higher levels of internal inequalities in life

expectancy than the England average, no Greater Manchester PCT has lower than average levels of internal inequalities.

The male life expectancy gap in Greater Manchester is 14.4 years, the difference between the most deprived area in Manchester PCT (68.9 years) and least deprived area in Trafford PCT (83.3 years).

The female life expectancy gap in Greater Manchester is 11.1 years, the difference between the most deprived area is Oldham PCT (74.6 years) and least deprived area is Bolton PCT (85.7 years).

This level of variance across Greater Manchester presents a significant driver within the Greater Manchester Case for Change. The identified programme outcomes are clear that all Greater Manchester residents should have greater parity of access to high quality, safe and sustainable services to impact upon health outcomes and life expectancy.

Further analysis of each Greater Manchester local authority compared to England averages in key areas shows an overall poor position for Greater Manchester (Figure 1.4).


Local Authority

Comparison to England average

General health

Deprivation Children living in poverty

Life expectancy Life expectancy gap. most and least deprived areas

Year 6 children

classed as obese

Rochdale Generally worse

Higher than average.

12,815

Lower for men and women

11.6 years lower for men. 9.9 years lower for women

20.7%

Trafford Better Lower than average

6,860

Higher for women


16.4%

Wigan Mixed Higher than average

12,110



19.3%

Tameside Generally worse

Higher than average

10,625



19.7%

Stockport Mixed Lower than average

8,605

Similar for men and women


16.5%

Salford Generally worse

Higher than average

13,125



23.1%

Oldham Generally worse

Higher than average

14,400


11.1 years lower for men 10.3 years lower for women

17.3%

Manchester Generally worse

Higher than average.

36,155



23.7%

Bury Mixed Lower than average

7,045



20.2%

Bolton Generally worse

Higher than average

13,775



21.2%

Fig 1.4 Greater Manchester Local Health Profiles compared to England Average

Source: 2012 Local Health Profiles, AHPO

Social Care

The relatively poor average health of the population of GM is not only a financial challenge to health

and social care institutions; it acts as a drag to the achievement of sustainable economic growth

objectives, and a barrier to the achievement of individual aspiration and ambition. Greater

Manchester needs more people to benefit from growth, fewer people dependent on or unnecessarily

using public services, and local services integrated around people and families and linked to quality

and safe specialised services.

Health and Social Care expenditure accounts for £6bn, or nearly one third, of public sector

expenditure in Greater Manchester. This scale of spending is unsustainable given the financial

challenges to the NHS and to local authorities in the light of demographic change and reducing

budgets. Care across institutional boundaries is often fragmented and not responsive to

patient/client choice and control. Actions are therefore required across a whole spectrum:


Prioritisation of interventions that improve health and well being and promote independence;

Increasing the capacity of the community and voluntary sector, supporting carers, and explicitly

encouraging self-care;

Prioritisation of services that seek to target and prevent unplanned use of the social care system;

Furthermore, the unsustainable model of ‘care and support’ services is based on the unaffordable

cost of admissions to residential care. The emergence of reablement and the presumption that

people can get better and be independent from service again has had clear strategic influence on the

practice of most Local Authorities. Similarly the presumption for direct payments and carer support is

about avoiding assessing for a service toward a focus on need, self-directed solutions and

independence. Local Authorities have a key wider role than social care in building stronger

communities and in supported housing as a wider and more sustainable component of healthy

lifestyles.

Mental Health and Wellbeing

Existing high levels of deprivation, the experience of the recession, higher rates of unemployment

and the changing demography indicate the potential for an increased demand upon mental health

services. Dorling (BMJ,2009) identified that para-suicide rates in young men who are unemployed

are 25 times higher than in employed young men, and a joint paper published by the Royal College of

Psychiatrists,NHS Confederation and London School of Economics (2009) noted a wide range of

effects on mental health services due to the financial recession.

The extent to which unemployment will increase as a consequence of the current economic

challenges is unclear, but it will almost certainly increase. This will bring a correlating increase in

associated social and psychiatric disorders including depression and other common mental health

disorders, risky drinking behaviours, problematic substance misuse and problems associated with

anti-social personality disorders.

Health and Wellbeing services are currently commissioned through PCTs, however this will change as

responsibility will go to Public Health leadership under Local Authority responsibility. Their approach

may change and the possibility of the greater utilisation of the 3rd sector must be considered as

many of the well being services provided do not involve clinically qualified staff. The ‘Any Qualified

Provider’ guidance re-enforces a direction of travel toward greater market and provider

development. A recently launched “Greater Manchester Health and Wellbeing Consortium” to act

on behalf of third sector organisations in order to ‘seek, secure and manage’ public sector contracts

underlines the importance of this issue for current and statutory providers in the area.

The new mental health strategy (2012) for England details the government’s expectation of parity of

esteem between mental and physical health services. Changes therefore in the scope, access

arrangements or of providing physical health services must consider and reflect on any impact on

mental health services and ensure these are mitigated, or improved.


Transport

An effective transport network is an essential catalyst to realise the potential of Greater Manchester as it connects people to places in a sustainable manner – places where they can work, study, shop, relax, and access health and public services. The social and environmental geography of Greater Manchester poses complex challenges for transportation systems challenges for transportation systems. Among the most notable challenges are:

Traffic congestion and parking difficulties; Longer commuting; Difficulties for non-motorized transport; Environmental impacts and energy consumption; Accidents and safety.

Greater Manchester as a city region has been delegated increased autonomy from central government to create innovate ways of meeting the generic challenges posed by urbanised demands on transport. Changes to health and care services will need to respond to the Greater Manchester Local Transport Plan (2011-16) and ensure that any significant changes to health and care services are fully assessed in terms of transport and access.

As a predominately urban conurbation, Greater Manchester has good road, bus and rail network (Figures 1.5, 1.6 & 1.7). Access to health and care services for patients and visitors remains a significant priority for the Healthier Together programme.

Fig 1.5: Traffic Flows (Motorways, A & B Roads)


http://www.gmltp.co.uk/

http://www.gmltp.co.uk/


Fig 1.6: Core Bus Network


Fig 1.7: Greater Manchester Metrolink and Rail Network



An understanding of why Greater Manchester’s Health and care system needs to

change

It is clear from the snap-shot introduction that the health of our population is not as good as it should be.

Greater Manchester has poorer outcomes than the England average in many areas and significant variation

across our 10 Local Authorities.

Deeper analysis taken from the Local Health Profiles (Figure 1.8) suggests that ten largest gaps in health outcomes between the most and least deprived populations within the Greater Manchester area are:

1. Liver disease Those in the most deprived areas are 8 times more likely to die prematurely than those in the least deprived areas

2. Mental health and wellbeing

Those in the most deprived areas are 6 times more likely to experience extreme anxiety and depression as those in the least deprived areas

3. Diabetes Those in the most deprived areas are 4 times more likely to die prematurely

than those in the least deprived areas

4. Quality of life Those in the most deprived areas are 3 times more likely to be experiencing

extreme pain and discomfort than those in the least deprived areas

5. Infant

mortality

Babies in the most deprived areas are 3 times more likely to die than those in

the least deprived areas

6. Coronary

heart disease

Those in the most deprived areas are 3 times more likely to die prematurely


7. Lung cancer Those in the most deprived areas are 3 times more likely to die prematurely


8. Stroke Those in the most deprived areas are 3 times more likely to die prematurely


9. Child health

and wellbeing

Those in the most deprived areas are 2.5 times more likely to die than those

in the least deprived areas

10. Accidents Those in the most deprived areas are twice as likely to die as those in the least

deprived areas

Fig 1.8: Key health inequalities identified in the Local health Profiles

Source: Local Health Profiles, April 2012, AHPO

These unjustifiable differences in health inequalities remain persistent across Greater Manchester.

There are many other indicators that can be used to highlight inequalities, however analysis related

to children; who will be using and experiencing our public services for the next generation, highlights

a powerful difference between a child currently born in Manchester and a child born in Stockport

(Figure 1.9)


Fig 1.9 Greater Manchester Local Health Profiles: Children

Source: Local Health Profiles, AHPO

As Greater Manchester’s communities change and develop, individual’s expectations of public

services are changing too. Many households have access to the internet and combined with greater

social mobility is resulting in a communication and connectivity revolution that is not isolated just to

younger people. Many people expect to access information about a service immediately and be able

to access it with convenience (i.e. after work or at the weekend) Furthermore, this information

empowerment allows our health and care providers to be reviewed and assessed against each other,

and to other industries highlighting inefficiencies or poor experiences.

The recently published British Social Attitude Survey highlights overall satisfaction with the way the

NHS across Britain runs fell by 12 percentage points from 70 per cent in 2010 to 58 per cent in 2011.

This is the biggest fall in one year since the survey began in 1983 (Figure 1.10).

Fig 1.10: How satisfied or dissatisfied would you say you are with the way in which the NHS runs nowadays.

Source: British Social Attitude Survey (2011)

http://www.kingsfund.org.uk/current_projects/bsa_survey_results_2011/satisfaction_with_the_nhs_overall/nhs_survey_overall_1.html


This high level analysis can be corroborated by local patient and representative groups who report

access to many services as fragmented and/or confusing. The combined impact of greater access to

information with growing dissatisfaction and uncertainty of how to access health and care services

highlights the current complexity of the system and lack of true integration. Many patients will

receive care from a number of organisations under the umbrella of the NHS, however will often

experience parts of the pathway that are not connected or duplicated.

As our Greater Manchester communities have changed and developed, so has our health and care

system in part response. The evolution of treatments and technology coupled with enhanced training

for doctors and nurses means that many traditional services can be provided in a very different way.

Patients are encouraged to take control of their ongoing management of certain conditions, often

receiving care in a primary or community setting. Advancements in care often means that

procedures that traditionally have meant a stay in hospital can be done more efficiently with patients

being supported in the comfort of their own home.

Health and care providers have started the integration journey that is allowing some of hospital sites

to focus more on specialist care; seeking to consolidate excellence driven by academic research and

innovative technology. Recently Greater Manchester has seen excellent results from the

reconfiguration of Stroke, Heart Attack (PPCI), Neonatal Intensive Care and Major Trauma. This allows

a more concentrated focus of doctors, nurses and support teams that are highly skilled and

undertake complex procedures on a regular basis enhancing outcomes for patients.

Greater Manchester should be established as the leading centre in the North of England for Health

research strengthened by the role of the Academic Health Science Network and the alliance with the

universities. This will provide opportunities for Greater Manchester research participation for our

patients to ensure the first breakthrough is here and the first beneficiaries are Greater Manchester

patients.


Three Key Messages to our patients and citizens

Demands on the NHS and social care are growing...

We can look forward to living longer which is great cause for celebration. But we need to plan ahead

and make sure the NHS and local services are ready for the extra demands that older people will

place on care services. Our lifestyle choices can put extra demands on the NHS, for example, poor

diet, smoking and lack of exercise are contributing to long term health problems such as diabetes and

obesity that need ongoing care and support.

Fantastic advances in medical technology and treatment mean we can do much more to treat people,

illnesses that would have been life threatening in the past are now treatable but there may be long

term consequences that need ongoing care. The mix of patients moves from being a reasonably

stable ratio of new cases to surviving patients to one where there are increasing numbers of survivors

needing appointments and ongoing care.

Expectations of the NHS are also growing; the public expect more and higher quality services.

Greater access to online material, social media forums is changing the way individual’s access

information and expect a response 24 hours a day, 7 days a week. This rise in demand expectation is

against a context of reducing resources in the public sector. The NHS and local authority services

cannot continue to do what they are currently doing and therefore must look to more ambitious

solutions to ensure all individuals have access to high quality, accessible, safe and sustainable

services for the future.

So the NHS is changing to meet these extra demands and improve the care it provides...

It is recognised that the care for people with long term health conditions and older people is best

provided outside of hospital where possible. People can be empowered to self care, with more care

services being offered within the community or in people’s own homes. The NHS and Local

Authorities are providing innovative services to keep people out of hospital where possible, or get

people home sooner if they do need to be admitted. We recognise that hospital is not always the

answer and that for many older people hospital admission can result in loss of independence or,

worse still, the risk of picking up an infection. Innovative use of new technology is allowing treatment

at home and access to GPs is being improved to avoid unnecessary use of urgent and emergency care

services.

Within our hospitals, lives are being saved by hospitals working together to provide the best possible

care. Recent changes to provide key elements of stroke care in fewer, but more specialist centres are

saving around 200 Greater Manchester residents’ lives every year. In addition, improved treatment

and rehabilitation support means that every year around an extra 300 more people are returning to

their own homes after a stroke rather than needing nursing home care.

Doctors and nurses have also developed the necessary expertise and have the technology to

undertake more and more operations that allow patients to go home on the day of their operation.

Recovery times are quicker than for more invasive procedures of the past so it is better for individuals

and the NHS. A number of hospitals are working in partnership recognising that sharing resources


including creating multi-disciplinary teams and joint medical rotas is a good first step in maximising

limited resources.

But even more change is needed.

We believe that further change is needed to respond to the sustained rise in demand, whilst striving to improve every individual’s health. There is a need to do more to prevent ill health with greater focus on empowering people to take greater responsibility for their own health. This includes leading healthy lifestyles whilst also taking responsibility as a member of their community and taking responsibility for using services appropriately.

There is a significant need to improve the support that is provided for people with long term conditions, especially individuals that have multiple conditions or co-morbidities. Too many people end up in hospital because appropriate services are not available in their community. Nationally, there are more than two million unplanned admissions for people aged over 65, which is equivalent to 68% of all emergency bed days. At any one time over 65’s use over 51,000 acute bed days in the NHS. Staff and patients agree that in many cases hospital is not the best place for these people to receive care but there are still insufficient alternative services, usually because funding is tied up supporting expensive hospital care.

The way hospital services in Greater Manchester have evolved and are currently organised, with a hospital in each borough providing a similar broad range of services, was designed to meet the needs of the last century. It is clear that this is not suited to the way in which a broad range of individuals require care. Many of the excellent developments we have seen have arisen from local interest rather than from strategic planning. This has led to variations in the range and quality of services available in different areas, resulting in inequality of access to services in different areas.

As more people receive appropriate treatment at home or in the community, those patients that do need to be admitted into hospital, especially in an emergency, are likely to have more complex needs. They are most in need of very specialist care and being assessed by a senior doctor will improve their chances of recovery. Senior doctors are not available in all specialities on site 24 hours a day, 7 days a week due to the large spread of services across Greater Manchester. This means that Greater Manchester has an inequity of provision out of hours and at weekends often leading to poorer outcomes for patients.


Exploring Variation across Greater Manchester

Health and Social Care Organisations

Secondary and Tertiary healthcare services in the Greater Manchester economy are provided by 9 NHS organisations (Fig 1.11 & 1.12):

Fig 1.11: Greater Manchester NHS Secondary Care Providers

Source: AQuA

Fig 1.12: Greater Manchester NHS Secondary and Tertiary Care Providers Map and PCT boundaries

In addition, a range of elective services are also commissioned from a number of private provider organisations.

Org Code Org Name

RBV THE CHRISTIE

RM2 UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST

RM3 SALFORD ROYAL NHS FOUNDATION TRUST

RM4 TRAFFORD HEALTHCARE NHS TRUST

RMC ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST

RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST

RRF WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST

RW3 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

RW6 PENNINE ACUTE HOSPITALS NHS TRUST

RWJ STOCKPORT NHS FOUNDATION TRUST

Org Code Org Name

NT4 BMI

NVC RAMSAY HEALTHCARE

NT3 SPIRE HEALTHCARE

NPG SPAMEDICA


The commissioning of healthcare is being reorganised from 10 PCT’s into 12 Clinical Commissioning Groups(Figure 1.13) which are currently planned to be:

Fig 1.13: Greater Manchester CCG PCTs to CCG

Source: AQuA

Finally, Social Care needs are commissioned by a number of Local Authorities including:

Fig 1.14: Greater Manchester Local Authority Social Care commissioners

Source: AQuA

There is a sophisticated and well developed system of monitoring and evaluating of all elements of

the Greater Manchester health and care system that is reported locally, regionally and nationally. A

number of key data sets can be utilised to provide a snap shot analysis of Greater Manchester

providers that further empathises the strategic need to change.

PCT

Code PCT Name

CCG

Code CCG name

5F5 SALFORD PCT --> 01G NHS Salford CCG

5F7 STOCKPORT PRIMARY CARE TRUST --> 01W NHS Stockport CCG

5HG ASHTON LEIGH AND WIGAN PCT --> 02H NHS Wigan Borough CCG

5HQ BOLTON PCT --> 00T NHS Bolton CCG

5J5 OLDHAM PRIMARY CARE TRUST --> 00Y NHS Oldham CCG

5JX BURY PRIMARY CARE TRUST --> 00V NHS Bury CCG

5LH TAMESIDE AND GLOSSOP PCT --> 01Y NHS Tameside and Glossop CCG

5NQ HEYWOOD, MIDDLETON & ROCHDALE PCT --> 01D NHS Heywood, Middleton & Rochdale CCG

5NR TRAFFORD PCT --> 02A NHS Trafford CCG

00W NHS Central Manchester CCG

01M NHS North Manchester CCG

01N NHS South Manchester CCG

5NT MANCHESTER PCT -->

Org Code Org Name

BL BOLTON

BP OLDHAM

BR SALFORD

BN MANCHESTER

BQ ROCHDALE

BS STOCKPORT

BW WIGAN

BU TRAFFORD

BT TAMESIDE

BM BURY


Mortality

Across the Greater Manchester health economy, as in the rest of the country, rates of death from

circulatory diseases, including stroke and coronary heart disease, and cancers, particularly lung have

fallen over recent years. However, despite these reductions, rates across GM health economy

remain at or above the regional and national averages. Furthermore, that gap is, in some cases

widening rather than closing as the GM health economy fails to keep pace with the reductions in

disease experienced across the rest of England

Analysis shows that across the GM health economy:

Actual and standardised mortality rates (SMR) have reduced over the last 17 years (Figure 1.15,

Figure 1.16). An SMR is a way of comparing the number of the observed deaths in a population

with the number of expected. It is expressed as a ratio of observed to expected deaths,

multiplied by 100. The England numbers all equal 100 and so are not shown.

The Greater Manchester area has a standardised mortality rate for all causes of mortality that is

at or above the England average with the exception of Trafford PCT which is slightly under. In

addition, the areas covered by Salford, Bolton, Oldham, HMR, T&G and Manchester PCTs are also

above the North West regional figures (Figure 1.16).

Age standardised data suggests that around 16000 potential years of life were lost as a result of

higher than expected all-cause mortality between 2006 and 2009 This equates to about 5300

years of life lost each year (Figure 1.17).

The rate of reduction in deaths across the GM health economy is lower than in the North West as

whole and in England (Figure 1.18).

Fig 1.15: Number of deaths, all causes, 1993-2009, all

persons aged under 75

Source: NHS Information Centre for Health and

Social Care

Fig 1.16: Standardised mortality rates, all causes, 1993-

2009, all persons aged under 75

Source: NHS Information Centre for Health and Social

Care


Fig 1.17: Potential years of life lost from all causes of mortality, Number of deaths, all causes, 2006-2009, all persons

aged under 75

Source: NHS Information Centre for Health and Social Care

Fig 1.18: % change in number of deaths, all causes, all persons, aged <75

Source: AQuA Analysis

Reducing in-hospital mortality

Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients

who died following a hospital treatment and the number that would be expected to die. The

expected number of deaths takes into account a number of factors including the average England

death figures for a given procedure and the characteristics of the patient concerned. It covers all

deaths reported of patients who were admitted to acute, non-specialist Trusts and either die while in

hospital or within 30 days of discharge. The NHS Information Centre for Health & Social care advise

that the SHMI requires careful interpretation, and should not be taken in isolation as a headline

figure of ant Trust’s performance. In their view it is best treated as a ‘smoke alarm' and when used in

conjunction with a range of measures can provide an indication of whether individual Trusts are

conforming to the national baseline of hospital-related mortality. Further analysis of Hospital

Standardised Mortality Ratios (HSMR) can be presented to enhance the overall picture for each

provider unit.

Last 10 years Last 5 years

(1999 -2009) (2005 – 2009)

GM health economy -2.03% -1.96% -1.11%

North West -2.27% -2.21% -1.30%

England -2.16% -2.14% -1.22%

Long term change

(1993 to 2009)

Year on Year % change in deaths from all causes (all persons, aged <75)


Analysis of Greater Manchester SHMI(Figure 1.19) shows that 6 of the 9 providers in GM have a high

SHMI despite their similar levels of both actual deaths and the reductions in actual death rates they

have achieved over the last 5 years.

Fig 1.19: Summary Hospital-level Mortality Indicator (SHMI), April 2010 – March 2011

Source: NHS Information Centre for Health and Social Care

Crude death rates for patients admitted on Saturdays and Sundays and for deaths on Saturdays and

Sundays are higher than on weekdays. Crude death rates (e.g. the number of deaths per day divided

by the number of discharges or admissions per day x 100) are sometimes used to assess the relative

safety and effectiveness of weekend services. It is true that these measures show higher crude death

rates at the weekend. However, it must be noted that the number and pattern of weekend

discharges and admissions is markedly different to that during the week and therefore the

denominator (number of discharges or admissions) will have a major impact on the difference in

rates.


Quality and Safety

Regular monitoring of Acute Trust quality and safety metrics highlights variability across Greater Manchester (Figure 1.20). Although a snapshot of

performance it is recognised that variance between providers should be minimised to ensure that all patients receive the expected level of care

across GM.


Fig 1.20 AQuA Acute Trust Quality Dashboard Q1 12/13

Source: AQuA Observatory


Finance and Workforce

Greater Manchester has a well established Quality Innovation Productivity and Prevention (QIPP)

programme that is seeking to ensure all resources are effectively utilised and required savings can be

reinvested to manage the increasing demand. The financial challenge within Greater Manchester

(Figure 1.21) presents one of the largest strategic drivers requiring significant change within Greater

Manchester.

Fig 1.21 NHS Greater Manchester Financial Challenge 2011-15

Source: Service Transformation PMO

A large proportion of the health and care economy relates to the employment of staff which provides the high levels of care to patients and their families. Figure 1.22 provides a breakdown of Medical, Dental, Qualified Nurses, Midwives and Health visiting staff in Greater Manchester secondary care providers.

Fig 1.22: Greater Manchester Provider Establishment

Source: AQuA


30p 20p 50p

35p

85p

25p 40p

“Status quo”

“Old success”

“New success”

Social Care Primary &

Community

Hospital

15p Joint Outcomes

It is imperative that Greater Manchester fully utilises the high skilled and trained workforce to

maximise their potential. There are positive examples of organisations starting to federate and share

workforces to respond to internal and external pressures. Furthermore, the priority by providers,

the North West Deanery and nursing schools to ensure high quality training to doctors, nurses and

midwives must be included within any reconfiguration of services.

The Greater Manchester health and care estate is a mixture of modern purpose built facilities and

inherited traditional hospital buildings that were built for the last century. Estate maintenance and

repair costs provide ongoing cost pressures, especially when seeking to provide innovative

technological solutions. It is imperative that all estate is utilised in an efficient way that maximises

the initial capital investment and subsequent running costs. Greater Manchester has started to

develop more innovative options for treatment out of core house (8am- 6pm), however there is a

significant amount of estate that could be utilised outside normal working days.

The strategic challenge for the health and care system is to change the traditional ‘Status Quo’ view

of funding the health and care system and move to a ‘New Success’ model that will ensure integrated

financial sustainability whilst allowing focus on joint outcomes.

In practice, this new approach to financial vitality should focus on new investment models for public sector organisations in Greater Manchester. Other health economies across the world have developed innovative models where joint outcomes for patient groups are shared across a series of providers with a single accountable provider (Corrigan & Laitner, 2012). This enhances the ability of providers to achieve efficiencies whilst recognising the political impact associated with changes to public sector expenditure.


Summary of Clinical Cases for Change

The Greater Manchester Case for Change seeks to provide an overview of the Greater Manchester

health and care economy whilst identifying strategic areas of change. However this document is

supported by 9 separate clinical cases for change:

Urgent and Emergency Care;

Acute Surgical Services; Emergency General Surgery; Oral and Maxillofacial Surgery; [Elective

Surgery]

Primary Care;

Acute Medicine;

Long Term Conditions: Neurosciences;

Women and Children’s;

Cancer;

Cardiovascular: Vascular; Stroke; Cardiac Imaging.

Rehabilitation

The following section provides a copy of the Executive Summary for each case for change, recognising

that the documents are at different developmental stages. A full copy of each document is available

on request.

Urgent and Emergency Care

Urgent and emergency services in Greater Manchester are facing an unprecedented challenge, to

maintain quality services within a restricted financial envelope, whilst the complexity, acuity and

quantity of urgent and emergency cases continue to increase. This is not sustainable.

Current urgent and emergency care pathways are often fragmented and complex, resulting in

confusing care journeys for the many patients experiencing them. This is resulting in many people not

understanding where and when to access urgent and emergency care. Public expectations of access

and quality of service within A&Es, coupled with increased mobility and changes to GP out-of-hours

services has further encouraged increased attendances at A&E.

Attendances at Greater Manchester A&E Departments continue to rise with over 1 million reported

last year. Over a quarter of all attendances at A&E could have been treated at another suitable

location (e.g. primary care provision). This increase in activity presents a significant financial

challenge to the wider health and care system as the population lives longer with greater needs. The

annual cost of A&E attendances alone for Greater Manchester was almost £122 million, with only 2

Trusts receiving income to cover expenditure.

There is much variation in the quality, access and outcomes for Greater Manchester patients that

access the current urgent and emergency care system. A combined increase in ambulance journeys

and delay in turnaround time at hospital is placing sustained pressure on every hospital. Waiting

times within departments have increased with patient experience deteriorating. The variance of


senior medical staff across Greater Manchester with an over reliance of training doctors is further

exacerbating the pressure on the system.

The case for change provides the first step in developing an integrated 24/7 urgent and emergency

care system, which is patient focussed, based on good clinical outcomes and a good patient

experience, and delivered right, first time, in a timely manner.

Acute Surgical Services: Emergency General Surgery

‘The delivery of emergency surgical care is currently sub-optimal. There has been a lack of

investment in, and understanding of, the risks of this type of surgery and the associated

workload. Mortality varies two-fold between units for surgical emergencies’ R. Collins, RCS

(2011a)

As providers and commissioners of emergency general surgical services, we have a responsibility for

ensuring that patients have sustainable access to the right surgeon, in the right place, at the right

time. It is widely acknowledged that there is a significant challenge in the delivery of emergency

general surgery across the UK.

Patients requiring an emergency surgical assessment or operation are among the sickest patients in

the NHS. Nationally, emergency admissions represent the largest group out of all surgical admissions

to UK hospitals and account for a disproportionately large percentage of surgical deaths. Surgical

morbidity and mortality rates for England and Wales compare unfavourably with international

results.

Presently, emergency general surgery is carried out in 10 of Greater Manchester’s hospitals, but this

service does not always have consultant staff present and admission to a critical care bed after

surgery is not routinely available. This leads to inconsistent quality of care and poorer patient

outcomes. A recent survey of consultant general surgeons found that 45% of surgeons believe that

they are not currently able to care well for their emergencies, and a further 80% described the

running of the emergency surgical list within their Trust as inefficient. This has contributed to a

variation in the delivery of emergency general surgery across Greater Manchester, in terms of activity

levels, performance and patient outcomes.

Barriers to improving poor emergency general surgery outcomes currently include the access to

required levels of diagnostics, theatre and critical care support, and workforce.

There is a clear need for change, and the case for change will provide the first step in developing a

comprehensive 24/7 emergency general surgical system based on good clinical outcomes for all

patients at the right place and right time.


Acute Surgical Services: Oral and Maxillofacial Services

In Greater Manchester, our vision for Oral and Maxillofacial surgery (OMFS) is to create a

comprehensive, local whole health system approach across care pathways to improve patients oral

health well being, health outcomes and reduce the current health inequalities.

Oral Surgery (OS) is an integral element of oral healthcare provision. As a distinctive branch of

dentistry, OS needs to be viewed separately from the specialty of Oral and Maxillofacial Surgery

(surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and

the hard and soft tissues of the oral and maxillofacial region) which is an internationally recognised

surgical specialty. In the (U.S.) (and many other countries) it is one of the nine specialties of dentistry;

however, it is also recognized as a medical specialty in the UK.

With the anticipated growth in the aging population, changes in the pattern of oral and dental

diseases and many more people retaining an increasing number of teeth throughout life, the vision

for clinical practice and underpinning science of OS and OMF surgery must continue to evolve to

improve the future needs of patients. Current care pathways are fragmented and complex, resulting

in confusing care journeys for the many patients experiencing them. There is much variation in the

quality, access and outcomes for Greater Manchester patients that access the OS and OMFS services.

To achieve the vision, we will encourage people to take greater responsibility for their own health

and promote self care and ensure highly trained professionals across the OS and OMFS pathway work

together in a cohesive team to drive economies of scale and drive up quality of care in the most

appropriate setting. We aim to improve health outcomes to deliver consistency across Greater

Manchester. We will challenge and aim to reduce the health inequalities and work across the

traditional boundaries of oral health.

There are many national drivers supporting this case which include the new commissioning of dental

services from April 2013 and recommendations for the review of OS and OMFS services nationally,

workforce and training issues, Head and neck cancer service delivery, varying provision and care

depending on where a patient attends and unsuitable equipment, staffing, activity levels and facilities

all of which adds to inconsistent and often reduced quality care for patients.

The case for change provides the first step in developing a comprehensive system, which is patient-

focussed, based on good clinical outcomes and a good patient experience, and delivered right, first

time, in a timely manner.


Primary Care

In order to support acute service redesign it is acknowledged that primary medical care will also need

significant changes. This document is the first step in describing a primary medical strategy that will

outline the changes required to meet those challenges.

Working with our partners across Greater Manchester we need to reduce the variation in primary

care so that our patients and our professional colleagues are assured that primary care is consistently

of the highest quality. Achieving the best possible clinical standards will require much more proactive

and anticipatory care, going beyond the standards set in the Quality and Outcomes Framework.

Primary care will need sufficient capacity to meet the needs of an aging population with more

complex and multiple health conditions, enabling the shift to prevention and well being and support

the delivery of care closer to home where clinically appropriate and safe. Delivery of enhanced and

extended primary care outside of current working hours, such as that required to support End of Life,

will require a different way of working and collaboration across larger populations than that served

by most GP practices.

We need a primary care system that refocuses on well being, prevention and restorative health. We

need to empower our patients to take greater responsibility for their health and promote and

support self care and management of their health, creating a population that is self –reliant and

resilient. Conversely, when in need of health care we should ensure that it is accessible and equitable

and that our patients are valued and involved in shared decision – making.

The expectations of our patients are changing. The demand placed on the NHS will continue to grow. People will increasingly expect the NHS to fit in with their lifestyle and demand the very best care. Primary care will need to respond to those demands.


Acute Medicine

Currently, our patients are not receiving the best possible care when they are admitted to hospital in

an emergency. Many hospitals fail to meet national standards for the treatment of acutely ill

patients, with patients often confused by the fragmented pathways to access appropriate care.

Acute illness is a seven day a week problem; patients are as likely to develop symptoms requiring

hospital assessment or admission during a weekend or bank holiday as they are on a week day.

Furthermore there is considerable UK and International evidence that patients admitted at weekends

are more likely to die in hospital than those admitted during weekdays. Patients deserve the same

high quality consultant-led care irrespective of the day or time of the week on which they are

admitted to hospital.

There have been significant developments in acute medicine over recent years in response to

achieving the best outcomes for patients with acute care needs, the increasing trend towards more

integrated care and the direction in moving care closer to home, the developments in medical sub-

specialisation and medical training, and compliance with the European Working Time Directive

(EWTD). The development of the sub specialty of acute medicine could pose challenges in staffing

A&E departments. Safety of patient care could be compromised where sub- specialty care is not

available.

There is increased pressure due to increasing numbers in A&E and acute medicine, there is an

increase in emergency re-admission within 2 days and there is variation in length of stay across

Greater Manchester Trusts for patients admitted as a medical emergency, including a growing

proportion of patients admitted to hospital with an ambulatory care sensitive condition who stay less

than one day.

Patients treated through an organised process of acute medical care achieve better outcomes.

Achieving a sustainable critical mass of inpatient admissions is a key driver in ensuring sustainability

of services to provide care that is safe and delivers the optimum outcomes for patients

A critical mass of admissions provides the opportunity for consultants to maintain a high level of skill

to provide safe services and provide sufficient consultant staffing and on call arrangements.

The case for change provides the first step in developing a comprehensive and integrated acute care

system, which is patient-focussed, based on good clinical outcomes and a good patient experience,

and delivered right, first time, in a timely manner.


Long Term Conditions: Neurological conditions

There are many diseases and injuries which fall under the heading of neurological conditions and up

to 10 million people in the UK are affected by such conditions. Over a number of years, the emphasis

placed on improving the care of people with neurological conditions has been relatively limited. The

National Service Framework for Long-term (Neurological) Conditions was welcomed as a way

forwards but did not deliver the anticipated improvements in care. The Government is trying to

address this through two new strategies currently under development but patient groups are

concerned that this will still not address some of the issues around complexity, specialist needs and

rehabilitation associated with neurological conditions.

Neurological conditions affect the brain, spinal cord and, or peripheral nerves and can result from

trauma or injury or internal disease processes. The numerous conditions which can be described as

neurological conditions can be grouped under four broad categories: sudden onset conditions;

intermittent and unpredictable conditions; progressive conditions, and; stable conditions.

There are a number of challenges associated with supporting people with neurological (long-term)

conditions which result from: lack of awareness; absence of national, strategic leadership; limited

integration within health services; commissioning of services in silos, and; limited integration

between health and social care services. There is also a variety of national policies and clinical

guidelines which offer support to improving services. However, the NSF is the only document which

covers the range of conditions and breadth of service delivery required to meet the needs of people

with neurological conditions.

This case for change for neurological (long-term) conditions is based on the need to: increase equity

of access to relevant neurosciences specialists and treatments; improve the accuracy of diagnosis for

neurological conditions; develop the emergency, non-elective aspect of care; avoid non-elective

admissions; increase patient safety; facilitate compliance with national guidelines for good practice;

improve patient flow through neuro-rehabilitation services; support primary care services to manage

people with neurological (long-term) conditions; integrate commissioning and provision of services;

improve consistency of patient outcomes.

The case for change provides the first step in developing a comprehensive and integrated service,

which is patient-focussed, based on good clinical outcomes and a good patient experience, and

delivered right, first time, in a timely manner.


Women & Children’s

The proposed case for major service change in Greater Manchester sits within the context of a

significant shift in NHS policy for commissioning and a focus on outcome measures as well as a

recently strengthened future role for clinical networks for delivering improvements in the quality of

services, in significant changes in the delivery of services and a reduction in unacceptable variations

of care.

In developing the case for change for women and children’s services , it is recognised that the

Making it Better (MiB) reconfiguration programme has already strengthened the safety and

sustainability of maternity and paediatric services across Greater Manchester in comparison to many

other large conurbations; responding to national challenges around workforce, meeting required

professional and service standards, introducing innovation in the form of expanding truly consultant

delivered care, centralising specialist services and expanding children’s community nursing teams to

provide care close to home. However, the proposals for the reconfiguration of secondary services

across Greater Manchester under the Healthier Together programme have provided the Maternity

and Paediatric Networks with an opportunity to consider further redesign.

This case for change has therefore considered the potential for further changes to service delivery,

responses to workforce challenges, improved use of capacity and the increased financial pressures,

but by continuing to focus on the needs of the baby, child, young person and family being at the

centre of any future clinical model. In particular, it:

Supports the evidence that pregnancy and birth is a normal physiological process in which

medical intervention is inappropriate unless it is clinically indicated and evidence-based;

Supports the development of a women’s health network, which would provide care for women

throughout their life-course; in line with recent RCOG guidance. As part of the development of

such a network, there is the potential to consolidate major gynaecology procedures on fewer

hospital sites; centralising specialist expertise to ensure that women receive high quality, safe

care;

Considers the future arrangements for the eight existing inpatient maternity units, given amongst

other things, the recommendations for consultant labour ward presence;

Considers capacity across the Greater Manchester maternity network, including the potential for

further development of co-located and stand-alone midwifery-led units;

Considers the future arrangements for the eight existing inpatient paediatric units, given the

reducing demands for admission and the drive to provide more care outside of a hospital setting;

Explores the option of paediatric inpatient units working within a federated model where

clinicians from across units form sub-specialist teams; thereby maintaining their skills through

sharing expertise, joint working arrangements and the pooling of caseloads. Examples of this

could be for diabetes care, epilepsy services and high dependency care for children;

Considers how best resources can be matched to occupancy levels, in particular, during the

summer months; and

Considers the impact that any changes to maternity or paediatrics services would have on the

Greater Manchester neonatal service model.


It will also be important to consider the conclusions of the other work streams being developed by

the Healthier Together programme, in particular primary care, urgent and emergency care and

cancer care, identifying the impact of these on the configuration of services for women and children

across Greater Manchester. This will be particularly important given the clinical inter-dependencies

of women and children’s services with other clinical services and the investment that has already

been made as part of MiB.

The case for change provides the first step in developing a comprehensive women and children’s

service, which is patient-focussed, based on good clinical outcomes and a good patient experience,



Cancer

The key issues impacting on Greater Manchester (& Cheshire) cancer services are well known to

healthcare professionals working in this area and have been highlighted in the case for change.

Although significant improvements have been made in the last decade our leaders within the Greater

Manchester (& Cheshire) healthcare system know that, in relation to health outcomes and

experience of care, we are, as a whole system falling short of our ambition to be amongst the best in

the UK and in the world.

A greater recognition is required of the importance of underpinning cancer research leading to

translational innovation and clinical trials. GM is better placed in this respect than most regions.

Some cancer services can be commissioned locally, but integrated commissioning of the majority of

cancer services, due to its complexity, needs to be at the centre of the change process. The

importance of research-focused multidisciplinary, integrated teams supporting these services has

been highlighted in this document. It therefore needs to be emphasised that planning each service in

isolation does not take into account interdependencies and often leads to unsustainable service

models.

Interdependencies and patient pathway flows between care settings need to be recognised in

developing new delivery models, to ensure relationships are strengthened and not fractured. An

integrated approach is particularly important to support the more disadvantaged groups in Greater

Manchester’s diverse population and to tackle the inequalities that exist in health and in access to

health services, including unscheduled care. Greater emphasis needs to be given to population based

approaches to prevent cancer, screen for early detection and prompt earlier presentation with

symptoms.

In the recent past we as a cancer system have placed our faith in the micro-process management of

services, strategies and policies. The Healthier Together umbrella is designed to work in partnership

with new commissioners to engage local communities and frontline clinicians – and patients and

service users themselves – to drive the improvements that we need to see and to put clinicians,

patients, service users and members of the public at the heart of decisions about their care. The

case for changing the way we commission and deliver cancer services is compelling.

The case for change provides the first step in developing a comprehensive and integrated cancer

service, which is patient-focussed, based on good clinical outcomes and a good patient experience,



Cardiovascular: Vascular

The vascular review and reconfiguration is a programme that started at the end of June 2010 in line

with other vascular service reviews across the country. The objective is to evaluate the vascular

surgical services across Greater Manchester and Eastern Cheshire in line with national standards and

guidance. The outcome is to determine how the service needs reconfiguring in order to produce

improved care and improved outcomes for patients following surgery.

There are many national drivers to reviewing vascular surgery across the region that include high

mortality rates for some groups of patients, non-vascular specialists carrying out vascular procedures,

comparatively long stays in hospital, varying provision and care depending on which hospital a

patient is admitted to and unsuitable equipment, staffing, activity levels and facilities all of which

adds to inconsistent and often reduced quality care for patients.

The review in Greater Manchester (and Eastern Cheshire) has so far established the current provision

across the conurbation and concluded that; there is not enough demand for the current number of

inpatient centres all carrying out key procedures such as Abdominal Aortic Aneurysm (AAA) and

Carotid Endarterectomy (CEA); there is insufficient 24/7 cover from vascular surgeons and

interventional radiologists in some centres; the quality of care varies from centre to centre; mortality

rates are consistent with the national average (the national average being the worst in Western

Europe) and centres currently do not have all the necessary equipment, components and access to

facilities as required by national guidance.

By early 2011 national and local guidelines were collated to form a set of quality standards that

establish what a vascular inpatient centre of the future should provide. The provider landscape was

then looked at against these standards and a set of recommendations for the future provision of

vascular services within Greater Manchester and Eastern Cheshire were produced.

These recommendations highlighted there should only be 3 inpatient centres; Royal Oldham Hospital,

Wythenshawe Hospital and Manchester Royal Infirmary until there was further evidence to suggest

the need to have just two inpatient centres. The remaining hospitals providing vascular care could

still continue to provide day-case surgery and outpatient care. It was also suggested there be two

clinical networks with hospitals working together to cover the conurbation; Wythenshawe Hospital

and Manchester Royal Infirmary working together to cover the Central and South and Royal Oldham

Hospital, North Manchester General Hospital and Tameside General Hospital working together to

cover the North and East.

Other recommendations propose; a standard approach to pre-operative clinical assessment; steps to

strengthen emergency on call rotas for both vascular surgeons and interventional radiologists;

specific equipment to be available in a number of clinical settings; networks working together to

develop consistent policies, pathways and protocols to ensure patients have equal access and the

importance of regular audits to review activity, outcomes and data quality.





Cardiovascular: Stroke

In 2007/2008, as a response to the National Stroke Strategy (DH 2007), the Greater Manchester (GM)

stroke community was the first in the UK to begin to develop plans to provide integrated stroke

services across the conurbation. This resulted in the development of an innovative ‘hub and spoke’

model – the Greater Manchester Integrated Stroke Service (GMISS) which envisaged all patients with

suspected stroke being sent to one of three specialist centres for the hyperacute period of their care.

The principles which underpinned the restructuring of stroke services were that there should be

Equal access to hyperacute and acute treatment.

The model resulted in the establishment of 3 hyperacute centres:

a 24 hour Comprehensive Stroke Centre (CSC) based at Salford Royal Hospital NHS FT and

12 hour Primary Stroke Centres (PSCs) based at Pennine Acute Hospitals NHS Trust (Fairfield

General Hospital) and Stockport NHS Foundation Trust (Stepping Hill Hospital) respectively

As stated, the original intention of the Greater Manchester Integrated [Hyperacute] Stroke Service

was that all patients with stroke should be diverted to one of these three designated hyperacute

stroke centres. However, in early 2009 the original plans were modified as a result of some concerns

around:

potentially unnecessary journeys as it was argued that to a large extent the services could be

provided by the district centres

repatriation of patients

some financial considerations (although this was not necessarily the dominant factor)

A review process, carried out in the summer and autumn of 2011 this included a 12 month review

report and the convening of an Expert Advisory Group – this found that the original aspirations of the

service had not been met as there was clear inequity evidenced by data which showed that the 1/3 of

patients attending the hyperacute centres were receiving better packages of hyperacute and acute

care. Furthermore, there was evidence of considerable variability of care amongst the district

centres. A comparison was made with London who had meanwhile adopted the Manchester concept

of a centralised Hub and Spoke model in full; London were found to be getting better results than

Manchester and it was felt that this was to a large extent due to them adopting a hyperacute service

which treated all patients with stroke.

The expert advisory group (EAG) therefore recommended that;

“the artificial 4 hour boundary [of the GM model] should be removed, and the system should not be

further de-centralised; if anything, it should be further centralised”.

The review also pointed to the relatively greater thrombolysis rates in London compared with GM.

The EAG concluded that it could well be the relative complexity of the GM model – whereby

paramedics have to make decisions regarding which centre to take the stroke patients – that could be

resulting in comparatively fewer cases receiving thrombolysis in GM.

In summary therefore, the case for change for GM stroke services in favour of greater centralisation

of GM stroke services (that is, all suspected stroke patients going to the hyperacute centres) is based


on the evidence which suggests that the 1/3 of patients accessing hyperacute services in GM are

consistently getting a higher standard of care in the crucial initials phase of their illness in comparison

with those who do not. It cannot be doubted that district centres are trying hard to meet the needs

of their patients – but the evidence suggests that centralised hyperacute stroke services help ensure

that all patients get immediate assessment and care by specialist teams resulting in consistently

higher packages of care.

The case for change provides the next step in developing a comprehensive and integrated service,




Cardiovascular: Cardiac Imaging

The North West continues to have the highest standardised cardiovascular mortality rate and faces

the greatest challenge of any health authority in England to achieve an equitable service by 2020.

Therefore, detection by cardiac imaging has to be an integral part of the pathway and considered a

high priority.

It is widely accepted that proceeding to invasive intervention (angiography) without prior non-

invasive functional imaging testing is inappropriate.

The functional imaging modalities have “the potential for directing coronary angiography more

effectively towards those patients most likely to require invasive intervention” and represent a cost

effective alternative. Therefore, the question for commissioners is the choice of modality and the

methods by which capacity can be increased.

To date, the choice of modality has been largely driven by accessibility, available expertise and a lack

of evidence to favour one modality over another. However, recently published randomised control

trials, provides evidence which creates an opportunity to develop commissioning policy based on

efficacy as well as patient benefit and cost.

The Stable Angina Pathway promotes the use of functional imaging and in particular DSE since it

represents the most cost effective functional imaging modality and does not carry a radiation burden.

The growth in functional imaging modalities has resulted in a significant reduction in angiography

with consequent savings and the future potential as a major QIPP initiative.





Rehabilitation

Rehabilitation in Greater Manchester is a core aspect of health and also of social care, but is inadequately defined either by commissioners or providers. This case for change challenges a number of assumptions that have challenged commissioning processes in the past:

Rehabilitation has been seen as an ‘add-on’, rather than as integral to healthcare

Rehabilitation’s crucial contribution to productivity has been neglected, allowing rehabilitation to be perceived as a barely affordable luxury rather than as essential.

Parts of the process (such as physiotherapy) are sometimes taken for the whole (which involves doctors, therapists, nurses and others along with patients and families)

It has been agreed across GM that rehabilitation is a “process” that required the input of multi-

disciplinary teams in hospital and community settings to ensure that progress would require the

input of many parties in the development of any strategic framework. There are significant ‘gaps and

inconsistencies’ in services across the range, and co production with Local Authorities is critical for

successful outcomes. It is felt that this case needs to focus on centralizing care where best outcomes

are delivered to ensure a specialist multidisciplinary team (MDT) delivers the best care, but not to

generalise rehabilitation care.

The incidence and resulting prevalence of conditions which give rise to the need for rehabilitation has

been shown to be highly variable across localities. This variability results from the complex

interactions of demographic, lifestyle and socio-economic circumstances. Planning for local services

across GM thus requires attention to a variety of key indicators, including baseline epidemiological

data, and clinical epidemiological data on the consequences and associated need for rehabilitation

arising from these conditions.

This compelling case for change calls for the development of a framework for rehabilitation, which is

based on the need to improve outcomes and equitable access to;

Acute Services - Prompt access to specialist assessment and treatment

Post Acute specialist In-patient service - To ensure that people achieve the best possible recovery and rehabilitation

Community Specialist Neuro-rehabilitation Services and Community non specialist services - To enable and support people to lead a full life in the community

Longer term support - To enable continuation of rehabilitation from generic community services with focus on enablement, maintaining health and independence

Out of area tertiary centre - To manage and assure access to specialist opinions required to support decision making in relation to out of area rehabilitation placements

This case for change has therefore considered the potential for further changes to service delivery of rehabilitation services, improved use of capacity and the increased financial pressures, by continuing to focus on the needs of the individual in a very complex pathway. The case for change supports;

gaining joint understanding of the present service provision for all rehabilitation across GM

strengthening commissioning objectives in the light of national & local priorities

recognising different positions of our localities and planning accordingly particularly where there is inequity


the development of a clinical rehabilitation network across GM

the consideration of the future arrangements for acute rehabilitation for Trauma and Non Trauma patients across the whole pathway from acute services to community and long term.

the consideration of capacity across GM including the potential for further development of community rehabilitation.

the integration of centralizing care where best outcomes were delivered to get a specialist MDT, but not to generalise rehabilitation care.

The case for change provides the first step in developing a comprehensive and integrated

rehabilitation service, which is patient-focussed, based on good clinical outcomes and a good patient

experience, and delivered right, first time, in a timely manner.


Conclusion

Greater Manchester is changing with vibrant communities growing with many people living longer.

However, more people are living longer with multiple long term conditions which increases the

demand on the NHS and social care services.

The Greater Manchester case for change highlights the need for a transformation our health and care

services in order to achieve our programme outcomes. The case for change illustrates a clear need to

review the current pattern of services across Greater Manchester. Redesigning services, as outlined

in all our clinical cases for change, will enable us to improve the quality of services, reduce inequality

and variance and aim to increase life expectancy within the resources available.

We need to ensure that people in Greater Manchester have access to the most appropriate care in

the most appropriate places. Higher quality and more effective treatments for patients need to be

provided more consistently, within higher quality, more efficient, safer places. Integration is crucial

within health services in partnership with local government, to ensure that patients are managed

seamlessly between care settings. All care should be of a consistently high standard, bringing better

routine treatments closer to home and supporting more services outside hospitals where

appropriate.

It is crucial that all Greater Manchester stakeholders work collectively in the Healthier Together

programme to achieve the identified outcomes. The strategic option is stark; we can either keep the

current model of care that will continue to fall behind the rest of the country and the needs of our

patients, or bravely embark upon a large scale change of our health and care system to ensure it is

designed for our current and future generations where we are healthier together.

healthier together - pat

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