You are on page 1of 31

Care Outside Hospital –

Delivering Successful

John Burton
Care Outside Hospital Team

1st November 2007

Projects that we have known
- just to tune you in….

Individually think….

• A great thing that happened once when I was in a project team

was when……
• A project I was involved in failed to achieve its objectives
• In my experience project team working goes like this…….

Then discuss on your table

This session will outline an approach for
successful project working developed following
work with seven health communities.

It will cover how to:

• Develop and run a series of workshops and reviews designed to

assist the team in progressing through the project delivery process
• Build a team with the right mix of skills and experience to
successfully design and deliver a Care Outside Hospital Project
• Support the team in using a range of tools and techniques.

But we shall start with an overview of the Care Outside

Hospital Programme

The White Paper posed a major challenge to
deliver more care in the community

“We aim to provide • Health care has traditionally been focused in

more care in more local, large acute hospitals. But:
convenient settings, – Patients expect services to be designed
including in the home.” around their needs
– Technology means activity no longer needs
to be done in hospital
– The aging population requires a greater
emphasis on supporting ongoing individual
• To deliver this vision, the NHS needs to make a
significant reorientation in the way care is
delivered, involving community-based,
responsive, adaptable, flexible services
• NHS Operating Framework 2008/09 is expected
to place renewed emphasis on the need to deliver
‘population scale’ shifts of services into the
The Department of Health
Care Closer to Home Project
30 pilots to define clinically safe pathways that provide:
• The right care in the right setting, with the right equipment
• Performed by the appropriate skilled person
Large Some Limited scope to provide additional activity in community setting

Initial appointment Diagnosis Treatment

Complex Non- Step-down Outpatient

GP/ Other Outpatients Simple tests Outpatients Day case Inpatient
tests surgical care follow-up

Evaluation published in June 2007.

• Much activity can indeed be delivered in the community
• Considerable patient benefit (access / convenience) can be secured
• Equal or better clinical outcomes can be delivered
• Activity largely additional to existing acute activity 5
Lord Darzi’s ‘once in a generation’ review – Our NHS,
Our Future – has reaffirmed the need to focus
attention on bringing care closer to home

• Focus on creating a fairer NHS

– Improving access to primary and
community care
– Making services more personal
– Integrating care through one-stop
centres and use of IT
• Clinical pathways are central to
improving services
– Local teams in each SHA
reviewing 8 key pathways
– National teams bring these local
insights together
– Several pathways linked to care
outside hospital
• Final report due in June 2008

The NHS Institute is today launching a suite of
resources designed to help the NHS nationally shift
care closer to home….

• The Opportunity Locator helps you identify many £m worth of

activity that could be shifted into the community
– Focus on the key areas for patient access and satisfaction
– Determine scope for improvements in value for money
• The Priority Selector allows you to translate your strategic vision
into operational plans that deliver ‘population-scale’ service
– Agree a balanced and realistic programme of change
– Secure ownership of the plan across the PCT, PEC and PBC
• Steps to Success dramatically improves your ability to deliver care
outside hospital projects
– Implement accelerated projects delivering greater results
– Achieve genuine improvements in services
They all fit within a cyclical process

Prioritise Opportunities lets you develop a programme
of change that brings together the best of many
potential initiatives…

The Opportunity Locator also gives you a detailed
analysis of where the greatest opportunities exist
for your PCT…

• Analysis across 7 key

– Emergency Admissions
– Intermediate Care
– Outpatients First Attendance
– Outpatient Follow Up
– Self Care
– Prevention
– Diagnostics
• Indicators can be broken down:
– Specialty
– Diagnostic
– Condition
• Access the raw data
Armed with the insights from the Opportunity
Locator, the team generates a ‘long-list’ of
initiatives broadly following the five steps

Agree Scope the Brainstorm Compile

Priority Opportunity with Local Complete
Areas of using Knowledge & Initiative
Opportunity Evidence Expertise ‘Long-List’

Once the ‘long-list’ is finalised, the Priority Selector supports you to
decide which initiatives to take forward…


14. Initiative 14

2 1
12. Initiative 12
Long List of

37. Initiative 37
Initiatives ...

1. Initiative 1 PRIORITY 2
2. Initiative 2
7. Initiative 7
3. Initiative 3

13. Initiative 13

4 3
4. Initiative 4 18. Initiative 18
5. Initiative 5 ...
6. Initiative 6
7. Initiative 7 PRIORITY 3
8. Initiative 8
9. Initiative 9 28. Initiative 28
23. Initiative 23

10. Initiative 10
45. Initiative 45
11. Initiative 11 ...
12. ...
13. ...

43. Initiative 43
8. Initiative 8

2. Initiative 2
... 
Patient Benefit Stakeholders
Clinical Benefit Buildings & Equipment
National Priority Workforce
Local Priority Service Delivery
Financial Benefit Investment Required

Finally, your Team selects a ‘medium list’ of
initiatives for further consideration…
Project Mini-Charter
Initial considerations:
Objectives & Scope
• Are there any 'must-do' Priority 1 projects?
• Are there any linked Priority 2 projects that should
be considered further?
• Are there any Priority 3 projects that should be
considered further to address localised/inequality
issues? Benefits & Outcomes

• Are there any Priority 4 projects on the cusp that

should be considered further?

Then ‘mini-charters’ are created for each

project, detailing:
• Objective and main scope
Risks & Dependencies
• Broad benefits and outcomes
• Stakeholders to engage
• Key risks & dependencies Funding Implications

• Collective funding implications

And coherent waves of projects are

identified as the agreed commissioning
The NHS Institute’s role is to provide answers to the
question ‘How can we make change happen in
practice, quickly and broadly?’
Large Some Limited

Initial Follow
Diagnosis Treatment
appointment -up

Simple Complex Non- Step-down Outpatient

GP/ Other Outpatients Outpatients Day case Inpatient
tests tests surgical care follow-up

Torbay Manchester Birmingham Torbay End-
Diagnostics Diabetes Back-pain of-life

Birmingham Derbyshire
Stour Birmingham Derbyshire Torbay Heart
Hypertension Continence COPD Diabetes End-of-life

Derbyshire Manchester Manchester

Urgent Care Urgent Care Gynaecology

• Field testing with 14 pilots across 5 health economies in 2006

• Provide insight into how to bring services closer to home successfully
Getting the Basics Right
An independent evaluation by the Health Services
Management Centre

• Challenges: • Key factors:

– Which opportunities should – Creating the right context
we take forward? – Managing projects well
– How can we make change – Engaging stakeholders and
happen? clinicians
– Overcoming barriers to
– Measuring and monitoring
– Setting stretching but realistic
timescales and ensuring
sustainability and spread

All the pilots have identified significant

service gains…

Steps to Success has five steps:

• Get Ready – establishing the right team to deliver the project and
briefing them on the process and their role within it

• Start – agreeing the scope of the project including understanding the

clinical case for change and assessing stakeholder interests

• Plan – designing the new pathway or service, including determining

benefits and setting a baseline against which to measure them, and
agreeing the business case for change

• Do – implementing the new pathway or service, based on

understanding the practical operational needs and supported by
project management tools

• Keep Going – handing over the project to “business as usual”,

the benefits, completing an end of project review, and preparing the
end-of-project report

Once you know what projects you want to take
forward, Steps to Success provides easy to grasp,
clear actions focused on shift so that the projects
achieve your goals…

The Gate Review Process

The right people need to attend
Gate Reviews
You should convene a gate review meeting between each major phase
in the project.
It is important to involve the right people in these meetings. You need people
who are knowledgeable about the project as well as senior people who can
authorise the next step to proceed.

Typical attendees at reviews for projects shifting care outside hospital include:

• Project Lead
• Clinical Lead
• Project Champion
• Organisational Senior Leader (not involved in the day-to-day activity)
• Data analyst
• Representatives of acute services
• Representatives of primary care (GPs, practice nurses etc)

Convening a gate review

Key activities for those convening a Gate Review include the


• Identifying attendees
• Giving notice of the meeting (ideally giving six weeks notice)
• Preparing and circulating the agenda and papers in advance
(including the relevant Gate criteria)
• Booking an appropriate venue
• Agreeing how the decision of the Gate Review will be reported to

An example Gate Review Report – Gate 3

Passing Through the Gate
Gate review meetings should be seen as an opportunity to report progress
against the project plan and identify any problems in an open and candid

Depending on the assessment of the project progress against the gateway

criteria, the project team have several options for moving forwards after the
gateway meeting, including:

• Moving into the next phase

• Deferring the project
• Increasing resources to address problems
• Terminating the project
• Reviewing the scope of the project or changing the approach (e.g.
reframing the problem more broadly and strategically – “one step up” – or
more operationally, at a smaller scale or in more detail – “one step down”)

Project Progress Report

Get Ready – Responsibility Charting

Responsibility charting will help you to clarify any confusion,

assumptions and misunderstandings about ‘who does what.’ It is
useful because it can:

• Make sure that someone is responsible for each task.

• Identify who needs to be given communication about each task.
• Prevent duplication of effort.

It can unearth a range of issues, including gaps in responsibility,

misunderstanding, miscommunication and areas where too many
people are given responsibility for the same thing.

Responsibility Charting
How will it help you in delivering care outside

There are two ways that this tool can help to deliver care outside hospital

1) Ensuring clarity about who is responsible for what in an operational

A lack of clarity about who is responsible for what, in an operational setting,
can waste people’s time, cause confusion and result in delays to projects.

2) Ensuring clarity about who is responsible for what in project or

change management
How often are the ‘same old things’ discussed and agreed but never taken
forward? Achieving new pathways will depend upon good project
management. You will need to be clear who is responsible for what action.

Developing a responsibility chart

1. List activities or tasks

List activities to be completed in a matrix; these become the row headings.
For example:
• Developing budgets, allocating resources
• Deciding which patient cohort to focus on
• Telling patients about what is happening.
• Giving information to patients about who to contact if there is a problem.

2. List the people involved

List all the people involved in the process, they are the table headings. They
can include:
• People directly involved in the process.
• Managers and committees who apply controls on the process.
• Other people who may impact the performance of the process.

Developing a responsibility chart - continued

3. Identify each person’s responsibility with respect to the


It is suggested that all care outside hospital projects should have the
following individuals on a team:
• A Project Lead who has the capacity and capability to take on the
• A Clinical Lead who provides valuable clinical input and can play a
crucial role in further clinical engagement
• A Project Champion who is someone of seniority that can promote
the project to both internal and external stakeholders

The key responsibilities of individuals and
groups within the project should be
communicated using a governance chart

Support for using these tools

Steps to Success User Guide - Contents

How to access these resources

• A rolling programme of release from 1 November

– Go to
– Contact us at
• Additional information and guidance
– Latest news & updates via email bulletins
– Series of webex / webcasts between November and Christmas
• Support to SHA
– LDP scene-setting sessions
– Co-producer throughout LDP period
• Additional support on cost recovery basis where wanted
• Action learning sets
• Skills development