The best of clinical pathway redesign - practical examples of delivering benefits to patients

NHS
NHS Improvement

CANCER DIAGNOSTICS HEART LUNG STROKE

NHS Improvement
The best of clinical pathway redesign
Practical examples delivering benefits to patients

CANCER
DIAGNOSTICS
HEART
LUNG
STROKE

03

The best of clinical pathway redesign - Practical
examples delivering benefits to patients

CONTENTS
04 Foreword

05 About us

06 The approach: NHS Improvement Framework
for Service Improvement

08 2010-11 achievements

10 Helping to deliver quality and productivity
improvements and sharing the learning

18 The external assessor perspective

21 The staff perspective

24 The stakeholder perspective

26 Best practice case studies
26 • Cancer
34 • Diagnostics
39 Audiology
44 • Heart
52 • Lung
58 • Stroke

www.improvement.nhs.uk

04

FOREWORD
Innovation has always been important in It is critical that we continue to innovate
the NHS – new ideas, listening and for our patients as we design the health
learning from each other and and care system of the future, ensuring
implementing what works best are at the we improve the quality of care for our
heart of many of the major steps forward patients, while making historic levels of
we have made for our patients over the financial savings to reinvest in frontline
years. services. NHS Improvement working with
and through clinical networks has been
The examples here showcase just some of proven as an effective and productive
the innovations that have enabled model and it ensures that positive
thousands of patients to enjoy better learning is spread more widely across
health and well-being thanks to practical the system.
service improvements implemented on
various clinical pathways. As we move forward, we will strengthen
and widen clinical involvement in
I urge each of you to read this report. commissioning decisions. To help
Some of its practical examples of service facilitate this I have asked Sir Bruce
improvement have also been endorsed by Keogh, who leads the NHS Medical
NICE as best practice examples on the Directorate, to work with the national Sir David Nicholson KCB CBE,
NHS Evidence website and I would like clinical directors to begin longer term Chief Executive of the NHS in England
you to ask yourselves whether you could work to strengthen our multi-disciplinary
take the learning here and replicate some networks and engage with the networks
of these achievements within your own to understand how best to improve
organisations. outcomes for patients. There is a central
role for networks in the new system as
Whether you are based in a local hospital, the place where clinicians from different
GP practice, consortia or PCT cluster, sectors come together to improve the
strategic health authority, clinical network quality of care across integrated
or within a community based setting pathways.
working with social care partners, there
are initiatives here that could help you While these examples demonstrate
deliver your own quality and productivity innovative solutions to major health
challenges. In addition, there are 200 challenges such as cancer, heart disease,
more QIPP case studies on NHS stroke and chronic respiratory conditions,
Improvement’s website that provide there is no reason why these
additional practical examples of improvements could not be applied to
implementation for health organisations other areas. That is why it is essential to
throughout England. continue the good work delivered by NHS
Improvement, the NHS and its partners –
we must take this opportunity to achieve
the best outcomes for our patients.


05

ABOUT US
NHS Improvement’s strength and expertise
lies in practical service improvement. It has • NHS Improvement was formed in
over a decade of experience in clinical April 2008, bringing together two
patient pathway redesign in cancer, existing national improvement
diagnostics, heart, lung and stroke services. programmes – the Cancer
The organisation demonstrates some of the Services Collaborative (including
most leading edge improvement work in Diagnostics) and the Heart
England which supports improved patient Improvement Programme. It also
experience and outcomes. extended its work to create a
three-year Stroke programme
Working closely with the Department of within existing resources.
Health, trusts, clinical networks, other • Its current work programme is
health sector partners, professional bodies defined through the Department
and charities, over the past year it has of Health on behalf of the NHS in
tested, implemented, sustained and spread the key policy areas of Cancer,
quantifiable improvements with over 250 Heart, Stroke, COPD and
sites across the country as well as providing Diagnostics and forms part of the
an improvement tool to over 800 GP NHS Medical Directorate led by
practices. Sir Bruce Keogh
• NHS Improvement employs 74
NHS Improvement is: staff, the majority working
• Demonstrating the practical • Having skilled expertise in full range peripatetically on a national
application of quality improvement of quality improvement tools and basis, and has a small
and service redesign with a track techniques including high level Lean administration team based in
record of delivering quantifiable and Six Sigma plus experience from Leicester. It is a relatively lean
improvement across the healthcare sector as well as organisation which ‘contracts in’
• Leading improvement work in commercial knowledge gained at most of its specialist support
primary, community, secondary and Toyota, GE, Aviva, Boots and private (e.g. IT) on an as required basis
tertiary care healthcare
• Providing clinical engagement and • Showing measurable results from
leadership by working with over 50 concept to delivery
clinical leads • Working in partnership with leading The case studies contained in this report are
• Aligning with policy direction, charities, professional bodies, Royal taken from across the clinical pathway and
providing a bridge between national Colleges and other associations are helping to deliver the objectives
strategy and local engagement and ensuring a strong alignment to contained within each of the domains. It
implementation, often through research, patient-facing organisations was only possible to feature a selection of
clinical networks and third sector work good examples from around the country,
however, there are numerous sites out there
NHS Improvement’s priorities across cancer, that could have been featured for the work
diagnostics, heart, lung and stroke have they are doing. NHS Improvement would
been aligned to domains one, two and like to thank its partners for their ongoing
three in the NHS Outcomes Framework work in improving services and bringing
2011-12. However, they could equally align benefits to patients.
to domains four and five.
Dr Janet Williamson, National Director,
NHS Improvement


06

THE APPROACH: NHS
IMPROVEMENT FRAMEWORK
FOR SERVICE IMPROVEMENT
What What & How What, How & How What & How

Define the need/ Frame ‘the story
Pilot/test Prototype
outcome objective to tell’

• Strategic alignment • Definition/proof • Test wider • Align learning for
• Scoping of principle applicability spread
• Agree approach • Test hypothesis • Proof the ‘how’ • Define what and
• Buid interest and • Identify emergent how
capability leaders • Recruit leaders
for spread

3 months scoping 12 months 12 months 3 months

CLINICAL
TEAM

SPECIALTY

SERVICES/SPECIALTIES
1 - 3 YEARS

SITE/ORGANISATION

LOCATION/REGION/CLINICAL NETWORK

WHOLE SERVICE

SPREAD

NHS Improvement applies a framework for service improvement and clinical pathway redesign to ensure a consistent and
systematic approach to its work.
The work falls into five key categories:
• Long term programmes of work to support delivery of a key national priority (Stroke Improvement Programme)
• Bespoke improvement work which is time limited (review of seven day services across England)
• Tailored support to assist delivery (working with SHAs to implement primary angioplasty)
• Establishment, development and support of clinical networks (cardiac and stroke networks)
• Advisory and development work (service improvement training for clinical and managerial staff)

It utilises the following approach as part of any service improvement work:
• Proof of principle: Piloting and testing new ways of delivering services – redesign and quality improvement (usually
12 month duration),
• Testing wider applicability of pilots: Prototyping new service models, innovations and improvements (usually 12 month duration)
• Spreading and disseminating learning and innovation more widely (two year plus duration).


The best of clinical pathway redesign - practical examples of delivering benefits to patients

08

2010-11
ACHIEVEMENTS
Working with health sector partners over the past year NHS Improvement has helped to deliver a
number of patient-centred improvements and identified many future benefits. These are just some:

Up to
1 million this has

women
removed 10m
waiting days
£10.5m
could be saved by halving the length of stay for
received cervical cancer and saved those patients having day case/one night stay
screening test results
breast surgery
within two weeks at 16
pilot sites £1.6m
Over 290,000 patients
123,000 bed days
could be saved each year if the Accelerating Stroke
now waiting less time for test results,
saving 655,940 waiting days, with up to

Improvement aim for 40% of stroke patients leaving
hospital to have access to early supported discharge
£300,000
saved at some sites
is achieved.

£45m
If every trust applied the Winning Principles
we promote, which includes: reducing length
of stay; enhanced recovery; and averting
admissions, this one initiative has the
could be saved nationally potential to reduce bed utilisation by 20%,
on home oxygen services
based on a minimum reduced
saving the NHS
spend of £600k across nine
project sites. 1m bed days


09

£1.8m £5.9m Over
could be saved per year could be saved
by increasing access to
psychological support for
stroke patients by 30%.
by giving nearly 66,000 650 health staff
Approximately
patients direct access to a have been trained to use the
tinnitus audiologist or hearing Discovery Interview™ technique

£64k
per stroke
clinical to engage with patients and
therapist
network carers

1.2m £3.25m
outpatient appointments could be saved
for cancer survivors could be over the next five years by using
released over the next five years safe risk stratified pathways for
thanks to testing on four tumour Children and Young People cancer
pathways survivors

8,000 strokes every year
could be prevented
£106m
by using the GRASP-AF detection tool. of savings
This could save could be released by working
with local hospitals to free
the NHS
£96m up avoidable bed days for
non-elective cardiac patients


10

HELPING TO DELIVER
QUALITY AND PRODUCTIVITY
IMPROVEMENTS AND SHARING
THE LEARNING
NHS Improvement’s tools and techniques, Most recently its works on developing the
combined with its expertise and experience, one day/one night stay breast surgery
could be applied to other service areas to model and computer modelling on the
support delivery of the five key domains potential impact of serum natriuretic
within the NHS Outcomes Framework peptide blood tests to GPs practices have
2011-2012 and priorities within the joined commissioning for stroke in primary
Operating Framework 2011-2012. care, and the optimal detection of Atrial
Fibrillation; Cytology 14-day standard for
It is committed to continue delivering test results and its work as part of the
quality improvements that are clinician-led enhanced recovery programme.
and patient-focused to enhance patients’
outcomes and experiences. In addition to its contributions to the
nationally-renowned NHS Evidence site,
Practical support for the delivery NHS Improvement continues to encourage
of QIPP the identification and scoping,
Delivering the Quality, Innovation, development, piloting, prototyping and
Productivity and Prevention (QIPP) challenge spread of best practice through the
successfully will be key to delivering £20bn Improvement System2 - a comprehensive
of savings across the NHS by 2015. NHS online resource to support shared learning.
Improvement’s approach to system It provides service improvement tools and
improvement aligns closely with the QIPP resources, practical guidance, case studies,
agenda QIPP and over the past year more useful contacts and signposting for further
than 200 good practice examples have been information.
identified across the country. These are now
showcased on the QIPP section of its
website www.improvement.nhs.uk/qipp

Examples can be viewed by specialty (heart,
lung, cancer, etc) or across the patient
pathway – primary care, referral, diagnosis,
treatment, aftercare and end of life care. In
addition to the case studies there is useful
information and tools and since summer
2010 the site’s pages have been viewed
over 25,000 times.

Demonstrating the
evidence
NHS Improvement’s
NHS
leading edge Evidence
improvement work
with partners across the country has been
recognised on a number of occasions
during the past year by NICE and it now
has six case studies which have been
commended on the NHS Evidence website1.

www.library.nhs.uk/qipp/SearchResults.aspx?searchText=ambulatory%20breast%20surgical%20care
1

http://system.improvement.nhs.uk/ImprovementSystem/Login.aspx?ReturnUrl=%2fImprovementsystem%2fdefault.aspx
2


11

Sharing the learning
NHS Improvement has captured the latest
learning and innovative thinking on a range
of healthcare topics and disseminated this
knowledge during the past year through a
number of channels. These have included:
• Review workshops with clinicians, cancer
survivors and representatives from a
range of NHS organisations and third
sector
• Social marketing training session for
those working in cardiac rehabilitation
• Sponsorship and facilitation of FiLM
(Frontiers in Laboratory Medicine) 2011 -
a forum where global influential leaders
address the key challenges facing
laboratory medicine
• A collaborative event jointly-led and
designed by GPs looking at the challenges
facing those working in the new
commissioning landscape
• Website which was accessed by 75,000
unique visitors last year from 140
countries
• an e-seminar on heart failure end of life useful information including personal Following successful testing the
care which attracted 100 participants and accounts from patients of their conditions trademarked ‘Discovery Interview™3’
is being explored further to help support and explanations of how work involving innovative approach is now used by a
stakeholders facing resource and financial NHS Improvement has helped improve their number of specialties in the UK health
challenges in the current climate lives. system to improve care by understanding
• Working with local, national and patient and carer experiences and by
specialist media Working with clinical networks, NHS gaining insight into their needs. They are
organisations across England and in based upon a philosophy that puts patients
Involving public and patients partnership with charities we support and carers at the centre, and values
Engaging the public and patients in its clinical teams and managers, providing listening to their experiences as a way of
activities is one of NHS Improvement’s core practical tools and techniques that gaining insight which is unavailable
principles in the way it works. It is transform, deliver and build lasting elsewhere to stimulate quality
committed to designing and delivering improvements across care pathways making improvement.
health and care services around the needs a difference to patients, services and staff in
of patients and carers and now has a new meeting the quality goals as part of the
section on its website showcasing this QIPP agenda. Most recently we have
partnership approach. The patient worked in partnership with the Stroke
experience website supports people Association to co produce Community Voice
working with patients and carers, offering events around the country designed to hear
easy to access engagement resources, the experiences of stroke survivors and
examples of good practice and links to carers.

The Discovery Interview™ technique was originally developed by the Coronary Heart Disease Collaborative in 2000
3


12

IMPROVING
CANCER CARE
NHS improvement - Cancer’s work has • Specific emergency pathways work is Priorities for 2011-2012 now include:
gained national recognition and continues focused on aligning with other continuing to support the 10 initial sites
to work closely work with its key emergency initiatives such as NHS 111 with ongoing testing and a package of
stakeholders including the Department of pathways, emergency care practitioners, evidence by October 2011; supporting the
Health and other members of the Cancer spread of tried and tested innovations four prototype sites to present evidence of
programme team, cancer networks, such as communication alerts, promoting four proposed models of care being tested
charities, local organisations and clinical acute oncology models and preventing and defining the quality key indicators that
teams. It is also liaising more closely with unnecessary readmissions need to be in place within services to
social care organisations and professional provide effective care of patients within all
colleges to further enhance outcomes for Adult Survivorship aims to improve the levels of after care. NHS Improvement is also
patients. outcomes for adults living with and beyond working towards providing evidence of a
cancer. Over the past year it has completed 20% reduction in CYP cancer survivorship
Integral to the Improving Cancer Outcomes the pilot phase of testing elements of the hospital-based outpatient appointments
Strategy (2011), NHS Improvement’s work care pathway, which are summarised in the (those patients already routinely followed
includes Transforming Inpatient Care, across case study section. Over the next year it will up) and achieving the goal that 100% CYP
elective and emergency care, Living with work with 13 tumour projects in breast, survivors have a treatment summary and
and Beyond Cancer (Survivorship) for Adults prostate, lung and colorectal cancer across care plan.
and Children and Young People, seven communities in England to test risk

“
stratified pathways of care based on the
Transforming Inpatient Care promotes the individual needs to:
spread and adoption of the four winning
principles (one: unscheduled (emergency) • Improve the patient experience and Our aspiration is that England
patients should be assessed prior to the reported outcomes of care
decision to admit. Emergency admission • Reduce outpatient attendances by 50%
should achieve cancer outcomes
should be the exception not the norm; two: • Reduce avoidable admissions by 10% which are comparable with the
all patients should be on a defined inpatient best in the world. However, the
pathways based on their tumour type and All patients will be offered an assessment
reasons for admission; three: clinical and care plan at key stages of their
changes required to deliver on
decisions should be made on a daily basis to pathways. this aspiration are complex and
promote proactive case management and will take time. However, I am
four: patient and carers need to know The enabling projects which are testing
about their condition and symptoms to remote monitoring and care coordination
confident that we are moving in
encourage self-management and to know will support the effective delivery of the right direction and will see
who to contact when needed. Tried and supported self managed care. more of the positive results that
tested models of care include:
In the Children and Young People (CYP)
have already been achieved by
• Day case/one night stay for major Survivorship workstream there has been NHS Improvement. Working with
breast surgery tangible progress since September 2010. a range of NHS partners,
• Approaches to reduce avoidable The initial 10 CYP tests sites have continued
emergency admissions and reducing evaluating and testing models of care,
national charities and patients,
lengths of stay for those who do need identifying proposed models of follow up they have delivered improved
to be admitted as emergencies care, and other non clinical initiatives to outcomes in some key areas. But
• Supporting the spread and adoption of support CYP cancer survivors. Achievements
enhanced recovery approaches across have included four existing sites moving
we can and we must go much
colorectal, gynaecology urology and into prototyping phase; defining further if we are to achieve the
musculoskeletal. The DH Enhanced measurable outcomes; developing after care levels of ambition for cancer
Recovery Partnership Programme ended pathways with clinicians, commissioners,

”
March 2011 but this partnership work patients and local teams and a patient
patients.
continues to support implementation experience workshop held with test sites
Professor Sir Mike Richards (CBE), National
within Transforming Inpatient Care and Teenage Cancer Trust. Clinical Director for Cancer and End of Life Care

www.improvement.nhs.uk/cancer

13

IMPROVING
DIAGNOSTICS
In areas such as cytology, pathology and
radiology, NHS Improvement has been
working with teams nationwide to
re-design services, focusing on efficiency
and quality.
“
NHS Improvement provides a
wealth of information and
support to imaging services
across England. Service
In cytology, it has used Lean methodology
improvement changes promoted
to support the new Vital Sign that all and delivered by NHS
women have their screening test results Improvement working with
within two weeks. At 16 pilot sites, this has
benefitted one million women, removed 10
imaging departments have
million waiting days and saved £1.6 million played a large part in the
(around £100,000 per site). reduction in waiting times for
In histopathology, NHS Improvement has
imaging services seen in recent
been working with nine pilot sites, aiming years. The implementation of
for 95% turnaround results in seven days, Lean methodology to radiology
with half of those sites processing tests
within three days. 290,000 patients are now
services has delivered massive
waiting less time for test results saving improvements for patients and
655,940 waiting days with up to £300,000 also for the staff working in
saved at some sites (extrapolating this
across England could deliver £3.375 million
these departments. NHS
savings). Improvement is seen as a beacon
of excellence in service delivery
In radiology, NHS Improvement has been
working to reduce waiting times and
both nationally and
internationally.

”
working towards creating a ‘no wait’
imaging service. The radiology team is
continuing to support the National Stroke Dr Erika Denton,
Strategy and contributing to the National Clinical Director for Imaging
Accelerated Stroke Improvement
initiative.

A programme of clinically-led SHA imaging
events and local site visits is helping to take
this work forward. The new radiology work
focusses on interventional radiology and
early diagnosis to support the Improving
Outcomes: A Strategy for Cancer (2011).
“
I have been extremely impressed with the work of NHS Improvement
and the contribution they have made to the diagnostics agenda,
particularly their work on pathology. Improving turnaround times for
histopathology and cytology is a vital step in the wider cancer
agenda and the evidence shows that this will have enormously
positive effects on patients and trusts alike. Phlebotomy is one of the
main ways in which patients experience pathology testing first hand
and so dramatically improving that experience - through reduced
waiting times and a more streamlined service - will have a profound

”
effect upon a huge number of people.
Dr Ian Barnes, National Clinical Director for Pathology

www.improvement.nhs.uk/diagnostics

14

IMPROVING
DIAGNOSTICS -
AUDIOLOGY
NHS Improvement has worked in
partnership with the Department of Health
National Audiology Programme since July
2008 supporting service improvements
across England. Assisting 12 challenged
sites to reduce waiting times for patients
and later 18 sites to improve the quality of
patient experience, four key winning
principles were identified and tested:

• Direct access
• One-stop clinics
• Care closer to home – community services
• Developing protocols for patients with
complex hearing problems

Amidst economic adversity and the
challenges posed by times of change in the
NHS, these teams rose to the challenge of
developing their services and delivering
successful projects that will influence the
future practice of audiology services across
England.
Emerging learning from the pilot and Society (NDCS), the Royal National Institute
Central to their philosophy was a prototype sites was shared via strategic for the Deaf (now Action on Hearing Loss)
multidisciplinary approach where health authority clinical lead networks, as and the British Tinnitus Society Association
consultants, clinicians, scientists, managerial well as through presentations and (BTA) to gain support and input for the
and administrative staff worked together to workshops such as the British Academy of improvement work.
deliver truly patient focussed services – Audiologists (BAA) and via an audiology
across primary and secondary care. e-bulletin subscribed to by nearly 300 Essentially these are proactive teams.
interested stakeholders. Strong partnerships Clearly, these are leading departments.
Fostering the right project approach was were forged with third sector partners More importantly, patients are benefiting.
key to planning, implementation and including the National Deaf Children’s
developing the new services. The audiology
pilot and prototype sites have proved they

“
are the epitome of today’s forward thinking
NHS staff.

Crucially, these teams are keen to share These pilot sites, working with NHS Improvement have applied Lean
their learning. Their onward aim is to principles to demonstrate how improvements can be made across
embed the approach that has been
achieved locally and the national goal is
the pathway that will change the way audiology services should be
delivered in the future.

”
adoption and replication across the country.

Professor Sue Hill,
Chief Scientific Officer, Department of Health

www.improvement.nhs.uk/audiology

15

IMPROVING
HEART CARE
Heart disease is still the second biggest
cause of death in England despite huge
progress and reductions in mortality and
morbidity since the publication of the
National Service Framework for Coronary
Heart Disease in 2000.

NHS Improvement – Heart, continues to
build on its excellent record of improvement
work across the cardiac agenda over the
past 10 years.

The current work programme is tackling a
variety of contemporary issues which span
the cardiac patient pathway including:
preventing strokes caused by atrial
fibrillation; improving efficiency in using
hospital beds in acute cardiology and
cardiac surgery; pioneering a new way of
commissioning cardiac rehabilitation and
improving efficiency and quality across the
heart failure pathway from early diagnosis
to end of life.

NHS Improvement has worked alongside The work is promoted through a range of
Department of Health colleagues to support publications, presentations on national and
delivery of national priorities such as the international platforms, e-seminars and
implementation of primary angioplasty for more recently as a publishing partner for
treatment of heart attack and jointly on the the NICE Quality Standards on chronic
development of a Commissioning Pack for heart failure.
Cardiac Rehabilitation.

The programme provides ongoing support
to cardiac networks across England, as they
continue to be a key resource in the delivery
of local improvements to services through
work with commissioners and providers of
cardiac care.
“
Service improvement does not happen spontaneously. It requires
organisation, leadership and a great deal of hard work. This is what
NHS Improvement has provided in spades over the years. Their
industry and commitment have been consistent levers for change
Collaborating with charities and over the years working with the local delivery mechanisms and the
professional bodies has always been an
important part of NHS Improvement’s work
28 cardiac networks.
and recent examples include an awareness
campaign with the Stroke Association and I would like to thank every one of them for their outstanding efforts
the Arrhythmia Alliance and also developed and their determination to extend healthy life and reduce suffering in
a cardiac rehabilitation resource and

”
partnership working on end of life care in
our population.
heart failure with the British Heart
Professor Sir Roger Boyle,
Foundation.
National Director for Heart Disease and Stroke, Department of Health

www.improvement.nhs.uk/heart

16

IMPROVING
RESPIRATORY
CARE
As one of NHS Improvement’s newer
programmes, 2010 saw completion of NHS
Improvement – Lung’s first full 12 months.
During this time the team worked with
stakeholders across the country in
contributing to the Department of Health’s
consultation on the national Chronic
publication of emerging learning, examples
and key measurable improvement principles
and approaches.

Through developing new and sustainable
models of care, using capacity differently,
reducing variations, and focussing on the
“
People who are training Olympic
teams at the moment will be
focusing on even very small
components of their team and how
Obstructive Pulmonary Disease (COPD) implementation of good practice, the team they can improve to ensure that
strategy. is aiming to: they will win a medal rather than
going out in the heats. That’s what
In addition, the team linked up with the • Reduce overall spend on home oxygen
British Thoracic Society, Primary Care services and prescriptions every single clinical team needs to
Respiratory Society (PCRS) UK, Asthma UK • Reduce avoidable unscheduled be doing, making the outcomes for
and the British Lung Foundation, admissions by 20% patients amongst the best in the
established a web presence and launched • Reduce the length of stay by 25%
the Lung Improvement News e-bulletin, • Reduce readmissions within 30 days by
world. On the NHS Improvement -
which now has over 1,200 subscribers. 20% Lung web pages there is a whole
• Increase patient satisfaction, experience host of resources, the result of 10
The programme has continued to support and outcomes years experience - which can be
the SHA Respiratory Clinical Leads and help
guide clinical network and community of Priorities for 2011-2012 include further used to help clinicians at a local

”
practice development across the country. In development of respiratory networks as level understand and improve.
addition, the website contains over 70 vehicles to spread good practice and
examples of good practice alongside other improve the access of data, and establish Professor Sue Hill, Joint National Clinical
resources, case studies, tools and practical high quality and cost effective commissioning Director for the Respiratory Programme
suggestions to guide improvement activities pathways with the new GP consortia.
in clinical teams and organisations.
Its work going forward will continue to
It has also provided direct support to over concentrate on six core areas of care, which
40 COPD and asthma national improvement are aligned to the NHS Outcomes
projects and trained a number of staff in Framework 2011-2012, domains and QIPP
project management and improvement workstreams. The six areas are: early
methodologies and approaches. As the accurate diagnosis, improving oxygen
COPD projects come to the end of the services, transforming acute care, chronic
testing phase of work, the results have seen care and self-management-models, end of
demonstrable improvements as well as the life care and asthma.

“ NHS Improvement is a collection of clinicians and experts in improvement science that help to
translate a clinical vision into a sustainable service improvement. They have been invaluable in
lung work in actually helping clinicians realise their ambitions and vision in terms of quality

”
improvement and improving clinical effectiveness, patient experience and patient safety.
Dr Robert Winter, Joint National Clinical Director for the Respiratory Programme

www.improvement.nhs.uk/lung

17

IMPROVING
STROKE CARE
The role of NHS Improvement - Stroke was
set out very clearly in the National Stroke
Strategy (2007) as supporting its
implementation and establishing clinical
networks in stroke care.

A system of Stroke Care Networks, covering
“
There has been a revolution in the improvement of quality stroke
care in recent years, and the work of the stroke networks and NHS
Improvement has been at its centre. In particular, great progress has
been made in raising public and professional awareness and in
all services in England, was completed in delivering comprehensive specialist acute stroke care. NHS
2009 when they were audited against
strategy specifications. Since then, NHS
Improvement will continue to guide and inform the work priorities
Improvement has continued to guide and in the stroke networks to address these areas in a timely, effective

”
develop networks, providing coordination and productive fashion.
and support for local improvement activities
and links to national initiatives. Damian Jenkinson, National Clinical Lead, NHS Improvement - Stroke and Consultant Stroke
Physician, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
Four years on from the strategy its role
remains as crucial, leading on the
Accelerating Stroke Improvement initiative -
launched by the Department of Health in In addition, the NHS Improvement website
response to the National Audit Office’s contains over 200 examples of stroke good
(NAO) report on stroke services. The NAO practice alongside other resources, case
noted the importance of NHS Improvement studies, tools and practical suggestions to
and Stroke Care Networks in improving guide improvement activities in clinical
services for people affected by stroke and teams and organisations. The most recent
called for further work to build on the addition - the Community Stroke Resource
progress in service development. page - is a comprehensive collection of
material including evidence from literature
NHS Improvement is also working closely and research, business cases, presentations
with the Care Quality Commission to drive and documentation to show how to
service improvements identified in its 2011 develop community stroke services.
report ‘Supporting life after stroke’. This
includes leading the drive to ensure that New developments include joint ventures
focus on improving outcomes extends to with two major stroke charities - The Stroke
the whole stroke care pathway, including Association and Connect - to improve
community services, nursing homes and stroke survivors’ experience in post-hospital
social care. care and develop practical tools to ensure
patients with aphasia can fully participate in
On the ground, it has also provided direct the planning, delivery and evaluation of
support to over 40 stroke projects, resulting their care.
in demonstrable improvements in clinical
outcomes and patient experience as well as Priorities for 2011-2012 include guiding Accelerating Stroke Improvement initiative,
the publication of learning, examples and stroke care networks through the transition aiming to ensure effective service
key development principles which have to new commissioning arrangements and development along the whole stroke
been subsequently used nationally to guide supporting their role in developing pathway pathway throughout England.
service improvement. commissioning for stroke patients within
the new GP consortia. NHS Improvement -
Stroke will continue to lead the

www.improvement.nhs.uk/stroke

18

THE
EXTERNAL
ASSESSOR
PERSPECTIVE
NHS Improvement was formed as a result of Diagnostics work programmes. It also Tribal did identify some areas where NHS
the Hosted Services Review (November reviewed existing literature and empirical Improvement could strengthen its offer to
2007). The review endorsed the evidence, conducting interviews with 26 the NHS. These included: ensuring systems
continuation of work delivered by the people and facilitating discussion workshops and processes demonstrate return on
Cancer Services Collaborative ‘Improvement between April and July 2010. investment; supporting and developing staff
Partnership’ and the Heart Improvement so they can maximise their contributions
Programme and requested that they be In summarising their findings, Tribal said and promoting its profile and identity with
integrated and extended to include other NHS Improvement had a “catalytic” role in stakeholders.
clinical specialties such as stroke. The bringing about improvements to outcomes.
objectives were to: share learning across It recognised the organisation’s importance Work to address some of these areas had
clinical specialties, increase impact and in disseminating best practice through already begun before Tribal’s final report
show value for money. clinical networks and other stakeholders - however, the external assessment has acted
using a range of channels such as its as a catalyst to accelerate this.
NHS Improvement was asked to deliver this publications, events and online support.
agenda by having: Tribal further argued that NHS Improvement In terms of ensuring our systems and
• A clear programme of work aligned to was “well positioned” to provide a processes can demonstrate return on
national priorities with measurable coordinated whole NHS system approach to investment, NHS Improvement has
outcomes healthcare improvement. developed three key systems that make best
• A focus on the delivery of high quality use of its knowledge and information and
improvements based on latest evidence According to Tribal: “Good value for demonstrate the impact its making across
based practices money can be demonstrated by the the full range of specialties – they are the
• Clinically led and patient focussed relationship between costs and website, NHS Improvement System
workstreams benefits. Our evaluation uncovered (available through the website), and new
• A close working relationship with other substantial benefits from the work of Performance System.
national organisations, stakeholders and NHS Improvement, even if not all of
professional organisations these can be measured. There are some The Performance System is central in
• Robust monitoring and performance projects which do have very evidencing the outcomes of its work,
measurable results, for example, the gathering information in a number of vital
To determine just how effective NHS faster access to diagnostics (cytology), areas such as patient experience,
Improvement has been since its creation, saving bed days (23 hour breast cancer productivity and efficiency gains and the
an external evaluation was commissioned. model), and primary angioplasty unit resources allocated. Using real-time data
Tribal Consulting carried out a robust, admission (PPCI roll out programme).” dashboards, it allows information to be
independent assessment and produced its qualified, quantified and aggregated in
findings in September 2010. The report concludes by saying: “...It is our order to demonstrate value for money,
considered view that NHS Improvement impact and return on investment against
Tribal based its work on a series of does represent value for money, QIPP. These data dashboards mean that NHS
questions: “Has the work of NHS playing a critical role in the Improvement staff can even drill down to
Improvement led to an improved quality of development, testing and roll-out of individual project sites - who are contracted
services? Does it continue to do so? Does it clinical improvements. Due to the to provide baseline information, monthly
represent good value for money?” ‘behind the scenes’ role that it often monitoring data and case studies - and
takes, especially when clinical evaluate performance against the project
Reviewing both ‘what we do’ and ‘how we improvements may have many milestones and identify any risks.
do it’, the consultants looked at NHS stakeholders and participants, it is easy
Improvement’s identity, value creation and to underestimate the relative impact
operational factors. They evaluated case and importance of NHS Improvement.”
studies from the Heart, Stroke, Cancer and


19

The great advantage of the Performance
System is that it is integrated with the NHS
Improvement System and website, providing
a seamless flow of information.
Stakeholders working with NHS
Improvement will be able to access the
Improvement System. This provides a
comprehensive online resource developed
to support every stage of an improvement
initiative, including initial scoping; project
management; reporting; case study
development and ultimately sharing the
outputs and outcomes with the wider NHS.

“
IDENTITY
Visible leadership and a mentoring
approach were demonstrated by
NHS Improvement in various
VALUE CREATION
Its ability to engage with key
stakeholders, the strength and
value of NHS Improvement’s
NHS Improvement’s knowledge and
understanding of the NHS context
was seen as a major asset.
Respondents noted that this
implementation programmes. connections, an ability to bring included both practical and
people together around a common theoretical knowledge – of key
NHS Improvement, to our agenda of improvement, and clinical areas, of the health service
knowledge, is unique in employing working in partnership with system and of the challenges faced
(on a part-time basis) a variety of charities and voluntary by NHS staff.
clinicians (consultants, GPs, nurses, organisations, as well as the NHS.
physiotherapists, ambulance staff NHS Improvement is a learning and
etc) who are chosen because of BUSINESS APPROACH teaching organisation with strong
their expertise and standing in the NHS Improvement has a strong commitment to improvement. It is
areas which the programmes are focus on aligning its planning to successful in terms of helping the
concentrating... as a consequence the strategic priorities of the NHS to focus on meeting the
of this background, all of them have Department of Health... at the national priorities, sharing
major national ‘street credibility’. organisational level, measures to knowledge and developing
evaluate the performance of the networks and relationships.
NHS Improvement staff appeared to organisation and individual
have a common set of beliefs and
values and work towards a
common objective of sharing
learning, increasing impact and
bringing tangible improvements in
the delivery of NHS services.
projects have been introduced
and aligned to QIPP.
”

20

How NHS Improvement has As a result of Tribal’s review, NHS In response, it has revamped its
responded to the Tribal report Improvement intends to re-affirm its communications strategy in order to better
commitment to supporting staff in a manage its brand and raise its positive
Supporting and developing its staff so number of areas including: profile so key stakeholders are better placed
they can maximise their contributions to know who NHS Improvement is, what it
NHS Improvement has run its ‘Valuing Staff’ • Sharing and learning between stands for and how it can help them. It will
initiative for three years and conducted two workstreams encourage feedback from its wide range of
staff surveys during that period to assess • Increasing use of IT solutions to support stakeholders to ensure what it offers and
how well it is doing. ‘Valuing Staff’ aims to virtual working how it is communicated is well-timed and
make sure that it provides personal • Ensuring a healthy work/life balance well-targeted.
development opportunities, improves • Introducing an anonymous questions
working between programmes, develops and answers facility to pose questions In the last year around 75,000 unique
more effective team working, and creates a to the national director as well as an visitors from 140 countries visited NHS
more supportive/ listening environment. As online forum Improvement’s website and there were
part of the initiative, 10 working principles • Maintaining the programme of monthly more than 350,000 page visits. Our
have been agreed to ensure that staff are National Team meetings to allow website was refreshed to include a new
valued and developed and a training contributions to future planning, QIPP section featuring more than 200 case
programme supporting business priorities knowledge sharing and networking studies from across both our specialty
funded. This has included: programmes and all parts of the patient
A member of NHS Improvement’s executive pathway. The site also links to our highly
• Statutory/mandatory training from the team is leading this work. Planning includes commended case study examples on the
NHS Core Learning Unit a funded training and development NHS Evidence website.
• A programme of service improvement programme which will encompass specific
training days/events for all staff skills, training opportunities and a broader Nearly 9,000 people have subscribed to
• Development days focused on team focus on career development in the NHS Improvement’s range of e-bulletins to
development changing health landscape. A two day receive news about best practice in their
• Attendance at courses and conferences workshop will be held in September 2011 particular field of interest as well as national
and ad hoc events with a focus on preparing for the future. guidance, latest news and information
about learning events and workshops. The
Other means of supporting staff to fulfil Promoting its profile and identity with organisation also showcased its services and
their demanding national roles have stakeholders achievements over the past year, reaching
included a practical focus on using new and thousands of people from across the health
emerging technologies to enhance The Tribal report stated that NHS sector and beyond through appearing at
communication and reduce avoidable Improvement: “In common with similar over 100 events and producing over 25
travelling. Notable examples include the bodies has been formed from the publications which help to further share and
increased use of teleconferencing and web amalgamation of previous programmes, embed best practice.
conferencing. The results of the latest staff following a review. As such, the exact
survey are shown in the following section nature of NHS Improvement is not
‘How our staff see us’. always immediately apparent to the
outside, and an improved market
profile is one of the recommended
outcomes of this evaluation.”


21

THE
STAFF
PERSPECTIVE
In 2008, an initial staff survey was carried
out to assess their views on life in the
workplace, what support they required to
perform more effectively, where progress
was being made and to identify potential
future improvements. This was repeated in
2010, with some identical questions for
comparison but also additional questions,
reflecting the new world and its challenges,
to establish what it was like.

The 2010 survey was completed by 51 staff
(a response rate of 74%). In summary, the
feedback was very encouraging, despite the
climate of uncertainty within the NHS and
wider public sector.

More than 80% of staff agreed or strongly
agreed that they understood the scope and
direction of work covered by their
workstream and NHS Improvement as a
whole. A total of 84% of staff said they felt
supported in forging strong working
relationships with their team and line
manager – a 22% increase on the previous
survey findings. More staff were receiving More than 72% of staff wished to take The survey revealed positive themes
inductions than in 2008 and these were advantage of additional training and around opportunities, relationships,
helping to provide reassurance of expected development in order to fulfil their roles communication, organisation and
performance. while 86% of staff said their line manager leadership, induction, training and
was genuinely concerned about their well- development, and work/life balance. This
Staff indicated they have freedom to act being – a similar result to 2008. will be used to further develop the role of
with 80% saying ‘I have an opportunity to line managers, explore training
do what I do best as part of my job’ – a A total of 72% of staff also felt there were
opportunities and build staff views into
similar result to 2008. While staff generally opportunities to discuss work issues with
future corporate plans.
acknowledged that the pace and volume of colleagues in other workstreams. Staff said
work has increased, 84% also recognised in general they felt empowered to
Direct comparisons between NHS
that support was provided to maintain an contribute to discussions regarding the
Improvement’s survey and the annual
appropriate work/life balance. future of their workstream (90% agreed or
national NHS survey are slightly difficult due
strongly agreed) and NHS Improvement as a
to different methodologies, however the
whole (64%).
general comparison is favourable.


22

According to a review of staff survey results
across the NHS for 2009 produced by the
Care Quality Commission (CQC) , 58% of
staff felt that they had adequate materials,
supplies and equipment to do their work,
“
The passion, energy and
motivation of NHS
Improvement’s staff were
commented on. Employees are
whereas the figure was 90% for NHS
Improvement.
drawn from a range of
backgrounds and professions;
In the national NHS survey (which covered however they appear united in
all 388 NHS trusts in England), just over
two-thirds of respondents said they had
their passion for improving the
clear objectives, but in answer to a similar health service. This was seen as
themed question, 84% of NHS an important asset, both to
Improvement staff said ‘I know exactly what
is expected of me in my work in NHS
inspire and energise the NHS
Improvement’. organisations they work with
and to sustain NHS Improvement
The national picture is that more than half
of all staff (57%) said they knew how their
staff in what can often be
challenging work.

”
role contributes to what their trust was
trying to achieve. The NHS Improvement
position is that 64% agreed or strongly Tribal Report, September 2010
agreed that ‘I feel empowered to contribute
to discussions regarding the future direction
of NHS Improvement’.

The national NHS survey found 63% of staff
felt they had frequent opportunities to
show initiative in their role, whereas 92% of
colleagues in NHS Improvement said ‘I have
some say over the way that I work’.


24

THE
STAKEHOLDER
PERSPECTIVE
NHS Improvement’s work can only be These results were broadly in line with other In a census of cancer networks carried out
successfully progressed in partnership with pieces of research carried out on a national by the National Audit Office in 2010, 89%
varied interest groups (clinicians, front line scale which involved consideration of NHS of respondents were ‘aware of’ and ‘had
staff, managers, policy-makers, charities, Improvement. A primary care trust census used’ NHS Improvement as an information
professional associations, carers and carried out by the National Audit Office in source whereas 11% were ‘aware’ but had
patients). 2010 showed 69% of respondents were ‘not used’ it. These figures compare
‘aware of’ and ‘had used’ NHS favourably with other national programmes
In order to better understand how NHS Improvement as an information source. and centres within the NHS. The census
Improvement is viewed by its stakeholders, revealed that 15% had found NHS
to improve its working relationships and Nearly a quarter of those polled were aware Improvement ‘very useful’ as an information
enhance its communication channels, of but had ‘not used’ the organisation while source, in this case we were behind the top
research was conducted at a number of 8% were ‘not aware’ of NHS Improvement. three of NICE guidance, Improving
events between November 2010 and June Their census found 52% of respondents Outcomes guidance and the National
2011 which involved nearly 500 had found NHS Improvement ‘very useful’ Cancer Intelligence Network. A further 69%
participants. as an information source (only topped by in their census stated they had found us
Hospital Episode Statistics and Improving ‘fairly useful’.
The overwhelming majority of survey Outcomes guidance results) and 42% said it
respondents viewed NHS Improvement’s was a ‘useful’ source.
contribution as positive – with 56% saying
its work was ‘good’ and a further 29%
saying it was ‘very good’. A similar response
was received in judging how effective
people saw NHS Improvement as an
organisation with 51% saying good and
26% saying very good.

The stakeholder research did indicate that
its reputation was seen as overwhelmingly
positive – 24% said it was ‘very good’, 48%
said was ‘good’, 26% were ‘not sure’ and
2% said ‘poor’.


25

Elsewhere, there has been support for NHS
Improvement’s work in an Ipsos MORI
review of the Coronary Heart Disease
National Service Framework. Their report
said national improvement teams
/improvement agencies “played a
fundamental role in supporting service
design and developing networks but were
much less at the forefront of most people’s
minds.”

NHS Improvement - Stroke worked with the
National Audit Office during production of
the 2010 report ‘Progress in Improving
Stroke Care’ and also cooperated with the
NAO to create an addendum to ‘Progress In
Improving Stroke Care: A Good Practice
Guide’. Similarly, the Care Quality
Commission 2010 report ‘Stroke services:
National report’ highlights the work of NHS
Improvement and directs those seeking
advice and information on improving
services to our resources.

The National Audit Office also in its recent
report ‘Managing high value capital
equipment in the NHS in England’ drew on
good practice identified by NHS
Improvement including case study evidence
and recommended that Trusts make use of
its work to improve their management of
high value equipment (MRIs, CT scanners
and linac machines for cancer treatment).


26

CANCER
IMPROVEMENT
Providing long term follow-up for all
childhood cancer survivors in a hospital
setting is not viable or appropriate in the
future given the exponential increase in the
number of cancer survivors.

The Children and Young People (CYP)
workstream, working with clinicians,
commissioners, patients and local teams,
has developed national safe risk stratified
pathways that identify how follow up for
children and young people can be delivered
in line with current pressures and
aspirations.
Helping youngsters The pathways form the basis of the
cope with cancer models of care now being tested by the
four prototype sites. The principles
emerging from the testing emphasise the
Strategic overview importance of:
Today more than 1.6 million people living in • Patient choice and being responsive to • Managing transition between paediatric,
England have had a diagnosis of cancer4 individual, clinical, psychosocial and young adult and adult services
and with an ageing population this is likely practical needs • All after care services need to be cost
to increase significantly in future years. The • Providing patients with treatment effective and delivered by the appropriate
Improving Outcomes - A Strategy for summary and care plan health care professional to ensure the
Cancer publication5 (January 2011) sets out • Stratify risk and signposting patients to best use of skill mix and resources
plans to drive up England's cancer survival these appropriate and tailored pathways
rates so that they match the best in Europe, • Providing differing levels of care and Patients have been involved in shaping and
saving an extra 5,000 lives every year by support based on risk assessment developing these pathways of care with an
2014-15. But as Professor Sir Mike Richards, • Effective coordinated supported care emphasis on actual / practical improvements
England’s clinical director for cancer, says: • Effective automated surveillance / remote for all cancer patients.
"... improving outcomes for people with monitoring systems to remind patients /
cancer isn’t just about improving survival healthcare professionals when specific The following case study is one aspect of
rates. It is also about improving patients’ screening/investigations are required the important issues identified for CYP
experience of care and the quality of life for • Fully supporting primary care within any cancer survivors.
cancer survivors and our strategy also sets shared care arrangements
out how that will be tackled."

An important population within these

“
figures are children and young people
affected with cancer.

There are approximately 40,000 survivors of All children and young people who are cancer survivors should
child or young person cancer in England expect to receive the same, high quality standard of individualised
who will need some level of care and long

”
term follow up as they live into adulthood,
care irrespective of where and when they are treated.
perhaps 50+ years after their cancer
diagnosis. Alex Brownsdon, Patient Representative NCSI CYP Steering Group

www.improvement.nhs.uk/cancer/documents/NCSI_Vision.pdf
4

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123371
5


27

CANCER
CASE STUDY
DOMAIN 5:
DOMAIN 3: DOMAIN 4:
DOMAIN 1: DOMAIN 2: Helping people to Ensuring that
Treating and caring
Enhancing quality for people in a safe
Preventing people recover from people have a
of life for people environment and
from dying episodes of ill positive
with long-term protecting them
prematurely health or experience
conditions from avoidable
following injury of care harm

The Christie Survivorship Programme
The Survivorship Programme aims to Questionnaire feedback was completed
provide relevant, sufficient and timely as part of the programme with further
information that informs, supports and follow-up evaluation to come. This work
empowers survivors in relation to many helped measure the value of the
aspects of their lives that have been intervention, ensuring continuous
affected by treatment for cancer. assessment and on-going refinement.
Participants were asked whether the
Through three education courses course met expectations and 12 sessions
completed in 2010, the programme out of 24 received 100% feedback of
seeks to improve the quality of patient either ‘agree’ or ‘strongly agree’. They
care and self-management. Sessions also gave 100% backing to eight out of
focused on a range of topics including 24 sessions that had motivated them to
relationships and body image, anxiety, learn more.
coping strategies and risky behaviours,

“ “
late effects of treatment, fertility,
finances, education, employment and
life skills. The programme is part of the
National Cancer Survivorship Initiative The survivorship programme A cancer diagnosis in children
(NCSI6) and The Christie is one of the helped me in many ways. and young people is rare.
test sites for the children and young Primarily it gave me a better However, when this occurs as
people workstream.
understanding of what help a child or young person this is
The pilot courses were held in was available after having at a time in their lives when
Manchester with patients from the cancer, as well as being able they need to meet many
Trust’s Young Oncology Unit. A total of
56 patients enrolled on the courses with to use the folder as a challenges. Physical and social
attendances varying between sessions. handbook to refer to in the development, education,
Attendees were aged between 16 and short and long term. It also and the learning to take
32, with the average age being 22. The
majority of people on the courses were gave me vital contacts to get responsibility to move on into
from the Greater Manchester area. in touch with which really the adult arena for example
helped a lot and on the The diagnosis, treatment
whole I think it’s a brilliant and later consequences of
idea! treatment puts this normal

”
Patient who took part
on the programme
development into jeopardy.
Longer term support is vital
to assist survivors to achieve
maximal quality of life.

”
Dr Gill Levitt, Great Ormond Street Hospital
for Children NHS Trust, National Clinical Lead
for Children and Young People Survivorship

www.ncsi.org.uk
6

28

CANCER
IMPROVEMENT
Transforming Inpatient Care: Driving improvements in
quality that values patients’ time and increases efficiency
Strategic overview The improvement programme promotes The lessons learned from testing prototypes
The Cancer Reform Strategy (2007) innovation and new models of care delivery: and new models is disseminated across the
highlighted the need to focus attention on • Day case/one night stay for breast NHS in order to improve the quality of care
inpatient care for cancer patients. The surgery and other procedures and experience for patients and to maximise
Transforming Inpatient Care Programme • Enhanced recovery approaches for the potential scope of savings.
was established to take this forward led by elective care (colorectal, gynaecological,
NHS Improvement. urological and musculoskeletal) The Transforming Inpatient Programme is
• Approaches to reduce avoidable underpinned by four ‘Quality Winning
The National Audit Office (2010) reported emergency admissions and readmissions Principles’.
good progress has been made in reducing • Reducing unnecessary lengths of stay for
the number of inpatient days per year for those who need to be admitted as
cancer patient’s, however, there is scope to emergencies and elective
go much further and to make a significant
contribution to the efficiency savings that
the NHS needs to make.

The Transforming Inpatient Care
Programme continues to be a cancer
priority and this is reflected within the The Quality Winning Principles
Improving Cancer Outcomes Strategy
(2011) supporting the QIPP agenda and Winning Principle 1 Winning Principle 3
Outcomes Framework. Unscheduled (emergency) patients Clinical decisions should be made on a
should be assessed prior to the decision daily basis to promote proactive case
to admit. Emergency admission should management.
be the exception not the norm.
Winning Principle 4
Winning Principle 2 Patient and carers need to know about
All patients should be on defined their condition and symptoms to
inpatient pathways based on their encourage self-management and to know
tumour type and reasons for admission. who to contact when needed.

29

Enhanced Recovery Partnership
The principles of enhanced recovery in elective surgery are currently being
implemented across the NHS nationwide and, as a result, transforming the approach
to care before, during and after surgery. This innovative, evidenced-based practice has
already resulted in dramatically improving the recovery times for patients across
colorectal, gynaecology, urology and musculo skeletal care pathways.

It has so far been recognised that implementing enhanced recovery pathways instead
of using traditional models actual improves efficiency as it is helps patients to get
better sooner after surgery - it also has improved their experienced due to shorter
stays in hospital and a more rapid return to normal living as they are encouraged to
contribute to their own recovery. The hospital itself benefits in stable or reduced
Getting breast surgery patients
readmissions rates, with lower complications and better bed utilisation as reductions
better sooner
have also been witnessed in the amount of high dependency and intensive beds
The ‘Quality Winning Principles’ were
which are normally required.
applied to the redesign and streamlining of
the breast surgery pathway for all patients
Enhanced recovery entails a multidisciplinary team and healthcare community
undergoing major breast surgery (without
approach as they are actively involved in the patients care before, during and after
reconstruction).
surgery. This means the patient is well informed and prepared pre-operatively, which
helps to reduce anxiety or stress levels prior to surgery and results in the patient
The working hypothesis was that the
making the correct decisions about their treatment and recovery pathway.
streamlining of the breast surgical pathway
could reduce length of stay by 50% and
The Enhanced Recovery Partnership led by NHS Improvement working in partnership
potentially release 25% of bed days and
with National Cancer Action Team, SHA Enhanced Recovery Leads, Cancer Networks
managing patient expectations the patients
and National Clinical Leads supports the NHS to implement and realise the benefits
experience could be improved.
of enhanced recovery.
Why breast surgery?
Baseline data drawn from local and national
sources indicated:

• Variation in clinical practice and • All admissions for mastectomy are Patient feedback tells us that being
conflicting clinical evidence surrounding elective but only a quarter of patients diagnosed with cancer can be a difficult
the use and effectiveness of wound (27%) were treated as day cases transition to make. Patients undergoing
drains, drainage of seromas, anaesthetics • In 2007-2008, there was 54,115 elective surgery for both cancer and non cancer
and pain control admissions form breast surgery that expressed they wanted to be in hospitals
• Breast cancer is one of the most occupied 305,061 bed days (HES) for as short a time as possible. Through
commonly diagnosed cancers in the UK. • The mean range of length of stay patient forums, diaries and interviews,
In England, female breast cancer equates between acute providers ranged from people have talked about how unnecessary
to approximately 34,000 new cancer 0-7 days for mastectomy procedures. waits and procedures increased anxiety.
cases registered per annum and Prompting the question. Why should Patients have stressed the importance of
approximately an additional 20,000 mastectomy be an inpatient procedure? getting back to normal as soon as possible
patients undergo breast surgery for It is a: and valuing their time.
benign conditions. (Cancer Registration • Relatively short operation
in England 2000) • Low post operative pain
• Breast cancer is one of the areas which • Patient can mobilisation early
appears to perform worst – survival rates • No high risks as with other major
• Significant geographical variation in surgery such as retention/ileus
length of stay • Rare significant post op events


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