The event in summary
On 31st January, over 120 delegates spanning commissioning, management and clinical roles in the NHS, gathered in Birmingham for the first National neurology transformation meeting. All but seven of the country’s integrated commissioning boards (ICBs) were represented and there was almost a 50/50 split between clinical leaders and managerial or commissioning roles.
The meeting was designed to offer practical information and insight into the transformation strategy at an ICB level, and to provide ideas for direction of travel and opportunities to develop networks. The content was developed in partnership with National Clinical Director for Neurology, Dr Niranjanan Nirmalananthan and Clinical Adviser for the NHS England Neurosciences Transformation Programme Dr Martin Wilson, and featured a range of eminent speakers with experience of both localised and specialised commissioning, or presenting insights into the challenges facing neurology both from a service planning, delivery and user perspective.
Hosted by Neurology Academy, the meeting was financially supported through sponsorship from a range of pharmaceutical partners. None of the sponsors had any control over either the organisation or educational content of the meeting.
There was a huge amount of practical insight offered throughout the day, with challenges openly acknowledged such as financial scarcity, the ageing population, a stretched workforce, and the growing treatment landscape, to service variance, equity of access, and deprivation. However, these challenges were shared alongside the opportunities they present, with examples of problem-solving and new ways of working also being shared, and ideas generated around other potential solutions.
Key takeaways from the day included the importance of ‘shifting left’, initially shared by Dr Andrew Kelso and then built on by other speakers. Other top messages were the need for widespread collaboration across health, social, community and voluntary sector services and with service users themselves, and the opportunities presented by learning from ‘Pathfinder’ whole-system service change around the country. Tools and support were shared by many speakers, and there was a vibrancy to the meeting’s atmosphere, with questions posed to speakers throughout the programme and animated discussions taking place during refreshment breaks and over lunch.
Looking through the programme
Setting the scene with the current requirement for, and experience of, neurology services, Georgina Carr, Chief Executive of the Neurological Alliance, provided insight into the variance in quality and access that individuals can experience. Sharing experiences gathered via the My Neuro Survey (Neurological Alliance 2022) to highlight key needs and the long term impact of not addressing these, Georgina encouraged ICBs to make use of the optimum care pathways (OCPs) (https://www.nnag.org.uk/optimum-clinical-pathways) which each set out the ideal flow through and access to services as mapped against national guidance, to map or review their own local pathways.
Dr Niranjanan Nirmalananthan, National Clinical Director: Neurology for NHS England, and Consultant Neurologist at St George’s University Hospitals NHS Foundation Trust then discussed the transformation agenda in terms of both priorities and goals. He outlined systemic challenges for ICBs such as inequity in funding, service delivery and accessibility as opportunities to engage. For example, reducing unnecessary spend, addressing high cost populations like migraine, reducing inequity of care and avoiding unnecessary admissions are all priorities for every ICB – and can all be supported by prioritising neurology.
From the changes in specialised commissioning budgets to the goals of transformation, Niranjanan provided clarity and optimism, presenting this shift as an opportunity to support those currently underserved by, or unknown to, the system, and he detailed Pathfinder projects that are working at a whole system level across the country as possible blueprints for future services.
Dr Andrew Kelso, Medical Director for NHS Suffolk and North East Essex ICB, provided candidly honest insights into his experiences working within an ICB to the benefit of the meeting. Clarifying the new system succinctly, he explained that Integrated care systems (ICSs)’s responsibility for health and social care planning and delivery utilises two branches: the ICB is the commissioning branch and the integrated care partnership (ICP) is the other. Investment in this partnership across health, social care, voluntary sector and patients themselves is why he feels his ICS is successful, and he emphasises that service plans developed in meaningful coproduction with patients are likely to receive more attention from the ICB.
Andrew shared some of his current challenges, introduced delegates to the core requirements of an ICB as a way to consider the transformation challenge and outlined the various national programmes which ICBs have been asked to work within and which present helpful levers for change. He was clear that presenting commissioners with a credible plan or solution is more likely to gain engagement than highlighting a need.
He presented the idea of the ‘left shift’, demonstrating how shifting patients to the left from each segment of care can have a positive impact on both the patient and the NHS (NHS Confederation 2023) (see figure). By keeping, or ‘shifting’ as much care as possible to the left (see figure 4), this ensures more patient-centred care, delivered closer to home, aligning with national strategy and patient preference.
Lucie Waters, Director of the South London Office of Specialised Services moved the audiences’ attention to the soon-to-be delegated specialist commissioning budgets and began with a brief yet encouraging history lesson in the face of the challenges raised so far, comparing the new commissioning landscape to that of pre-2012 primary care trusts (PCTs) and reminding delegates that much of this is part of commissioners’ ‘day job’.
Lucie explained the benefits to returning to delegated budgets, and the gradual shift of specialised commissioning responsibilities across to ICBs over the next two years. Highlighting patient care, equity of access, and cost effective care, Lucie shared that holding the entire service budget will allow all aspects of a persons’ care, from specialist units to district nursing, to be joined up in a holistic pathway. To demonstrate how this can work in practice, Lucie presented a number of non-neurology pilots that South London have had in place to date and the learning from these, before turning to a neurology pilot running across Southwest London and Surrey Heartlands – all of which have employed the ‘left shift’ that Andrew Kelso spoke of.
Next, Dr Martin Wilson, Consultant Neurologist, Chief Clinical Information Officer (CCIO) at the Walton Centre NHS Foundation Trust, and Clinical Adviser for NHS England’s neurosciences transformation programme, introduced the new national data dashboard for neurology services. He explained its roots and purpose, how it builds on the excellent work done by Dr Geraint Fuller via the Neurology GIRFT report (2021) and how it can be accessed and used. He gave a demonstration of the new dashboard through screenshots across the tool which is specifically designed for ICB use. He showed how it can be used to gather information on equity of access across a whole ICS, both in-patient and outpatient metrics, flows into and out of an ICB, cost effectiveness, and benchmarking. Accessible to anyone with an Octa account, Martin encouraged access for everyone involved in service planning and provision.
Speakers each allowed five minutes for questions after each of their presentations, but a dedicated 45 minutes session was allocated before lunch where a panel formed of the morning’s speakers responded to broader questions that had been raised by delegates via sli.do throughout the morning.
After lunch, the meeting was joined remotely by Dr Geraint Fuller, Clinical Lead for Neurology within the Getting it Right First Time (GIRFT) programme and Consultant Neurologist at Gloucestershire Hospitals NHS Foundation Trust. Geraint discussed the next steps for the GIRFT programme. Geraint suggested 18 questions that GIRFT Neurology asks, and suggested that everyone needs to consider these questions, from the various commissioning bodies all the way to the consultants, clinicians and patients themselves.
He then systematically went through these questions segmented into in-patient, outpatient, treatments and referrals, demonstrating how data can help us to find the answers, and how learning of solutions implemented around the country can provide blueprints to meeting similar challenges, or applying new ideas to similar populations. Some examples included dedicated neurology beds within district general hospitals (DGHs) with multidisciplinary teams as liaison, using super-clinics or patient-initiated follow-up (PIFU) to reduce outpatient waiting lists, and considering DGHs or community infusion units rather than neuroscience centres. He advocated for network connections and collaborative working to establish these services, reducing pressure on neuroscience centres, and bringing patient care closer to their homes.
Expanding on some of the ideas presented by Geraint, Dr Fiona McKevitt, Clinical Director for outpatient recovery and transformation for NHS England, Consultant Neurologist at Sheffield Teaching Hospitals NHS Foundation Trust and an Honorary Senior Lecturer, delved more deeply into transforming neurology outpatient appointments. Highlighting the Royal College of Physicians report (RCP 2018) which suggested outpatient services were not fit for purpose and face to face appointments should be reduced by a third – and explaining how this target was met overnight due to the coronavirus pandemic, Fiona discussed the challenges that have been facing outpatients’ appointments for years, and examined the different tools that might be leveraged to improve outcomes.
From initial referral, to follow up appointments, optimising the appointment itself to minimising those that are missed, Fiona presented a whole suite of solutions that have been trialled and found effective through Pathfinder pilots across the country. Some ideas such as remote monitoring or patient-initiated follow-up (PIFU) require shared-decision-making to ensure they work to the benefit of both the patient and the service, whilst others like one stop shops and super clinics require multidisciplinary collaboration or commissioning changes. Being clear that assessing workforce skillset and appropriate resource use are both needed, Fiona also suggested using the FutureNHS tool to support collaboration across health and care agencies at no cost.
Shelley Jones, Consultant Pharmacist: Neurosciences, and Deputy Chief Pharmacist for transformation and systems integration at King’s College Hospital NHS Foundation Trust opened with a message of hope: that delegated commissioning of high-cost drugs will enable better service delivery whilst ensuring national standards of prescribing and monitoring are adhered to.
She presented how the new changes in delegated budgets affect high cost and highly-specialist drugs by demystifying what these are and how they are delivered and highlighted a number of challenges which may be overcome through delegated budgets, whilst also identifying a number of new problems which may arise as a result.
Her key message was to embrace this opportunity to create bespoke solutions and design new pathways, which, by collaborating with financial services around design decisions, can ensure the funding flows well and access is without hurdles.
The final presentation of the day was given by Dr Arani Nitkunan, Consultant Neurologist and Neurology Lead, Croydon Health Services NHS Trust, Co-chair for Southwest London’s (NWL) neurology network and Chair of the Association for British Neurologists (ABN)’s services committee. She provided a brief but helpful review of the ABN’s perspective on service improvement, with specific focus on what the ABN themselves can do, and are doing, to support and enable neurology transformation.
The afternoon closed with a number of breakout sessions each seeking to address one of five fundamental questions relating to neurology transformation, from effective clinical engagement and collaborative working across systems and providers, to applying generic integrative services to neurology needs, embracing new ways of working, and commissioning across multi-ICB geographies for specialist services.
With awareness that not everyone who would benefit from these presentations and discussions would be able to attend, the whole meeting was recorded so that this valuable content could be accessible to all. Registration for the free online content is now open to allow anyone with an interest in neurology transformation, across healthcare professionals, managers, commissioners and the voluntary sector, to delve more deeply into the ideas that were explored (Neurology Academy 2024).
References
Arden & Gem, and NHS England, National clinical data repository, accessed via https://www.ardengemcsu.nhs.uk/services/business-intelligence/ncdr/
Fuller G, Neurology: GIRFT programme national speciality report, September 2021, accessed via https://gettingitrightfirsttime.co.uk/medical_specialties/neurology/
NHS Confederation, ‘The link between non-acute investment and system productivity, September 2023, accessed via https://www.nhsconfed.org/system/files/2023-09/The-link-between-non-acute-investment-and-system-productivity%20.pdf
Neurology Academy, National neurology transformation meeting, held 31st January 2024, content accessed online via https://neurologyacademy.org/events/meeting/national-neurology-transformation-meeting
Neurological Alliance, Together for the 1 in 6: UK findings from My Neuro Survey 2021-2022 accessed via https://www.neural.org.uk/wp-content/uploads/2022/05/Together-for-the-1-in-6-UK-Findings-from-My-Neuro-Survey-v6.pdf
Royal College of Physicians, Outpatients: the future – adding value through sustainability, 9 November 2018 accessed via https://www.rcplondon.ac.uk/projects/outputs/outpatients-future-adding-value-through-sustainability
