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Trailblazing the redesign of neurological services

Patients who suffer from neurological conditions including, Parkinson’s disease; Multiple Sclerosis; Epilepsy and Headache and Migraine conditions are set to benefit from improved care and treatment following a complete redesign of the local area’s neurological clinical services, in what is believed to be one of the first integrated community based models of neurological care in the country.

Investing time, energy and drive, to improve local neurology services, Dr Jackie McGlynn, Sunninghill GP and East Berkshire CCG locality lead for Bracknell and Ascot, provided the clinical leadership on behalf of the Frimley Integrated Care System (ICS) to review neurological care in the area.

Work commenced with the application the NHS Right Care approach to problem solving;  diagnosing key issues; identify opportunities; making good use of data,  evidence and intelligence to go on and deliver tangible improvements for patients, populations and systems.

This systemic approach helped identify that neurological care across the area was at risk of becoming an outlier in terms of the care and treatment offered to patients requiring neurological care.

The Frimley Health and Care Integrated Care System, (ICS) is a partnership of thirty statutory health and social care organisations including local authorities, NHS trusts providers and commissioners covering Surrey Heath, East Berkshire and North East Hampshire and Farnham - with a population of over 800,000 people - working together to improve local health and care services and sharing a common vision to make the best use of their combined resources.

Speaking of the new multidisciplinary team Dr McGlynn said: “I’m absolutely delighted that we have successfully created this new pathway for neurological patients across the whole community served by the Frimley Integrated Care System. On behalf of our patients, I’d like to congratulate my colleagues for their hard work and tenacity in making this new service such a success.”

Over a period of two and a half years following engagement with patients, clinicians and wider stakeholders, the programme of work began with a simple question, “If we were to begin again, what would a new neurological pathway service look like.”  The answers were equally simple:

  • Provide a better patient experience
  • Reduce patient admissions to hospital
  • Reduce the time patients stayed in hospital
  • Make sure that consultant appointments are efficiently utilised.
  • Improve the offer of a truly multidisciplinary team (MDT) in the community.

The solution was to design a new pathway that improved the coordination of a patient’s care, redesigning and refining the quality of clinical and social care interactions; or to put it another way, design a service that ensures patients see the right professional, in the right place and at the right time and delivering meaningful care solutions in a co-ordinated way.

By February 2018, a dedicated team was ready to submit the detailed business plan to the ICS Board.

Consultant Neurologist Dr Matt Craner has provided the leadership and drive that has brought the service to a point where it is now ready to begin the new service.  Matt said: “We’ve been on an exciting journey to get to this point, and I’m grateful to the multi- disciplinary team and wider ICS partners for their hard work and effort in making this happen.  This represents a tangible improvement in the service we provide to neurological patients across our whole community.”

On the money front, investment of around £519K was needed to bring life to the new pathway, paving the way for the introduction of a pivotal new role - the Neurology Care Coordinator - four people including team leader Clare Nickols have been appointed to ensure each and every patient follows the defined care pathway that best meets their individual needs.

The attention to detail that Clare and the team bring will ensure that patients’ maintain their specific journey of care and treatment according to their specific needs.  They are at the ‘helm of care’, navigating patients through the newly designed multidisciplinary team of around twenty professionals, including Consultants, Occupational Therapists, Psychologists, Specialist Parkinson’s and Epilepsy nurses.

At all times, patients’ will remain under the care of their nominated Consultant;  within a service that is complemented by a pathway that binds together the area’s existing professionals, creating a team that  for the first time works across historical  county and organisational borders offering a seamless level of service. One that demonstrates the kind of benefits to be achieved through collaboration and working as an integrated care system.

For example, for several years, some patients who suffer with neurological conditions have been required to travel regularly to London for outpatient appointments and care. Such journeys are costly, time-consuming and of course exhausting.

The new pathway allows those existing patients (who may have built up relationships with their care providers over many years) to choose to have that care closer to home (if they so wish).  New patients however, will now receive all of their future care locally and will not have to travel to London.

Frimley ICS project lead for the neurological pathway, Julie West said:
“The Frimley ICS has enabled us to create a new, high quality system-wide pathway for patients with neurological conditions, and has allowed colleagues from across the system to work more closely together.  This has resulted in much improved care and treatment for at least nine thousand patients in our area every year.”

Frimley Health and Care

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