Collectively, Shelford Group Trusts provide a significant proportion of specialised services across the country. In this blog, Emily Hughes, Shelford Group Policy Fellow, sets out how members are improving specialised care for patients, as well as addressing inequities of access.
Shifting specialised care commissioning and delivery
Specialised services support people with a range of rare and complex conditions. They are a catalyst for innovation, and at the forefront of new treatments, technologies, and clinical practices that improve the quality of health and care. The number of people who need specialised services – and subsequently, the cost of providing these services – is rising, due to people living longer, as well as advances in medicines and medical technology.
In line with the policy ambitions of establishing Integrated Care Systems to meet the wider health, care, and wellbeing needs of local populations, NHS England have set out a roadmap for Integrated Care Boards (ICBs) to take on responsibility for commissioning many specialised services, marking a shift from national commissioning to a more localised approach. This shift aims to reduce fragmentation in care pathways, promote a system-wide focus, and encourage investment in prevention and early intervention.
As significant providers of specialised services, Shelford Group members are committed to working with system partners to ensure the success of these reforms. Over the years there have been marked changes in the delivery of many specialised services – as innovation spreads from specialist centres to secondary care and the community, many services that were designated as specialised years ago are now delivered commonly and locally, such as chemotherapy and renal dialysis. Two case studies, one in South London and one in Sheffield, demonstrate how Shelford members are working to redesign the way specialised services are delivered, through building strong system relationships to enable preventative care, and through the use of data and technology to support people with long-term conditions to stay well.
A programmatic approach to transforming specialised services
Providers and commissioners across both South East and South West London have taken a programmatic approach to transforming specialised services over the past seven years. A range of pilots have been developed, all seeking to intervene earlier in the care pathway (e.g. through the rollout of comprehensive blood-borne virus screening across all Emergency Departments in South London), and to address inequalities in access to care.
Several pilots are being delivered in cardiac services. Aortic Stenosis (AS) occurs when the aortic valve narrows and blood cannot flow normally. It is one of the most common and serious heart valve disease problems, and mortality rates for untreated disease are high. Care pathways must flow seamlessly, ensuring rapid detection, diagnosis, and treatment – a recent study by the Lancet estimates that there were 500 avoidable deaths in the UK in 2019 while people with aortic stenosis waited for lifesaving TAVI treatment. Historically, separate elements of the care pathway have been planned, paid for and provided in discrete settings, however the South London pilot is demonstrating how these services can be integrated to provide better and more equitable patient care.
AS is detected in the community, typically through general practice, and diagnosed via echocardiogram. By offering increased point of care scanning, health checks, and echo clinics in the community, as well as developing culturally appropriate promotional materials to raise community awareness of heart valve disease, partners across South London are working to ensure rapid detection and diagnosis of AS, and are actively addressing inequities in access for previously underserved communities.
Through development of this work, partners across South London uncovered a healthcare inequity in treatment for aortic stenosis, with Black and Asian communities and people from more deprived areas significantly under-represented in accessing specialised procedures like surgical AVR and TAVI. Treatment rates vary between boroughs, and the intervention rate in the white population is around 8 times higher than in the Black population. To support pathway improvements and address these inequities, South London has streamlined the tertiary pathway, with a single point of entry and joint review by surgeons and cardiologists – this will reduce variation in access and treatment, enabling the equitable delivery of interventions across the system.
Crucially, this pilot work is owned collectively by South London providers and commissioners, who plan, fund, and deliver this approach together. Investment in local programme and analytical support has ensured that commissioning decisions are as close to patients as possible, and services are redesigned and delivered to support better population health outcomes.
Shifting from rescue to prevention in Cystic Fibrosis care
Cystic Fibrosis (CF) is a long-term condition, affecting around 11,000 people in the UK. There are effective treatments in CF, and higher adherence to these treatments is associated with better outcomes. However, adherence to prescribed treatment is low. This has consequences for the long-term health outcomes of people living with CF, and can make clinical decision-making more complex, where levels of adherence are not known.
Jointly developed by researchers at Sheffield Teaching Hospitals and several academic and charitable partners, CFHealthHub is a digital learning health system, helping patients with CF to monitor their condition using real-time data collected from their nebuliser and transferred to an app on their phone. The real-time data allows for objective nebulisation usage to be recorded, and adherence calculated against prescribed treatment. CFHealthHub supports identification of specific barriers to adherence for each patient, and provides evidence-based strategies, tools, and educational information to support positive behaviour change. This approach is helping thousands of patients build their confidence in managing their long-term condition.
For the 60% of adult CF centres in England where the tool is now active, this approach supports a shift in care, from rescue to prevention, supporting people to stay well at home, and reducing unnecessary hospital trips and consultations. In Sheffield, where the tool was first piloted, CFHealthHub supports patients far beyond its specialist centre, in places such as Grimsby and Lincoln. Advances in medical technology that support digitally-enabled care at home are fundamental to increasing equity of access in specialised services, now and in the future.
Driving transformation through collaboration
Specialist providers hold significant expertise in planning and delivering specialised services, and have an important role to play in realising the ambitions of delegated commissioning reforms. To improve care for patients and increase equity of access, the clinical and operational insights of providers, as well as their strong links to life sciences and academia will need to inform the shaping of the future.
Reforms to specialised commissioning also present an opportunity for increased provider collaboration, harnessing the collective expertise and experience of providers in transforming services. In the East of England, the seven acute provider trusts are forming a Specialised Services Provider Collaborative, exploring how through working together, clinical pathways can be transformed for patients with certain conditions, such as severe asthma. This would allow for biologic therapies to be prescribed closer to home, through clinical collaboration between specialist centres and local hospitals across the region. Clinical networks will also play a vital role in co-ordinating pathways of care, supporting equitable access, and assuring and improving care quality.
The delegation of specialised commissioning budgets to ICBs presents a powerful opportunity to focus efforts on early intervention, integrated care pathways, and where possible, prevention. These reforms will need to be supported by policies that ensure quality is sustained and services are commissioned on an appropriate footprint, and with safeguards in place to ensure the shift in resource allocation leads to the intended improvements in access. The examples highlighted above demonstrate the importance of meaningful collaboration and joint ownership between providers and commissioners, which will be fundamental to the success of these reforms.