Demonstrating the value of specialist nursing services Roald

Demonstrating the value of specialist nursing services Roald Dahl Nurses Conference Friday 18 th November 2016 Institute in the park – Alder Hey Children’s Hospital Dr Ann Mc. Mahon, Royal College of Nursing, UK ann. mcmahon@rcn. org. uk @research_innov

Demonstrating the value of specialist nursing services F RCN Frontline First Campaign F Cuts F Waste F Innovation

Demonstrating the value of specialist nursing services F Nurses F are innovators…… . . . the intentional introduction and application within a role, group or organization of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, the organization or wider society (West, M. A. and J. Farr (1990).

Demonstrating the value of specialist nursing services F Nursing knowledge and skills in evaluation and audit…… – Clinical impact – Patient experience – Economic impact

Demonstrating the value of specialist nursing services The need to change Empowering patients; Engaging communities; New models of care Diverse solns. Local leadership. Modern workforce. Exploit information revolution. Accelerate innovation. Drive efficiency and effectiveness

Demonstrating the value of specialist nursing services Values-based approach q Who defines ‘value’ and has role in demonstrating ‘value’? q Not all ‘cuts’ are ‘savings’ q ‘Quality’ as well as ‘efficiency’ q Frontline workforce has a key role in: q Generating the evidence q Knowing what to do with it in practice to make a real difference

Demonstrating the value of specialist nursing services F RCN working in partnership with OPM Incremental steps • demonstrating potential with FLF innovations • building nursing capability in economic assessment in Scotland, Wales and Northern Ireland • publishing CPD articles to share methods • developing the programme base on the lessons learned and securing more funding from the Burdett Trust to provide the programme in England

Demonstrating the value of specialist nursing services Recognising challenges q q q No time Not my job Too difficult Myths and jargon offputting On the other hand, some terminology entered common use, but with little or no understanding of what it actually means

Demonstrating the value of specialist nursing services Children's continence nurse service - an affordable luxury? Rhonda Reilly Specialist Nurse - Continence, Western Health and Social Care Trust, Northern Ireland

Demonstrating the value of specialist nursing services Child with day-time wetting Cf. nurse-led community based continence service vs. consultant-led hospital clinic Nurse-led service £ 85. 50 Consultant-led service £ 456 Costs avoided £ 35454

A clinical nurse specialist-led children’s continence service (Reilly 2012) Inputs Investment DIRECT • 1 WTE Band 6 nurse • Secretary Band 2 - 8 hrs. /wk. • Service funded from CCN budget • Clinical rooms within Trust properties • Clinical supplies and equipment – enuretic alarm, urine testing strips, bladder scanner, uroflow • Office supplies and equipment • Nurse INDIRECT • Travel costs • Download information leaflets from ERIC, Promo. Con • Leaflets from pharmaceutical companies • Non medical prescribing • Containment The service Activities and outputs Clinics/home visits/telephone • Assessment • Investigations – ultrasound scanning, uroflow, urinalysis • Diagnosis • Individual treatment/ management plan • Follow up and review • Independent nurse prescribing and continence medication review • Referral on discharge • Education of carers / health care Groups Targeted For intervention • Children aged 0 -18 yrs who have a continence issue residing in the Northern sector of the Western Trust For partnership • Children with continence issues • Carers of children with continence issues • Other health professionals involved with children with continence issues • Education professionals • Support groups eg. ASD, Downs Source of Referral 2011/2012 • Community Paediatrician 39 • Hospital Consultant 94 • GP 69 • Health Visitor 84 • School Nurse 65 • Parent 13 • Other 44 • Total 408 Summary of benefits For service users Short term outcomes • Better management of continence issue • Prevent exclusion from school/ social situations • Timely support for family and child - frequent follow up, telephone access to advice • Individual management plan • Expert care provision • Reduced need for hospital referral/admission for continence issues Medium term outcomes • Improvement in continence symptoms • Early intervention for children with continence issues Long term outcomes • Reduction in number of children with long term continence issue • Avoidance of unnecessary tests and investigations • Reduced need for medical referral in management of childhood For the healthcare system • Comparison of costs for child with daytime wetting, attending nurse led community continence clinic and child attending consultant led hospital clinic £ 85. 50 vs £ 456 140 children referred to the children’s continence nurse with daytime wetting. Of these 140, 36 children had attended consultant led hospital clinic and were referred on to the children’s continence nurse for urotherapy. Total cost : 104 patients X £ 456 = £ 47, 424 140 children referred to the children’s continence nurse led clinic with daytime wetting Total cost: £ 11, 970 Cost savings to the Trust of the nurse led service for children with daytime wetting 2011/2012. (Assuming that those children referred to the children’s continence nurse would have been referred to the paediatrician) £ 35, 454/2 yr in Northern Sector of Trust • Comparison of costs for child with constipation and soiling attending nurse led community continence clinic and child attending consultant led hospital clinic £ 85. 50 vs £ 461 Cost savings to the Trust of the nurse led service for children with constipation and soiling 2011/2012 (assuming that those children referred to the children’s continence nurse would have been referred to the paediatrician ) £ 37, 738/2 yr in Northern Sector of Trust

Demonstrating the value of specialist nursing services Economic Assessment of the Community HIV Clinical Nurse Specialist role Shaun Watson Community HIV Clinical Nurse Specialist, Chelsea & Westminster NHS Foundation Trust

Clinical Nurse Specialist, HIV Community (Watson 2016) The Service Inputs Investment Journey through Service No set up costs Community HIV CNS (£ 77, 702. 98 per annum / £ 46 per hour) Active caseload of 67 complex HIV positive patients who live in Westminster around 10% of all HIV patients in Westminster, CNS manages just under half. Resources • • • 1 x WTE Band 8 a, Community HIV CNS (provides cross cover for Hammersmith & Fulham, Kensington & Chelsea) Travelcard (zone 1 -2) £ 1, 495 a year Shared ‘hot desk’ @ 56 Dean Street Referral routes Via HIV services or GP, 1 -2 new referrals per month. Activity/ delivery • Complex Case-management – vigilance and rescue work around safeguarding and vulnerabilities. Adherence management and support Symptom control management and support Assessment and Care planning Multi-disciplinary liaison and team approach to care delivery • Patient/ carer/ professional education • • Summary of Benefits For Adults living with HIV and complex needs who reside in Westminster • Avoidance of Antiretroviral therapy (ART) wastage by effective management and monitoring of adherence. Average ART £ 2000 - £ 3000 (6 months unsupported adherence) With a 60 -70 patient caseload, assuming 50% would waste without intervention, ensuring adherence avoids costs of £ 162, 500 – £ 260, 000 per annum • Carers and family of patient feel supported • Prevention of avoidable hospital admissions by vigilance, rescue work and effective case management (£ 1, 776 - £ 3, 500 a week) For other local services • Prevention of onwards HIV transmission potential avoidance of £ 3. 360, 000 – £ 4. 320, 000 per annum by management and monitoring of ART adherence for 12 sexually active patients in caseload. • Management and support of those who have disengaged from HIV services. Opportunities for service development • Enhancing service with physical assessment and Non -medical prescribing. • Development of a Community HIV Nursing model to strengthen funding.

Demonstrating the value of specialist nursing services Value of the nurse-led stoma care clinic Sheila Jones Clinical Nurse Specialist (Stoma Care), Royal Glamorgan & Ysbyty Cwm Rhondda Hospitals

Value of the Nurse Led Stoma Care Clinic (Jones 2015) Inputs Set up Costs • Direct Costs ØIT Costs £ 6, 477. 63 (one off payment by the Coloplast Ltd. Sponsorship) ØStaff Costs none • Indirect Costs ØFacilities Cost i. e. office space, clinic rooms and stationery provided as an in kind contribution by Cwm Taf University Health Board Running Costs • Direct Costs (Paid by the Coloplast Ltd. Sponsorship): Ø Staff Costs £ 39, 781. 9 ØTravel Costs £ 1, 074. 2 • Indirect Costs ØStoma Appliance Costs (£ 3, 958 of £ 45, 318. 32 paid by UHB) The Service Key Points • Experienced, specialist nurses • Leads clinical care; providing specialist plans of care according to patients individual needs • High quality of care and good clinical outcomes for patients. • Managing supply and demand of the correct stoma supplies and can attain cost savings for the Trust. The Service • Ensures a well defined pathway to support patients. • Provides a patient focused approach to diagnose, care planning, treatment provision • Empowers patients to return to previous lifestyle • Prevention of health deterioration • Provides clinical information to GP/MDT re progress of patients & appliance management Summary of Benefits Quality- Patients/families • Receive an evidence based, structured follow up programme of care and support • Reduced Peristomal Skin Complications (PSC) rate from 48% to 19. 6% Quality- Wider Organisation • Education of health and social care professionals • An efficient, evidence based, patient centred clinic meeting key targets, policies and guidelines Productivity – Wider Organisation • Estimated cost avoidance in value of: - Hospital Ward Staff Time £ 25, 746. 05 - Community Staff Time £ 5, 224. 23 • Management of PSC £ 78, 998 • Treating PSC in Stoma Care Clinic and not in the patients` homes £ 3, 292 • Not routinely using stoma accessories £ 1, 354. 98 • Cost effective use of appliances and accessories; comparable to the national average. Prevention – Wider Organisation • Estimated cost avoidance of preventing patient: - Hospital admission/readmission £ 3, 709 - Appointments with GP £ 42, 056 • Freeing up of Consultant, GP, District Nurse appointments ; allowing time for non stoma patients Service Development Opportunities To maintain current staffing levels Annual appliance review within GP surgeries

Demonstrating the value of specialist nursing services Are we worth it? Exploring the economic value of specialist nursing in practice Jill Nicholls Heart Failure Specialist Nurse, NHS Tayside, Scotland

NHS Tayside Heart Failure Nurse Liaison Service – HFNLS (Nicholls 2012) Inputs Investment Set up costs: None Operational costs: £ 202, 604 per year (broken down below) Staffing › 3 x Band 7 Heart Failure Specialist Nurse › 1 x 0. 8 Administrative Support › 1 x 0. 5 Physiotherapist Other resources ›Clinical supplies ›Training budget ›Physical resources e. g. office furniture ›Service equipment ›Stationery ›Travel costs The service Service use ›Patients with heart failure due to Left Ventricular Systolic Dysfunction (LVSD), either post admission or remain symptomatic/complex at out-patient clinic assessment ›Total 515 patients in service 2011 -12 ›Patient discharge if stable >6 months and on optimal medication Services Home visiting model: ›Individual management plan ›Expert symptom and clinical assessment ›Optimise medication management ›Investigations ›Multi-disciplinary team working across all sectors of care ›Patient and carer education ›Self-monitoring ›Rapid response service ›Palliative care Summary of benefits For service users › 86% of users report stable or improved symptom control based on internationally recognised New York Heart Association classification tool ›Reduction in hospital readmissions from 26. 7% to 8. 3% of LVSD patients ›Length of stay reduced by average 4. 8 days for those who are admitted ›High levels of patient satisfaction with HFNLS measured using University of Glasgow CARE measure tool For healthcare system › Hospital admissions costs avoided › CHP primary care costs avoided › Annual running cost for HFNLS › Overall costs avoided › Average return on investment £ 303, 518 £ 151, 410 - £ 202, 604 £ 252, 324 £ 489 per patient/per year If referral rates improved: › Potential overall costs avoided › Potential return on investment £ 345 -959 - £ 401, 257 £ 671 -779 per patient/per year

Demonstrating the value of specialist nursing services Marvellous nursing: demonstrating the value of nursing services for seriously ill children

Demonstrating the value of specialist nursing services Roald Dahl Nurses Conference Thank you for inviting me! Any feedback or questions? Dr Ann Mc. Mahon, Royal College of Nursing, UK ann. mcmahon@rcn. org. uk @research_innov