This publication reports back on a review undertaken by NHS Improvement to examine the progress and impact of 25 Acute Trusts who took part in the Transforming Cancer Inpatient Care Programme (July 2007-2008) and the subsequent spread of the Winning Principles and models of care across England (Published July 2010).

1. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
LUNG
STROKE
Transforming Inpatient Care Programme
Consolidation Report (2009)
From testing to spread

3. Consolidation Report - From testing to spread | 3
Contents
Foreword 4
Summary 5
Introduction 8
25 NHS acute test trusts: Progress, impact and benefits 9
Reported benefits and investments 10
Impact of the Winning Principles and Models of Care 11
Winning Principle 1 12
Winning Principle 2 16
Winning Principle 3 22
Winning Principle 4 23
Summary: Consolidation of testing 24
Beyond testing: Coverage and spread 25
Levers for spread 28
Conclusion 29
Acknowledgements and references 30

4. 4 | Consolidation Report - From testing to spread
Foreword
The NHS has to identify ways to improve both quality and productivity in
order to continue to improve patient care in a tight economic climate.
This report provides significant encouragement that we can achieve the
joint aims of quality and productivity in the care of people with cancer.
It describes a range of ways in which cancer care can be streamlined and
become more patient-centred. The techniques all follow the four
Winning Principles. The report contains details of the spread of these
techniques accompanied by an estimate of the potential savings that Celia Ingham Clark
they can deliver in terms of bed-days and costs, and it demonstrates
effective implementation of the Cancer Reform Strategy.
I hope that Trust Medical Directors and Cancer Managers who have not
yet adopted the ‘Winning Principles’ will be motivated to do so on
reading this report. For those who have already delivered some quality
improvements, many of whom are mentioned in the report, the
challenge now is to implement the other improvements too!
Celia Ingham Clark
Colorectal Surgeon and Medical Director, Whittington Hospital, London.
National Clinical Lead Transforming Inpatient Care Programme

5. Consolidation Report - From testing to spread | 5
Summary
The Cancer Reform Strategy (CRS 2007) highlighted the need to focus attention on inpatient
care. Too many patients were being admitted into hospital and lengths of stay were often
unnecessarily prolonged. The CRS established the Transforming Cancer Inpatient Care
Programme to take this forward and test out ideas that would improve quality and reduce
unnecessary inpatient bed days.
This report is the product of a review undertaken From testing to spread
by NHS Improvement examining the progress and The learning from testing was disseminated widely
impact of 25 Acute Trusts who took part in the throughout the testing period (July 2007-2008) to
Transforming Cancer Inpatient Care Programme encourage early adopters. Spreading the Winning
(July 2007-2008) and the subsequent spread of Principles Strategy was launched in July 2008.
the Winning Principles and models of care across Evidence from the subsequent spread survey
England. (December 2009) identified:
The report forms part of NHS Improvement • 54 NHS Trusts (covering 72 hospital sites) were
evaluation strategy, and provides evidence of spreading the quality principles and models.
progress to the Department of Health Cancer • 183 improvement activities have been reported.
Programme Board supporting the quality, • The main focus for spread surrounds Winning
innovation, productivity and prevention Principles 1 and 2; emergency and elective care,
(QIPP) agenda. the application of communication alert systems,
enhanced recovery approaches, 23 hour breast
Achievements of the 25 Acute Trusts model and symptom specific pathways e.g.
The 25 Acute Trusts incorporates 37 hospital sites febrile neutropenia.
which covered 16% of acute providers for cancer • Coverage increased across England from 16%
services across England. In terms of improving to 34% of secondary acute providers
quality and productivity good progress was made (see Figure 1).
against the baseline position (see Figure 2). • The 2008/09 national picture shows that the
total of bed days peaked at 5.25m in 2005/06.
• Through testing the Trusts identified four simple Since then there has been a 15% fall. The
quality principles, published as ‘The Winning ‘Spread activity’ contribution to the national
Principles’ (July 2008); fundamental to picture over the last two years saw a shifted
improving emergency and elective pathways, from 2.4% bed capacity released during testing
clinical decision-making and enhancing patient to 34.17% as subsequent spread.
self-management. • Nationally, 264,340 bed days were released
• Across the Trusts 108,067 potential bed day towards saving a million beds days (2012).
capacity was released (Figure 2). Progress is being made but the pace of spread
• Based on the lower estimate of £200 per needs to be accelerated.
patient, per bed day, the potential released • The four key levers identified by Trusts to
efficiency saving for the 25 trusts was £21.6m. accelerate spread were planning for spread,
having communication and awareness
strategies, identify and the use of opinion
leaders and sharing comparative data (see
Figure 24).

6. 6 | Consolidation Report - From testing to spread
Figure 1: What contribution are the 54 Trusts making to
the national picture and the potential impact?
Spread strategy
launched
July 2008
2007-2008 2008-2009 2009-2010 Full
year projection
(provisional)
54 Trusts episodes ( emergency/elective 298,595 288,527 309,657
inpatients)
54 Trusts bed days 1,750,564 1,660,251 1,730,149
54 Trusts reduction in length of stay from 0 90,313 20,415
2007-2008 Year
54 Trusts reduction potential savings in £0 £18,062,600 £4,082,933
length of stay from 2007-2008 Year
54 Trusts % contribution bed days towards 0.00% 34.17% 16.03%
national coverage 2007-2008 Year
2007-2008 2008-2009 2009-2010 Full
year projection
(provisional)
National Episodes (emergency/elective 775,279 757,494 807,621
inpatients)
National bed days 4,759,067 4,494,727 4,631,701
National reduction in length of stay from 0 264,340 127,366
2007-2008 Year
National potential savings in length of stay £0 £52,868,000 £25,473,133
from 2007-2008 Year (£200 per patient per
bed day lower estimate)
National bed day saving from 0.00% 5.55% 2.68%
2007-2008 Year
The national picture shows that the total bed days peaked at 5.25m in 2005/2006.
Since then there has been a 15% fall to around 4.5m.

7. Consolidation Report - From testing to spread | 7
Where to next: A focus on spread • Spreading Winning Principle 2, key models:
Retaining the focus on accelerating the pace of • The 23 hour breast model of ambulatory care
spread remains a priority. across cancer networks.
• Enhanced Recovery approaches
This review provides a useful baseline upon which • Shifting procedures from inpatient to
to build the next stage of the Transforming alternative care settings.
Inpatients Spread Strategy (2010-2012). This will • Repeating the spread survey during the
include: summer of 2010 and 2011.
• Emergency and Urgent Care Initiative led by The Winning Principles
NHS Improvement. Due to the increasing
number of emergency admissions, the focus 1. Unscheduled (emergency) patients
needs to be retained on spreading Winning should be assessed prior to the decision
Principle 1 and the new models of emergency to admit. Emergency admission should
and urgent care that include: be the exception not the norm.
• Triage, Treat, Transfer Pathways
• Telephone triage
• Crisis resolution teams and integrated 2. All patients should be on a defined
community working inpatient pathways based on their
• Improved patient signposting to urgent tumour type and reasons for
care settings admission.
• Proactive risk management by telephone to
avoid unnecessary admissions
• Communication Alerts 3. Clinical decisions should be made
• Emergency Care Practitioner assessment on a daily basis to promote proactive
case management.
and triage
• Home tele-monitoring - Diagnostics and
testing at home
• Patient ownership of health records and 4. Patient and carers need to know
emergency/urgent care plans about their condition and symptoms
• 24 hour pharmacies holding emergency drug to encourage self-management and to
box (for OOH GPs) know who to contact when needed.
• Pain management without hospital admission
• Acute Oncology Models

8. 8 | Consolidation Report - From testing to spread
Introduction
The report draws on 180 pieces of evidence from qualitative and quantitative sources, including;
learning diaries, case studies spread planners, local data and a spread survey (October 2009 -
December 2009). Hospital Episode Statistics (HES) provided baseline measures (2006/7) and
measures of progress (2009).
Review objectives Since the commencement of the Transforming
The objectives of the review were firstly to Inpatient Care Programme 2007, the learning
consolidate the progress of the 25 test gained has been disseminated nationally
trusts by: (Transforming Care for Cancer Inpatients 2008-
• Examining the progress and quantifying 2009) and shared with the Department of Health
benefits, investments and potential reductions in Enhanced Recovery Partnership Programme (2009)
lengths of stay and bed days. to accelerate the pace of spread; of Winning
Principle 2 across the NHS.
Secondly to:
• Assess the coverage, spread of the Winning Continuous Improvement
Principles and models There is a danger in a report of this nature, to
• Provide direction for the next stage of the judge progress and success on ‘bottom line
Transforming Cancer Inpatient Care Programme deliverables’, particularly at a time when
Spread Strategy. productivity and cost savings are high on the
health agenda. It is therefore important to
Spread recognise that the improvements tested involve
The definition of spread in the context of this many dimensions of change including systems,
report has been used as a measure not only of process redesign, changes in behaviour and
increasing numbers but also indicating which clinical and managerial practice. This report is
winning principles and models have been spread based on the evidence received which may not
or adopted and what local levers are being used reflect all the local variables. In most cases, the
to support this. spread reported is ongoing and therefore the
findings in this report should be read within this
context.

9. Consolidation Report - From testing to spread | 9
25 NHS acute test trusts: Progress, impact
and benefits
Achievements
Continuous incremental progress has Figure 2: Average Length of Stay - All Cancers
(All episodes emergency and elective inpatients)
been achieved across the 25 test 25 Test Trusts Emergency and Elective Inpatient Cancer Admissions
trusts. The majority of sites achieved a Average LOS 2006/07 Baseline, 2007/08 Testing
reduced length of stay from the
original 2006/07 Hospital Episode 9
2006 - 2007 2007 - 2008 2008 - 2009
Statistics* baseline position (Figure 2). 8
Average Length of Stay (days)
7
• 80% - Reduced length of stay
during the testing period (July 6
2007/08). Releasing 73,582 5
potential bed day capacity 4
• 80% - Continued to reduce length
3
of stay following the testing period
• Overall - 76% reduced length of 2
stay from the 2006/07 baseline 1
position, releasing potentially
0
108,067 bed days, which is a 12% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
reduction from the 2006/07 Trust
baseline position (Figure 3) NHS Trusts
• The contextual information around 1. Barking, Havering and Redbridge 14. Royal Berkshire NHS Foundation Trust
Hospitals NHS Trust 15. Sandwell and West Birmingham Hospitals
the trusts where length of stay was 2. Barts and The London NHS Trust NHS Trust
not reduced or sustained indicated 3. Blackpool, Fylde and Wyre Hospitals NHS 16. Scarborough and North East Yorkshire Health
issues surrounding data collection, Foundation Trust Care NHS Trust
4. Brighton and Sussex University Hospitals 17. Sherwood Forest Hospitals NHS
improvement work discontinued NHS Trust Foundation Trust
and changes in leadership. 5. The Christie Hospital NHS Foundation Trust 18. South London Healthcare NHS Trust
6. East Sussex Hospitals NHS Trust 19. St Helens and Knowsley Hospitals NHS Trust
7. Great Western Hospitals NHS Foundation Trust 20. The Hillingdon Hospital NHS Trust
8. Hull and East Yorkshire Hospitals NHS Trust 21. The Whittington Hospital NHS Trust
9. King’s College Hospital NHS Foundation Trust 22. United Lincolnshire Hospitals NHS Trust
10. Milton Keynes Hospital NHS Foundation Trust 23. University Hospital Birmingham NHS
11. North West London Hospitals NHS Trust Foundation Trust
12. Northampton General Hospital NHS Trust 24. University Hospitals of Morecambe Bay NHS Trust
13. Oxford Radcliffe Hospitals NHS Trust 25. Whipps Cross University Hospital NHS Trust
Figure 3: Inpatient episodes and bed day data
25 Test Trusts
2006/07 2007/08 2008/09
Baseline Testing Commence
*All the HES data used in the review refers to:
Spread
LoS = HES Length of Episode (Epiend - Epistart).
If more than one episode was present in spell Episodes 144,442 148,222 141,650
then episode LoS may not equal full spell
length.
Bed days 894,417 859,932 786,350 108,067
All HES data used is retrospective. Bed day capacity
released
HES Baseline Data - April 2006/07 - Used as a
retrospective baseline. Range 7.8 - 4.28 7.57 - 3.97 6.9 - 3.61
Average LOS 6.9 5.8 5.5
HES Testing Data – 2007/08 – Testing
commenced July 2007 to July 2008
HES 2008/09 - Spread phase Hospital Episode Statistics

10. 10 | Consolidation Report - From testing to spread
Reported benefits and investments
Review of the qualitative information Alert systems have improved Example: Breast 23 Hour Care
identified common themes aligned to communication, reduced length of Model
the current Quality, Innovation, stay and in some cases averted A reduction in wound drains and the
Productivity and Prevention (QIPP) unnecessary admissions and enhanced intervention of not draining seromas.
agenda. timely clinical decision-making. Saved patients extra visits to the
hospital and released clinic time which
Quality Productivity and prevention was utilised for breast pre-assessment.
Key elements for improving the quality Reductions in unnecessary admissions
of patients, and carers, experience and reductions in prolonged lengths Example: Enhanced Recovery
were identified by the sites as: of stay can reduce the risk of hospital Models
• Valuing patient’s time acquired infections, reduce demands The current work of the Enhanced
• Setting and managing patients on staff and releases bed capacity. Recovery Partnership Programme has
expectations identified the potential costs (Figure 4)
• Improving communication and Capturing the benefits and investments required to support
information How trusts individually captured the implementation, if organisations have
• Removing duplication, and non- released capacity and finances in real none of the enhanced recovery
value adding time through terms was a local decision and not elements in place. Dedicated time,
streamlining the pathway of care. captured in the review. Feedback clinical leadership and change
from test sites indicated some management skills are the key
Innovation organisations utilised the released investments required.
Changes in clinical practice such as capacity to achieve the18 week wait
the enhanced recovery approaches and the cancer 62-day target.
and 23 hour breast care model:
Figure 4: Enhanced recovery
• Improved the knowledge of Investment
model estimated costs per patient
outcomes Investment during testing varied from (8 major surgical procedures)
• Reduced postoperative site to site dependent on trusts,
complications. individual starting point and local Pre-referral £9 - 35
capacity and capability. Investment Pre-operative £20 - 82
This reflects the Varadhan reported was predominately time, Admission £4 - 10
study (2010) that indicated the support from clinicians, management
Surgery £69 -111
implementation of four or more and service improvement and change
elements of Enhanced Recovery leads management expertise. Costs Post- surgery £30 - 73
to a reduction in length of stay by identified were minimal and often Total net cost £142 to £311
more than two days and an almost offset by cost savings from reduction
Department of Health Enhanced
50% reduction in complication rates in use of unnecessary equipment such Recovery Partnership Programme
in patients undergoing major open as drains and by re-organising (2009)
colonic/colorectal surgery. resources.
These clinical models use the most up
to date surgical and anaesthetic
techniques, challenge traditional
practices and promote the
management of patient
expectations.

11. Consolidation Report - From testing to spread | 11
Impact of the Winning Principles and Models of Care
Testing identified four quality
focused ‘winning principles’ and
practical models of care.
The Transforming Inpatient Programme
has been acknowledged as providing The Winning Principles
excellent examples of ‘Quality, Innovation Winning Principle 1
and Productivity in Practice’ (David Unscheduled (emergency) patients should be assessed prior to the decision
Nicholson CEO NHS, 2009), and the to admit. Emergency admission should be the exception not the norm.
Transforming Inpatient publication (2009)
Sharing the Learning, was commended Winning Principle 2
as best professional education initiative All patients should be on defined inpatient pathways based on their
in Oncology (Excellence in Oncology tumour type and reasons for admission.
2009). Winning Principle 3
Clinical decisions should be made on a daily basis to promote proactive
case management.
Winning Principle 4
Patient and carers need to know about their condition and symptoms to
encourage self-management and to know who to contact when needed.
www.improvement.nhs.uk/cancer/inpatients

12. 12 | Consolidation Report - From testing to spread
Winning Principle 1
Unscheduled (emergency)
patients should be Figure 5: Winning Principle 1 - Baseline and potential impact
assessed prior to the
decision to admit. 15 Test Trusts
Emergency admission Emergency 2006/07 2007/08 2008/09
should be the exception Baseline Testing Commence
not the norm. Spread
Episodes 95,361 96,668 96,764
Fifteen trusts tested different
models that included defining Bed days 560,516 540,418 518,371 42,147
emergency pathways for Bed day capacity
symptoms, palliative care and released
specific conditions such as
neutropenic sepsis. Trusts tested a Range LOS 7.57 - 4.25 7.57 - 3.97 6.85 - 3.72
range of communication alert
systems and approaches for rapid
access to timely clinical decision
making, which supports Winning
The average length of stay for cancer
Principle 3.
related emergency admissions
nationally by PCT is 6.5 days across
Across the 15 test sites, the
England, ranging from 4.1 days to
potential of 42,147 bed day
9.0 days. (HES. 2008/09).
capacity (from the baseline
position) was released
• Emergency bed days average 11.3
(Figure 5).
bed days per new cancer case,
ranging from 7.1 to 17.7 bed days.
Model of Care: Communication
Alerts
Three trusts tested communication
alert systems across specific tumour
groups. Local data showed that alert
systems had an impact on reducing
length of stay by 25% in some
tumour groups (Figures 6 - 9).
Communication alerts were
significantly effective for patients
previously diagnosed with cancer
admitted as an emergency (Sherwood
Forest Hospitals NHS Foundation
Trust case study 2008). Local data
WINNING PRINCIPLE 1
identified a number of admissions
averted, this data is not captured by
HES.

13. Consolidation Report - From testing to spread | 13
Figure 6: Average Length of Stay: Emergency Lung Inpatients
10
2006 - 2007 2007 - 2008 2008 - 2009
9
Average Length of Stay (days)
8
7
6
5
4
3
2
1
0
Northampton Sherwood Forest United Lincolnshire
General Hospital Hospitals NHS Hospitals NHS Trust
NHS Trust Foundation Trust
NHS Trust
HES data.
Figure 7: Communication Alert for Recurring Admissions Across
Tumour Sites - Kings Mill Hospital.
Comparison of median length of stay for non-elective breast, gynaecological,
lower GI and lung patients, pre, during and post implementation of RAPA
15
15
Breast Gynaecological Lower GI Lung
10
Time (days)
9.5
8
5 6 6 6 6
5
4 4
3 3
0
Pre RAPA Feb 2007 April 2009
RAPA Trial Post RAPA
Based on local trust data.

14. 14 | Consolidation Report - From testing to spread
United Lincolnshire Hospitals NHS
Figure 8: Trust commenced testing in urology
Average length of stay by known cancer patients readmitted to hospital non
and upper gastrology and this has
electively with symptoms related to primary cancer or treatment -
United Lincolnshire Hospitals NHS Trust now spread to lung cancer patients
across four hospital sites (Figures 8
12
Upper GI Urology Lung and 9).
10
Number of days
8
6
4
2
0
2006/07 2007/08 2008/09 2009/10
Based on local trust data.
Figure 9:
Average length of stay by known cancer patients readmitted to hospital as
emergencies with symptoms related to primary cancer or treatment -
Lung - United Lincolnshire Hospitals NHS Trust
14
2008/09 2009/10
12
10
Number of days
8
6
4
2
0
Lincoln Louth Grantham Boston
United Lincolnshire Hospitals NHS Trust includes Lincoln County Hospital, County Hospital
Louth, Grantham and District Hospital and Pilgrim Hospital Boston.
Based on local trust data.

15. Consolidation Report - From testing to spread | 15
Model of Care: Emergency and
Symptom Pathways Figure 10: Emergency and Symptom Pathways
Average Length of Stay All Cancers (All Episodes). Diagnosis = All Admission.
13 trusts defined emergency Method Group = Emergency. Class of Patient = Ordinary Admission
pathways and symptom specific
pathways. Models of care to improve 9
daily clinical decision-making 2006 - 2007 2007 - 2008 2008 - 2009
8.5
Average Length of Stay (days)
(Winning Principle 3), emergency
8
triage approach to identify the
7.5
patients preferred place of care
7
(Figure 10).
6.5
6
5.5
5
4.5
4
Barts and Blackpool Brighton Christie Great Hull & Milton Oxford Royal St Helens The The University
The London Fylde & Sussex Hospital Western East Keynes Radcliffe Berkshire and Hillingdon Whittington Hospitals of
NHS Trust & Wyre University NHS Hospital Yorkshire Hospital Hospitals NHS Knowsley Hospital Hospital Morcambe
Hospitals Hospitals Foundation NHS Hospital NHS NHS Trust Foundation Hospitals NHS Trust NHS Trust Bay NHS
NHS NHS Trust Trust Foundation NHS Foundation Trustt NHS Trust Trust
Foundation Trust Trust Trust
Trust
Trust
HES data.

16. 16 | Consolidation Report - From testing to spread
Winning Principle 2
All patients should be
on defined inpatient Figure 11: Winning Principle 2 - Baseline and potential impact
pathways based on their
tumour type and reasons 10 Test Trusts
for admission. Elective 2006/07 2007/08 2008/09
Baseline Testing Commence
Spread
Ten trusts defined elective Episodes 52,852 53,149 48,182
pathways and models including
the 23 hour for Breast Care Bed days 358,884 344,064 290,931 67,953
Model, enhanced recovery Bed day capacity
approaches and shifting inpatient released
procedures to an ambulatory
setting. Range LOS 7.81 - 5.08 7.36 - 4.97 7.07 - 4.79
The trusts potentially released
67,953 bed days (from the
baseline position) (Figure 11). The average length of stay for cancer
related elective admissions nationally
by PCT is 7.2 elective bed days per
new case. The range was from 4.9
days to 11.5 (HES 2008/09).
Clinical Models of Care: Breast 23
Hour Care Model
The Breast 23 hour care model was
significantly successful. It started in
one trust with one clinician and
spread across the Pan Birmingham
Cancer Network. Clinicians engaged
with the testing following a visit to
Kings College Hospital NHS
Foundation Trust where clinicians had
tested not inserting wound drains.
This practice was incorporated into
the 23-hour pathway and formed
part of testing with further
improvements in clinical decision-
making, clinical practice, design of
the pathway, pre-assessment,
discharge planning and team
working.
WINNING PRINCIPLE 2

17. Consolidation Report - From testing to spread | 17
Figure 12: 23 Hour Breast Care Model across the Pan Birmingham Cancer Network
April to December 2009 (9 months)
LENGTH OF STAY (DAYS)
HOSPITAL SITE Breast Conserving Surgery (wide local excisions) Mastectomy
11+ 6 to 10 2 to 5 1 0 11+ 6 to 10 2 to 5 1 0
0% 0% 15% 43% 42% 2% 5% 51% 37% 5%
0% 6% 6% 22% 67% 0% 13% 31% 31% 25%
0% 0% 1% 46% 53% 5% 10% 25% 56% 5%
1% 0% 1% 16% 83% 0% 4% 16% 52% 29%
0% 10% 10% 30% 50% 0% 27% 55% 9% 9%
1% 0% 5% 43% 51% 9% 12% 43% 30% 6%
0% 1% 10% 74% 14% 1% 6% 54% 36% 3%
0% 1% 5% 39% 55% 3% 9% 39% 38% 10%
City Hospital provides 94% of all breast surgery within 0 to 1 days.
The network achieves a combined total of 74% in 0 to 1 days 94% 49%
Data taken from CBSA and relates to payments made.
Pan Birmingham local data (April - Pan Birmingham Cancer Network
December 2009) demonstrates the overall delivered the 23 hour breast
spread and adoption position of the care model (at the time of the review)
23 hour breast care model across the to 74% of all breast surgery patients
cancer network. Figure 12 shows the (excluding reconstructions).
overall delivery of wide local excisions
is 94% with 548 patients The original test site at the City
experiencing this pathway approach. Hospital now delivers the 23 hour
Mastectomies are currently at 49% breast care model to 94% of all
(348 patients) and the approach breast surgery patients (excluding
continues to spread. reconstructions).

18. 18 | Consolidation Report - From testing to spread
Potential savings identified
Figure 13: 23 Hour Breast Model - Potential Value for Money The realisation of these efficiency
Potential cost savings for breast across the Pan Birmingham Cancer Network benefits across the Pan Birmingham
Cancer Network was a by-product of
Test sites Total number Average Inpatient Day case Potential improving quality. It was locally
of episodes length of cost at £200 cost at £250 savings determined how to use the released
stay per day per day capacity and capture the efficiency
gains (Figure 13).
Sandwell & West 473 5.32 503,272 118,250 385,022
Birmingham
During testing the figure of £200 per
University Hospital 394 4.04 318,352 98,500 219,852 day inpatient bed day is based on the
Birmingham lower estimate of costs used to
provide a baseline figure and to
Birmingham 270 5.19 280,260 67,500 212,760 illustrate the potential.
Heartlands
Hospital
Good Hope 156 5.03 156,936 39,000 117,936
Hospital
Walsall Hospital 231 3.95 182,490 57,750 124,740
Network Total 1524 4.70 1,432,560 381,000 1,051,560
Based on local trust data.
Across the West Midlands 15 out of
Figure 14: Average Length of Stay: Breast Inpatient Admissions 17 PCTs had the lowest average
length of inpatient stay for breast
7.5
7
2006 - 2007 2007 - 2008 2008 - 2009 surgery (Figure 14).
6.5
Average Length of Stay (days)
6 The future potential of the 23
5.5 hour Breast Care Model is
5
4.5
significant if spread
4 • National average length of stay for
3.5 breast surgery is 2.8 days (HES
3 2009)
2.5
2
• 34,000* new cases are registered
1.5 per annum in England.
1 • 34,000 x 2.8 days = 95,200 bed
0.5
days. Lower estimate £200 per bed
0
day = £560 per patient.
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Elective
Emergency
Net cost £19.04m
East East of London North North South South East South West Yorkshire &
• 23 Hour Breast Model - 34,000
Midlands England
SHA SHA
SHA East
SHA
West
SHA
Central
SHA
Coast
SHA
West
SHA
Midlands the Humber
SHA SHA
new patients = 34,000 bed days
= £6.8m.
SHA of Trust/Admission Method
*Cancer Registrations in England 2000

19. Consolidation Report - From testing to spread | 19
Clinical Models of Care: Enhanced
recovery approaches Figure 15: Colorectal Enhanced Recovery - Winning Principle 2
Average Length of Stay: Elective Inpatients Lower GI Procedures.
Enhanced recovery approaches (Lower GI Neoplasm. Procedure L1 = Colectomy, Excision of Rectum)
tested in colorectal (Figure 15),
gynaecology (Figure 16), and urology,
14
reduce length of stay from the 2006 - 2007 2007 - 2008 2008 - 2009
baseline position.
Average Length of Stay (days)
12
10
The learning from this testing has
been shared with the Department of 8
Health Enhanced Recovery Partnership
programme. 6
4
2
0
City Hospital Queen Mary’s Hospital Whipps Cross
Sandwell and West South London University Hospital
Birmingham Hospitals Healthcare NHS Trust Whipps Cross University
NHS Trust Hospital NHS Trust
Trust/Hospital Site
Figure 16: Gynaecology Enhanced Recovery - Winning Principle 2
Average Length of Stay: Elective Inpatients Gynaecological Procedures.
(Gynaecological Neoplasm. Procedure L1 = Procedure on Uterus)
9
2006 - 2007 2007 - 2008 2008 - 2009
8
Average Length of Stay (days)
7
6
5
4
3
1
0
Queen Elizabeth The Queen Mother Hospital
East Kent Hospitals University
Trust/Hospital Site

20. 20 | Consolidation Report - From testing to spread
Model of Care: Shifting care
Figure 17: Barking, Havering and Redbridge Hospital NHS Trust - Baseline & progress from an inpatient setting
(Elective Day Care and Inpatients Breast. Gynaecology, Haematology, Head & Neck, Shifting care to an alternative setting
Lower GI, Thorax, Upper GI, Urology)
was tested by Barking Havering and
Redbridge Hospital NHS Trust.
700
Day case admission - Barking, Havering and The testing focused on shifting
Redbridge Hospitals NHS Trust - Queen’s Hospital
600 procedures traditionally carried out in
Ordinary admission - Barking, Havering and haematology and oncology inpatient
Redbridge Hospitals NHS Trust - Queen’s Hospital
beds to a day case setting (Figure 17).
500
Number of Episodes
The local data in figure 18 illustrates
400 the potential investment and the
valuing of patients’ time.
300
200
100
0
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
Breast Gynaecology Haematology Head & Neck
Tumour Group/Year
700
600
500
Number of Episodes
400
300
200
100
0
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
2006 - 2007
2007 - 2008
2008 -2009
Lower GI Thorax Upper GI Urology
Tumour Group/Year
Based on local trust data.

21. Consolidation Report - From testing to spread | 21
Fig 18: Quantifying the impact and valuing patients time
Procedure Average no. Average no. Average no. Average cost Average cost Number of Released
of hours of hours of hours per inpatient per day case patients cost for
spent as spent as saved per procedure (audit data through day audit
inpatient day case procedure (baseline data based based on £18.75 unit during period
(baseline data) (baseline data) on £8.30 per hour) per hour) audit
Hickman line insertion 92 4.5 87.5 £763.60 £84.37 5 £3393.15
Blood Transfusion 35 7.5 27.5 £290.50 £140.62 14 £2098.32
Ascitic Drain 76 9 67 £630.80 £168.75 9 £4158.45
CT Guided Biopsy 128 6.5 121.5 £1062.40 £121.87 6 £5643.18
US Guided Biopsy 20 6 14 £166.00 £112.50 3 £160.50
HDR Full Insertion 24 7 17 £199.20 £131.25 9 £611.55
IV Antibiotics 113 7.5 105.5 £937.90 £140.62 2 £1594.56
Total Cost Saving £17,659.71
Barking, Havering and Redbridge NHS Model of Care: Parencentesis in
Trust is continuing testing and the hospice setting
spreading the principles making East Sussex NHS Trust tested averting
improvements in: inpatient admissions for patients from
the local hospice that required a
• Direct access for Sickle Cell parencentesis, and tested this being
patients. undertaken at the hospice. The
• Further reducing wasted patients concept was tested successfully, and
time for some procedures in spread to another site, although
assessment beds. numbers of patients are small. The
• Testing protocols for outpatient outcomes of testing has spread and
management of Neutropenic integrated into local emergency
Sepsis. improvement work.
• Further shifting care to and
reducing unnecessary inpatient
admissions.
• Testing whether assessment beds
could be included in the 4-hour
bed wait target?

22. 22 | Consolidation Report - From testing to spread
Winning Principle 3
Clinical decisions should The Whittington Hospital Brighton and Sussex University
be made on a daily basis NHS Trust Hospitals NHS Trust
to promote proactive case The local approach was to have the Tested several strategies to maximise
management. availability of an acute oncologist and timely clinical decision-making which
rapid access clinics. included improved communications
between clinical teams, weekly MDT
This is not a stand-alone principle Access to daily clinical decision ward discussions, Daily paper review
as timely clinical decision-making making has: of inpatients including outliers,
is a key component integrated admission priority assessment and
within all the principles, • Reduced unnecessary lengths of agreed pathway trigger points to
pathways and models of care. stay for new unknown cancers - avoid discharge delays.
Two trusts, Brighton and Sussex from 17.1 days to 12.1 days. A
University Hospitals NHS Trust reduction of five days for Evidence relating to surgical, medical
and The Whittington Hospital previously unknown cancer and haematology daily clinical
NHS Trust tested this principle patients who were admitted as decision making appears to be well
across oncology. emergencies compared with the established and built into consultant
year before adopting Winning job plans. This does not appear to be
Principle 3 for acute oncology. the case in oncology. Further
• Made a reduction in average evidence may emerge in this area
length of stay of 3.7 days for from the National Chemotherapy
known cancer patients. Implementation Group.
• Significantly decreased the number
of unnecessary tests patients
would have undergone. This values
patients’ time and improves the
patient experience.
WINNING PRINCIPLE 3

23. Consolidation Report - From testing to spread | 23
Winning Principle 4
Patient and carers need to
know about their condition
and symptoms to encourage
self-management and to
As part of the testing, all sites were
encouraged to engage patients in
promoting self-care. Various
approaches were used during the
“
The patient’s stories in the
DVD are very powerful and
make much more impact on
know who to contact
testing including patient education, other patients and carers
when needed.
information, production of a DVD and about the importance of
”
telephone help lines as central contact presenting early.
points. The view from the review
Lead cancer nurse
team was that testing had not
demonstrated or captured ‘real self-
“
management’ and only a few sites
had been able to quantify the impact
of the interventions during testing. It This DVD is a good idea.
appeared that once implemented or
products produced the capture of
Verbal information and
impact data/audit was discontinued, leaflets don’t really sink in
although patient satisfaction audits because it’s such a difficult
continue. time. You can’t take it all in,
it’s a bit too much, but I think
We know that patients are receiving
information and that for example,
the DVD will stick in people’s
”
Blackpool, Fylde and Wyre NHS minds.
Foundation Trust has distributed a Husband of a patient
DVD to over 500 patients across the
cancer network. The DVD is given to
patients on chemotherapy, helping
them to identify the signs and
symptoms of neutropenic sepsis. The
DVD has been acknowledged as good
practice and has been adopted by
other areas.
There will be the opportunity to
capture more information from the
National Patient Survey regarding
inpatient care and with the new
emergency initiative this will provide
the opportunity to focus on some
specific areas of self-care
management.
WINNING PRINCIPLE 4

24. 24 | Consolidation Report - From testing to spread
Summary: Consolidation of testing
The 25 test sites provided evidence of
progress, potential impact and the
ongoing implementation of the
winning principles and models of care
that improve quality of the patient
experience and productivity. The
progress reported here demonstrates
that test trusts have moved from
initial testing and that improvement
continues. The quantitative figures
however should not be judged in
isolation of the organisational context
and complexities of change involved.

25. Consolidation Report - From testing to spread | 25
Beyond testing: Coverage and spread
Since the commencement of the Expansion and coverage beyond the 25 test sites
Transforming Inpatient Care Spread is evident across England, going beyond the 25 test trusts (Figure 19), with
Programme 2007, the learning has 34% of the potential acute secondary providers indicating they are involved in
been widely shared and disseminated spreading the quality Winning Principles and Models of Care. This provides a
nationally as part of the spread useful baseline position of coverage.
strategy (Transforming Care for Cancer
Inpatient Publications, 2008, 2009.
Annual Conference 2008, 2009).
Figure 19: Beyond testing - coverage and spread map
155 Potential Acute Secondary 8
Care Provider Trusts*
25 Test Trusts (covering 37
hospital sites)
December 2009 - 54 Trusts
(covering 72 hospital sites)
2 2 14
4 10 26
3 6 8
2 6 16
1 18
4 6 9
8 12 26
1 2 13
1 9 17
*Does not include Children, Mental Health, Eyes, Orthopaedics, Heart/Chest, and Rheumatic Diseases.

26. 26 | Consolidation Report - From testing to spread
Spread activity
In some areas, to accelerate the pace
of spread, the tested models of care
have been identified as a health
community priority and brought in as
part of local commissioning for quality
and innovation framework quality
accounts (CQuINS).
Figure 20: Spread and adoption activity by SHA
SHA Emergency Neutropenic Communication Enhanced 23 Hour Shifting Clinical Decision Self
Pathways Sepsis Alerts Recovery Breast Procedures Making Management
East Midlands
East of England
London
North West
South Central
South East Coast
South West
West Midlands
Yorkshire & the Humber
North East

27. Consolidation Report - From testing to spread | 27
Figure 21 highlights which quality Winning Principle is being adopted and spread.
Figure 21: Extent of spread
Spread Survey
December 2009 - January 2010
Communications Alert Systems - Winning Principle 1
Emergency Pathways - Winning Principle 1
Palliative Care Pathways - Winning Principle 1
23 Hour Breast Care Surgical Model - Winning Principle 2
Enhanced Recovery Pathway - Winning Principle 2
Patient Transfers/Repatriation - Winning Principle 2
Shifting Procedures from Inpatients to Day Care - Winning Principle 2
Carcinoma of Unknown Primary - Winning Principle 2
Clinical Decision Making - Winning Principle 3
Neutropenic Sepsis - Winning Principle 1 & 4
23 Hour Helpline - Winning Principle 4
Acute Oncology Model - Winning Principle 1 & 3
0 5 10 15 20 25 30
Number of Hospital Sites
Good ideas and innovations are • 72 hospital sites are actively
spreading and being adopted by spreading the improvements. Some
organisations, clinicians and managers sites are embarking on more than
across England with quality as the one improvement activity.
key driver. • From the evidence reviewed
(December 2009) - there are
currently 183 improvement activities
supporting spread across England.