The document discusses two examples of service transformations in the NHS: OG Cancer services and Healthier Together. For OG Cancer, the transformation team developed a repeatable process over 10 years to consolidate surgical sites for a rare cancer type, involving clinical leadership, co-design with patients, and clear governance. Healthier Together was a larger transformation of emergency services across Greater Manchester. It involved designing new standards and a different staffing model to improve outcomes for high-risk emergency patients, as well as a robust decision making process to select hospital configurations that withstood judicial review.

1. Jen Parsons - Leading on transformation
in the NHS what it really takes to deliver
meaningful change

2. Who are we?
~35 strong team
of skilled
professionals
~35 strong team
of skilled
professionals
We are NHS
but not as you
know it…
We are NHS
but not as you
know it…
A not-for-profit
internal
consultancy
A not-for-profit
internal
consultancy
Passionate
about improving
care for patients
Passionate
about improving
care for patients
Specialists in
service
transformation
Specialists in
service
transformation

3. Why transformation?
Why not incremental change?

4. Incremental change doesn’t always get you to
where you need to be…
Today - share with you some of our learning and experience
of what it really takes to deliver change

5. The NHS is facing some huge challenges
The NHS belongs to us all
Reconfiguring services can challenging, rewarding and
controversial…
The NHS belongs to us all
Reconfiguring services can challenging, rewarding and
controversial…

6. Two examples
OG
Cancer
OG
Cancer
Healthier
Together
Healthier
Together

7. OG Cancer Service, Oct 2016
“Greater Manchester hasn’t been compliant on this service since new
guidelines came out in the early 2000s, so efforts to consolidate the surgical
sites have been going on for more than 10 years. This is a really powerful
sign that Greater Manchester is now able to sort its own stuff out.”

8. How did we get there?
• Picked something difficult, but small 150-170 patients a year
• Developed a repeatable process with 5 deliverables:
• Clinical leadership to design a ‘best in class service’
• Co-design with patients
• Clear governance for commissioner decision
System co-design
Commissioner
decision making

9. Sue was diagnosed with breast cancer 14 years ago, and while in remission
became chair of a patient group in Chester, and a member of a patient group
for Upper Gastro Intestinal Cancer. She was then diagnosed with cancer again.
“It is ironic that whilst sitting on this group, I was diagnosed with a rare UGI
cancer. After a big operation and part of my stomach removed, I felt I had
earned my badge to sit on the group.
It is amazingly powerful to speak at these meetings and start a sentence with
‘as a patient’. The professionals listen to you and respect our input. We have
had many successes of tweaking the system for the good of patients.
There have been challenges, yet throughout, we didn’t lose sight of the need
to make meaningful change for Greater Manchester residents. We’ve started
from scratch from diagnosis to recovery. I feel proud that there are a set of
standards developed by patients and professionals.”
Co-design with patients – Sue Kernaghan

10. Healthier Together
A&E, Acute Medicine, General Surgery
• Larger scale ~160 patients a day experiencing a life-
threatening condition
• High variation in patient outcomes from hospital to
hospital
• Patients who may need emergency abdominal surgery are
high risk, need to be assessed by a consultant surgeon, will
require critical care
• Critical shortage of A&E consultants, and general surgeons
• Geography of Greater Manchester provides an opportunity
to work together

11. Patient with a bowel obstruction, Lynda 69
Lynda was unlucky. By the time she was operated on some bowel had died and had to be
removed. She suffered a chest infection after surgery but slowly recovered on the surgical
ward for 12 days before being discharged with a wound infection.
Average mortality nationally following emergency general surgery is ~15% and ranges from 3
– 40+%. These patients have been called ‘the forgotten group’
At the ED, Lynda
is assessed by an
A&E junior
doctor who is on
shift.
It’s 8pm
She examines
Lynda and notes
she is vomiting,
with abdominal
pain and
distension. She
refers her to the
general surgical
F2
15 hours after
Lynda arrived at
A&E a critical
care bed is
confirmed and
the consultant
performs an
emergency
laparotomy
The general
surgical F2
examines Lynda
and arranges
blood tests and x-
rays. She is not
sure what is
wrong and is not
senior enough to
order a CT scan
The general
surgical registrar
sees Lynda 6
hours after she
arrives.
He suspects
adhesion-
obstruction and
orders a CT scan
The radiology
registrar isn’t
sure whether the
CT scan shows
strangulation but
decides it can be
reviewed by his
consultant in the
morning
Lynda is reviewed
by the consultant
general surgeon
at 9am.
She suspects
bowel
strangulation and
the radiology
consultant agrees
The general
surgical registrar
is busy in theatre
for several hours.
The consultant is
on call at home
and is scheduled
to do an elective
operating list in
the morning.
Lynda has been in
hospital more
than 4 hours so
she’s been
moved to a ward.
A&E CT scans
take priority so
her scan is
delayed
The surgical
registrar is busy
so it’s 6am before
he reviews Lynda.
Her abdomen is
rigid but he
wonders if it will
settle.
There are no
dedicated
surgical critical
care beds which
delays Lynda’s
surgery further.

12. Future model of care – example standards
EGS013
EGS022
In hospitals specialising in general surgery, a specialist general
surgical doctor is available at all times within 30 minutes
In all high risk cases, a consultant surgeon and consultant
anaesthetist is present for the operation
EGS103
In hospitals specialising in general surgery, emergency patients will
be assessed within 30 minutes of referral in the case of a life-or
limb-threatening emergency, and within 60 minutes for a routine
emergency referral
A new model of care is needed, with new standards and
a different staffing model…
But none of our hospitals can achieve this on their own
A new model of care is needed, with new standards and
a different staffing model…
But none of our hospitals can achieve this on their own

13. Decision making challenge
How do you design a decision making process that will
stand up to scrutiny in court?
How do you design a decision making process that will
stand up to scrutiny in court?
~29,000
consultation
responses
~29,000
consultation
responses
8 options
consulted upon
8 options
consulted upon
42 permutations
of hospitals
working
together
42 permutations
of hospitals
working
together
Travel analysis
Cost £
Workforce
Travel analysis
Cost £
Workforce

14. Healthier Together
17th
July 2015: Unanimous decision on the configuration
of services
17th
July 2015: Unanimous decision on the configuration
of services

15. January 2016 Judicial Review
We planned for it… governance takes on a new level of
importance sat opposite a high court judge…
We planned for it… governance takes on a new level of
importance sat opposite a high court judge…

16. Our services

17. What’s next?
• Standardising acute hospital care across Greater
Manchester
• Large programme ~£1.6bn provider cost base
• Clinically sustainable services
• Big financial challenge

18. Our work is rapidly expanding
Our ambition is to keep skills in the NHS and
reduce NHS reliance on external consultancy
Our ambition is to keep skills in the NHS and
reduce NHS reliance on external consultancy
(Pan Staffordshire)

19. Thank you
jen.parsons@nhs.net
www.transformationunitgm.nhs.uk