Networks

Introduction
The need to involve clinicians and patients is borne out in World Class commissioning (WCC) and in
the process demonstrated in the Our NHS, Our Future review. WCC requires commissioners to:

Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation (Competence 4)
Promote and specify continuous improvements in quality and outcomes through clinical and
provider innovation and configuration(Competence 8)
Proactively seek and build continuous meaningful engagement with the public and patients, to
shape services and improve health (Competence 3).

We strongly advise that the local health economy sets up, or expands, existing networks/planning and strategy groups to ensure that there is representation of service users and carers, public health, smoking cessation and exercise experts, primary and secondary care clinicians (doctors, nurses and allied professionals), practice based commissioners, PCO commissioners, social care, and other parties who have expertise and local knowledge to contribute. There are useful resources from NHS Networks about running networks http://www.networks.nhs.uk/network_support and from NHS Evidence. http://www.evidence.nhs.uk/Search.aspx?t=networks

The evidence about networks suggests that the inclusion of “boundary spanners” and a network manager is also vital to its success. We suggest its role should be to agree on an assessment of local need, undertake a gap analysis using pathway mapping or other improvement tools describe a vision for local services and set standards. In Scotland, where Managed Clinical Networks are an essential part of policy implementation, one of the key roles is overseeing the training and education requirements of local clinicians, audit, and monitoring service provision. In Scotland this role has come out of the findings of the needs assessment process that typically highlights a lack of knowledge amongst clinicians in primary care.

It may be possible to build on the review group work that contributed to the Our NHS, Our Future as the starting point.

Example from our guide How to Prepare a Service Specification: use of a network for implementing NICE guidance
Source: Steve Connellan.

We had a NICE implementation group which sat monthly and comprised consultants/GPs/finance/audit/IT/pharmacy reps and was chaired by the acute trust and PCT alternately. This considered all issues to do with horizon scanning, recently published guidance, Payment by Results, and financial implications for the whole health economy rather than 'them and us'.

Whenever a new guidance was published, a grid of recommendations was produced and this happened for COPD and more recently TB. All stakeholders were then given the opportunity to respond to the guide and the collated response distributed so that everyone could see any hurdles to NICE implementation and (usually) any financial restrictions. There were timeframes for completion of these parts of the process and a database produced that could be accessed by both primary and secondary care. With regard to COPD, we were able to proceed with appointment of a GPwSI (with session for Consultant Respiratory Physician and training resource), establishment of a resource centre, community pulmonary rehabilitation and stronger links between our Consultant Respiratory Nurse and the PCT. There were inevitable frustrations regarding timeframes, finance, attendance and it certainly wasn't all 'rosy' but the model was at least one way, based on NICE, to have a structured dialogue which required a response, whether negative or positive.

What is the network’s role in service delivery?

The network may also have a role in service delivery. In the Scottish system, the network acts as an advocate, plugging into existing systems for provision and commissioning and offering /expert advice and facilitating change. In England, networks are less formally developed. However, the more successful the trust and relationships are between the network, the more likely it is that the commissioner would look to the network to advise on the service and to find ways to improve it.

If a new service is required, with significant investment, then commissioners are likely to be bound by European Union rules on procurement, and they will have to decide how best to do that. See IMPRESS procurement page.

We expect that the forthcoming National Strategy for COPD in England will support the development of networks at regional level. We also recognise that networks can improve care coordination but some policies, such as the policy on competition, may create barriers to integration. Some of these points are drawn out in a recent Health Services Management Centre paper Integrating Care and Transforming Community Services: What Works? Where Next? 2009.

Lessons from IMPRESS as a network role model

1. Involve:

Project manager - argue for dedicated project management time
Managers, commissioners, healthcare professionals
Primary and secondary care and community providers
Lay rep and ways to involve patients
Social care
Will also need to work out position on third sector providers

2. Communicate face-to-face because it achieves:

Increased respect across boundaries
Shared beliefs

3. Share resources, knowledge, opinion eg primary care innovation

Learning: gain from different attitudes eg to risk
Positive relationship with pharma industry (check PCT view but national policy is supportive)
Primary care : find ways to demonstrate competence
Secondary care: consider responsiveness
Campaign for investment in respiratory care: demonstrate how it can meet commissioners’ aims:
reduction in avoidable hospital readmissions and admissions
care closer to patients’ homes
prevention (“upstream” eg system-wide leadership for smoking cessation)

4. Use to horizon scan

Further resources

A new NHS Lung Improvement Programme has also been launched by NHS Improvement to support the development of clinical networks and the implementation of the forthcoming National Strategy for COPD. Its Lung Improvement team will support respiratory leads in the SHAs, the development of Respiratory Networks, and pilot programmes to improve the management of respiratory disease. It will build on the successes of existing national improvement programmes in Cancer, Cardiac, Diagnostics and Stroke services. The Lung Improvement Programme aims to support clinical teams, commissioners, service managers and other key stakeholders deliver effective clinical practice through process improvement and redesign. They have set up a Lung Improvement page here.

IMPRESS will work with LIP to share examples of good practice, and to support the development of local networks.

Presentation at IMPRESS inaugural conference from Dr Iain Small

Cancer networks: http://www.cancerimprovement.nhs.uk/

Royal College of Paediatrics and Child Health: A Guide to Understanding Pathways and Implementing Networks - December 2006
It includes a guide to setting up networks.
http://www.rcpch.ac.uk/publications/recent_publications/Managed Networks.pdf

Scottish Managed clinical networks
http://www.nhshealthquality.org/

http://www.networks.nhs.uk/136.php
has links to all guidance papers and checklists on networks from Scotland and England. Neil Goodwin papers are good.

Nigel Edwards paper 2002 BMJ on PubMed
BMJ. 2002 January 12; 324(7329): 63
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1122027