Rhwydwaith y Galon Gogledd Cymru North Wales Cardiac Network
North Wales Cardiac Network
– The Way Forward
July 2005 Amended November 2005 North Wales Cardiac Network – The Way Forward
1. Introduction
The purpose of this paper is to present the way forward, building upon the work already undertaken as part of the North Wales Cardiac Network Review. The review aimed to ensure that the Network is fit for purpose and effective for the future. To date the process of review has included a period of consultation through questionnaires and analysis, which culminated in the Interactive Workshop facilitated by the National Leadership & Innovation Agency for Healthcare (Report previously circulated).
The interactive workshop gave stakeholder organisations the opportunity to explore themes identified as areas of potential network territory in relation to the ‘Network Purpose and Activities’. The findings from these discussions form the basis of the proposed activities presented in this paper.
The consultation exercise also asked stakeholders to give views on the current Network Support Structures and Board Arrangements. Respondents recognised the need to make the Board effective and influential with support structures designed to deliver against a prioritised work programme agreed by the Board. In responding to this, the initial focus has been the purpose and activities of the Network which will drive the work programme. Structures have been reviewed to support the activities identified by the Stakeholders and proposals are presented in this document.
Supporting all of this is the need for clarity regarding the definition of the ‘network’ and its associated structures, which will help stakeholders understand respective roles, responsibilities and accountabilities.
2. Network Definition and Purpose
There has been a considerable degree of confusion regarding the use of the term Network, which has been interpreted in differing ways by partners. For the purposes of this paper the Network is defined as follows :-
“The Cardiac Network is a coalition of stakeholders involved in the planning, commissioning, delivery and monitoring of cardiac services in North Wales”
The Network must be seen as distinct from the supporting structures which allow it to function. These structures consist of a Network Board and a series of advisory groups which will be identified later in this document. The structures are supported by a group of staff who facilitate the activities of the Network and are referred to as the Network Support Team.
______1 North Wales Cardiac Network – The Way Forward From the responses received to the review questionnaire the role of the Network may be described as :-
“to provide a source of expert clinical advice to support the planning, commissioning and delivery of equitable, effective services for patients with cardiac disease in North Wales”.
In this context cardiac disease refers to the range of conditions covered by the Coronary Heart Disease National Service Framework.
The role of the Network as defined above is very extensive. In order to give a degree of clarity regarding specifically what this entails and the way in which it might be delivered this is discussed in further detail below, under the headings considered at the interactive workshop.
3. Network Activities
The interactive workshop focussed upon five potential areas of Network activity as set out below :-
Supporting Clinical Governance Health Promotion & Disease Prevention Enhancing practice through further development of Care Pathways and Standards Supporting Commissioning and Service Planning Patient & Public Involvement (PPI)
Each of these areas is discussed in turn in the sections which follow. For each there is a description of the role which the Network has to play and where these were identified, potential early tasks for the Network to address. Consideration has been given to the Network using its resources to greater effect by targeting on fewer specific cardiac problems. This should ensure improvement in the quality of advice rather than the adoption of a diverse approach which hitherto has not been truly effective.
Supporting Clinical Governance
Clinical Governance is a statutory duty for the partner organisations in the Network. There are clear lines of accountability both within organisations, professionally, and to the Welsh Assembly Government for the discharge of these functions. It must be recognised that the Network cannot assume any of these responsibilities on behalf of individual clinicians or organisations.
______2 North Wales Cardiac Network – The Way Forward However, the effective discharge of governance is undertaken through a series of processes and systems which could benefit significantly from the advice and support of the Network. Areas for potential activity within the governance field include :-
• The development or adoption of clinical standards for service delivery • The effective implementation of care pathways for specific conditions • The audit of clinical service delivery against standards • Benchmarking of clinical performance between Providers within and outside North Wales • Access to the clinical knowledge and expertise of other neighbouring Networks • The identification of key workforce development and training needs to support delivery of safe, effective services. • The facilitation of training events across North Wales to support effective service delivery.
Through these activities it is envisaged that the Network will assist partners in achieving an equitable, high quality service throughout North Wales.
Health Promotion & Disease Prevention
Effective health promotion and disease prevention is an integral part of the National Service Framework for Coronary Heart Disease and therefore is an issue which is integral to the Network. However, the implementation and delivery of health promotion is firmly rooted in the local Health Social Care and Well being Strategies of Local Health Boards and their Local Authority partners. Furthermore the models for delivery of such activities will reflect local circumstances.
In light of this the conclusion of the discussion at the interactive workshop was that the Network should not seek to play an active role in delivering this aspect of the NSF. However, there is a role which the Network can play in terms of identifying and facilitating the dissemination of good practice across North Wales to support the delivery of these aspects of the NSF.
Care Pathways and Standards
A core component of the role of the Network is to facilitate the development of equitable, effective services across North Wales. Achieving this demands an ability to influence the design of services to adhere to best practice and evidence. Much of this can be achieved through the design of care pathways which include clear standards for service delivery.
______3 North Wales Cardiac Network – The Way Forward Through its access to clinical expertise the Network will support the development of clinical care pathways and standards which will deliver a consistently high quality service across North Wales. This will build upon the success of the recent activity in relation to Heart Failure services.
The development of care pathways will support the governance agenda highlighted earlier in this paper. Common training needs will be identified and education facilitated to optimise the benefits to patients of this approach to service planning and delivery. The Network will support audit of delivery against agreed care pathways to improve performance and outcomes for patients.
Planning, Commissioning, and Performance Management
Through its access to clinical and managerial expertise the Network is well placed to offer advice to inform the future planning and commissioning of services. The Network will support these activities in the following areas :-
The Network will establish a clinical forum to help shape the future direction of services in North Wales. This will provide a horizon scanning function, identifying future potential changes in practice and advising as to how these issues should be dealt with in North Wales. The clinical forum will also be instrumental in considering emerging national guidance regarding the delivery of cardiac services and setting this in a North Wales context. This forum will develop advice for the Network Board in relation to the future models of delivery of services and potential areas where current services need to change to meet future demands.
Analysis of service performance and delivery through benchmarking and the development of performance monitoring information will help inform commissioners and providers alike. Key datasets will be developed which will enable performance to be compared between providers, and over time. Service performance and delivery will be benchmarked against national standards and comparative performance elsewhere. Access rates will be monitored to ensure that the population of North Wales are receiving adequate access to particular services e.g. echocardiography. All of this data will be shared with the Network Board and provided to health communities to feed into local performance management processes in support of the delivery of SAFF and other key targets.
Each of these functions will exist to guide and support the other areas of activity of the Network, whilst providing information and advice to partner organisations which will influence the planning, commissioning and performance management of service delivery.
______4 North Wales Cardiac Network – The Way Forward Patient and Public Involvement (PPI)
Effective patient and public involvement is essential in all aspects of the planning and delivery of services. If the Network is to be a key player in these activities then it must demonstrate the adoption of best practice in this area throughout its range of functions. This will apply in all areas from membership of the Board through to involvement in the many work streams of the Network.
4. Network Structure
As defined earlier in this document the Network is a coalition of stakeholders who contribute to the cardiac services agenda in North Wales. To enable the Network to function and to allow it to connect with the organisations within the NHS who are responsible for the planning and delivery of services a clear network structure is required. This structure is described below and shown diagrammatically at Appendix A.
Network Board
The Network Board is drawn from the key stakeholders across North Wales. Its remit is to set the work agenda for the Network, identifying priorities for action and allocating Network resources accordingly. The Board oversees the activities of the network and is the body which endorses the work undertaken within the Network and offers advice to partner organisations regarding cardiac issues. The proposed membership and terms of reference for the Board are given at Appendix B.
Cardiac Collaborative Group
This multidisciplinary group will bring together clinicians, managers and others within the Network to drive forward the work programme agreed by the Board. It will develop the information base to support the key activities of the Network and facilitate collaborative projects such as audit, training, pathway development and implementation. At its core will be the CHD leads from each of the partner organisations. Task and finish groups will be established to drive forward particular pieces of work, drawing together appropriate skills in a focussed manner to deliver improvement. The proposed membership and terms of reference of the collaborative are given at Appendix C.
Clinical (Topic) Work Groups
These Groups will be fluid in nature and time limited. Membership will vary and be dependent upon the topic agreed in the Workplan. The Groups will draw together clinicians from all disciplines and settings of care to develop expert advice for the Board in relation to Cardiac issues. The Groups will focus on key clinical issues as determined by the Network Board, developing guidelines and
______5 North Wales Cardiac Network – The Way Forward evidence based clinical advice for commissioners and providers of cardiac services. The proposed generic membership and terms of reference for these fluid groups is given at Appendix D. Membership of Groups for specific tasks will be tailored to respond to the clinical issues under consideration.
For example: The first group of this kind will be the Clinical ‘Community Echocardiography’ Work Group. The purpose of the group is to produce guidelines and recommendations for healthcare organisations and commissioners across North Wales with regards to the development of community echocardiography. Specific aims and objectives for this group are given at Appendix E.
Network Support Team
The Network Support Team exists to co-ordinate and give leadership to the activities of the Network. The support team will consist of :-
A Consultant Cardiologist A General Practitioner Other clinicians, e.g. nurse, allied health professionals A Network Manager A Network Support Officer
This team will provide the core support to the Network in delivering against its priorities. It will be supplemented by other skills and resources required to deliver the Network agenda through the flexible use of the remaining Network budget. This may include analytical skills, audit support, training and education, or external clinical advice.
5. Network Accountability
The Network Board will be accountable for overseeing the activities of the Network and assuring the quality and integrity of work undertaken.
As defined earlier the Network is a collaboration of stakeholders and as such does not hold formal accountability for the actions and decisions of its partners. However, the Network holds significant authority which stems from the expert clinical advice it is able to offer to stakeholders which will shape the planning, commissioning and delivery of cardiac services.
Within the Network arrangements Board Members will be responsible for ensuring that the advice of the Network is formally communicated within their organisations and acted upon appropriately. There will be a responsibility placed upon Board Members to report as to the way in which partner organisations have responded to the advice of the Network Board.
______6 North Wales Cardiac Network – The Way Forward Should the Network be unable to reach a consensus on any key issue the Chair of the Network Board will consider what further action is required. This may include discussion of the issue at the North Wales Planning Forum or any alternative group, as the Chair determines.
Where the Network proposes actions which have impacts across several organisations these will be discussed with the North Wales Planning Forum to seek endorsement to the changes proposed.
6. Summary
The proposals outlined in this paper have been shaped by the views of stakeholders within the Network as to how the Network should function and the issues it should seek to address. They set out a clear framework for securing expert clinical advice and delivering key actions to improve the planning, commissioning and delivery of cardiac services to the residents of North Wales.
______7 North Wales Cardiac Network – The Way Forward APPENDIX A NORTH WALES CARDIAC NETWORK
STRUCTURE
Cardiac Network Board
Cardiac Collaborative Group
Clinical Clinical “Topic” Work “Topic” Work Group Group Clinical Clinical “Topic” Work “Topic” Work Group Group
Network Support Team
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APPENDIX B
Cardiac Network Board – Terms of Reference
Purpose
The Board is established to oversee the activities of the Network and to provide advice to the stakeholders regarding the planning, commissioning and delivery of cardiac services in North Wales.
Accountability
The Board is accountable, through its members, to the stakeholder organisations in North Wales. The stakeholders are :-
Conwy and Denbighshire Trust North East Wales Trust North West Wales Trust Welsh Ambulance Services Trust Anglesey, Conwy, Denbighshire, Flintshire, Gwynedd and Wrexham Local health Boards National Public Health Service North Wales Regional Office, WAG Health Commission Wales Countess of Chester
Terms of Reference
The Network Board will :-
Agree the work programme and priorities for the Network Oversee the activities of the Network Monitor progress against the implementation of the NSF in North Wales Monitor access to, and the quality of services across North Wales and advise stakeholders accordingly Provide clinical advice to stakeholder organisations regarding the planning, commissioning and delivery of cardiac services, to guide investment decisions. Review national and other guidance in relation to cardiac services and provide advice to stakeholders regarding its application in North Wales Establish care pathways to support the effective delivery of services Produce a clear framework for the future delivery of cardiac services to the residents of North Wales. Facilitate service re-design including, where appropriate changes between organisations and providers
______9 North Wales Cardiac Network – The Way Forward Assist with education and training with the purpose of facilitating service re- design across North Wales.
Membership
The Network Board membership will be drawn from the key stakeholders as set out above. Each organisation will have a seat at the Network Board which will be taken by a representative with sufficient seniority to speak on behalf of their organisation. In addition the Network Board will have representation from other key providers (CTC and Manchester when appropriate) and will have patient representation.
Membership will also be open to the CNCG Co-ordinator to interface with the All Wales agenda. Representatives from both the neighbouring Cardiac Networks, (Cheshire & Merseyside and Greater Manchester and Cheshire) will be invited to join as appropriate to maintain cross border network links.
The Board will be chaired by Network Chair who will be appointed by the Regional Director of the Health and Social Care Department, WAG.
______10 North Wales Cardiac Network – The Way Forward APPENDIX C
Cardiac Collaborative Group – Terms of Reference
Purpose
The Cardiac Collaborative Group will the oversee the projects and activities of the Network ensuring that the work undertaken by Network is supported by clinical consensus and builds upon evidence of best practice.
Accountability
The Collaborative will be accountable to the Network Board for the delivery of its work programme.
Terms of Reference
The collaborative will :-
Oversee the projects and activities of the Network ensuring that they are delivered in accordance with the requirements of the Network Board. Ensure that all projects are built upon clinical consensus by reference to the Clinical (Topic) Work Group. Develop the information base to support performance monitoring and audit activities within the network Develop care pathways to support the effective delivery of services in North Wales. Audit care pathways and report results to identify areas for further improvement. Undertake benchmarking activities to compare service delivery performance across North Wales, and with other areas. Establish links with neighbouring Networks to identify and share good practice Establish sub groups to progress work topics drawing in appropriate expertise
Membership
The core membership of the collaborative will be drawn from the CHD Leads within partner organisations and the Network Support Team. This will be supplemented as required to provide a balance of clinical and managerial inputs to the Group. The Group will establish sub groups to take forward particular pieces of work and will co-opt clinical and other staff to these groups to ensure an appropriate knowledge and skill base to deliver the task at hand.
The Collaborative will be chaired by a Network Lead Clinician and facilitated by the Network Manager.
______11 North Wales Cardiac Network – The Way Forward APPENDIX D
Clinical (Topic) Work Groups – Terms of Reference
Purpose
The Clinical (Topic) Work Groups are established to provide authoritative clinical advice to the Network Board, upon which recommendations may be made to the Stakeholder organisations.
Accountability
The Clinical (Topic) Work Groups will be accountable to the Network Board
Terms of Reference
The Clinical (Topic) Work Groups will :-
Produce expert Guidelines and recommendations for the North Wales health economy in order to advise commissioners with regard to service development. Consider a specific area of clinical activity as required by the Network Board. Consider the future health need for cardiac care in North Wales and advise on the models which will ensure effective delivery. Review evidence of best practice in order that service developments are in line with All Wales and National Guidelines Consider emerging national and other guidance and advise as to its application in North Wales within the context of specific clinical areas.
Membership
The membership of the Groups will be drawn from the clinical community in North Wales, and those outside North Wales providing services to North Wales residents. The core membership will be the clinical lead from each partner organisation. However, Groups must have representation from across the range of clinical professionals delivering cardiac care, including –
Consultant Cardiologists General Practitioners Nurses Allied health professionals Technical Staff Ambulance personnel
The Groups will be chaired by the Network Lead Cardiologist, supported by the Network GP and Network Lead Nurse.
______12 North Wales Cardiac Network – The Way Forward APPENDIX E
North Wales Cardiac Network
Clinical Community Echocardiography Work Group
AIMS AND OBJECTIVES
Background The incidence of heart failure in the Welsh population is around 1% with a prevalence of 3%.Thus for each DGH with a population of 200,000 this will give 2,000 new cases of heart failure per year. As only 20% of patients referred to open access echocardiography have a confirmed diagnosis of heart failure this equates to 10 000 echocardiograms per year.
Repeated guidelines including those recently prepared by the NWCN and the New GP contract advise all presumed new diagnoses of heart failure to be confirmed by echocardiography.
The NSF for CHD standard 4 key action 24 gives a Health Improvement Program target of the establishment of a specialist heart failure service in each DGH. Key action 25 gives a target of 4 weeks for echocardiography in suspected heart failure referred from Primary Care. The current SaFF target for echocardiography is 36 weeks but may be reduced to 24 weeks. Most DGHs in North Wales do not meet these targets.
Aims and Objectives The overall purpose of the group is to produce guidelines and recommendations for healthcare organisations and commissioners across North Wales with regards to the development of community echocardiography (+/- heart failure services). The group will be multi-professional and will aim to complete its tasks within an agreed timeframe.
Key tasks Undertake baseline assessment of current echocardiography provision across North Wales to include waiting times, availability of trained echocardiographers and equipment and to identify different models of service provision. This work should utilise or build on any work already completed by Trusts as part of their Diagnostic Modernisation programme; Review existing standards for community echocardiography to include British Society of Echocardiography and All Wales Standards; Benchmark with other service providers;
______13 North Wales Cardiac Network – The Way Forward Produce recommendations and guidance for North Wales service providers and commissioners with regards to the development of community echocardiography (+/- heart failure) services; Identify training issues and produce directory of relevant echo courses and contacts.
Working arrangements The group will be Chaired by the NWCN lead Cardiologist, Dr Richard Cowell and the Vice Chair will be the NWCN Lead GP, Dr Matthew Dymock. Administrative support will be provided by Julie Green, NWCN Administrator.
The group will agree a fixed term period for the completion of its tasks and a report will be produced for the NWCN Board. The agreed membership of the group will include: Dr Richard Cowell (Chair) Dr Matthew Dymock (Vice Chair) Dr Christine Allen, Flintshire Local Health Board Dr Eric Beckett, Flintshire Local Health Board Andy Bennett, Conwy and Denbighshire NHS Trust – to be confirmed
Nia Coster, Anglesey Local Health Board Dr Paul Emmett, Conwy Local Health Board Alan Featherstone, North East Wales NHS Trust Clive Fisk, North West Wales NHS Trust Mrs Chris Jones, Conwy and Denbighshire NHS Trust Karen Keating, North East Wales NHS Trust Peter Liptrot, Gwynedd Local Health Board Dr Sandeep Talwar, North West Wales NHS Trust Dr Nick Waterfield, Conwy and Denbighshire NHS Trust Jenny Wellstand, North East Wales NHS Trust Dr David Whyler, Conwy Local Health Board
Members of the group will be expected to nominate a colleague to represent them should they be unable to attend the meetings; Additional membership on an ad hoc basis may be required depending on the tasks required; Meetings will be held monthly but may be more or less frequent depending on the nature of the work programme.
Reporting mechanisms All group members are expected to accurately report progress and action points to the areas of the organisation they are representing.
Operationally, the group will report to the NWCN Board.
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Accountability The Clinical Community Echocardiography Work Group will be accountable to the Network Board
Timescales The Group will report back to the Board in March 2006.
Supporting documents • NSF for CHD • Designed for Life • WHC 24.5.05 GPwSi • Wales guidance for the development of GPs with a special interest in Cardiology prepared by the Cardiac Networks Coordinating group and accepted at the Cardiac Reference Group October 2005 • Recommendations for the delivery of Community / Primary Care echocardiography in Wales prepared by the Cardiac Networks Coordinating group
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