Clinical Networks
The Black Country Provider Collaborative's clinical improvement programme currently has 11 clinical networks in place, all of which are led by a clinical lead and a small leadership team:
- breast
- critical care
- colorectal
- ophthalmology
- ear, nose and throat (ENT, head and neck)
- general surgery and upper gastrointestinal
- gynaecology
- orthopaedics
- pharmacy and medicine optimisation
- dermatology
- urology.
In the early stages of the collaborative, the clinical improvement programme was structured around the elective recovery backlogs sitting within the six surgical specialties (orthopaedics, general surgery, gynaecology, urology, head and neck and ophthalmology) and the four cancer specialties (colorectal, breast, skin and urology). This led naturally to the selection and development of the first clinical networks in these areas.
Network leadership
SRO Diane Wake was able to secure funding from the cancer board and the elective programme to recruit clinical lead positions for the initial six surgical clinical networks, expanding later to the 11 clinical networks as they are today. This structure allows the core collaborative team to liaise with the clinical leads directly, rather than duplicating conversations at the individual organisation level.
A critical part of the clinical improvement programme was ensuring that strong relationships were established between clinicians across the different providers, and it was crucial that the clinical leads could relate to their colleagues and peers and build connections which would enable effective collaborative working across the system. It was also key that there be equal representation from each provider to encourage equal investment and inclusivity.
An important principle for chief medical officer Dr Jonathan Odum was ensuring that the leads were given time and funding for their work at the network level (two sessions/ one full day a week) rather than asking for additional work to be done without allocated time or funding.
Whilst the clinical network lead recruitment process was ongoing, managing director Sohaib Khalid was simultaneously appointing his own project leads which enabled the clinical leads, once appointed, to work into an effective infrastructure from the beginning.
The clinical network leads work closely with their project leads and with the organisational Getting it right first time (GIRFT) teams to ensure that they are looking at the GIRFT data, which demonstrates the backlogs and variability in performance across all surgical specialties.
Each network has identified two priority targets to work on within their pathways using the GIRFT data and are now pursuing activity to make a top quartile performance this year against their original metrics.
Three examples of the progress underway are set out below, focusing on dermatology, orthopaedics and urology.
Dermatology
The dermatology network had an ambition to manage skin cancer referrals in a new way and tackle delays in diagnosis and treatment.
The clinical leads proposed two key programmes of work – the systemwide roll out of tele-dermatology, and introduction of Mohs micrographic surgery:
Tele-dermatology
Background and implementation
- The proposal was for all skin cancer referrals to come via imaging to a central point of access, to be triaged and brought in on a needs only basis. Patients would then be biopsied and diagnosed or discharged as appropriate.
- The rationale behind this was that it would remove 85% of skin cancer queries to dermatology clinics and open up accessibility for those who required treatment, cutting waiting times.
- To successfully implement this proposal, capturing high quality images was crucial. This meant that all GPs across the Black Country required appropriate technical equipment, as well as training to allow them to take suitable images.
- The central point of access also needed to be implemented effectively in order to receive all images and manage patients.
- The clinical leads engaged closely with primary care across the system to ensure that GPs were aware of what was needed.
- This is now being implemented in stages across the Black Country – images are coming in and patients are receiving care under this new scheme.
- Following the successful roll out to date, the plan is to extend the new arrangements to all GPs across the system.
Mohs micrographic surgery
Background and implementation
- The second proposal was the implementation of Mohs micrographic surgery (margin controlled excision) across the Black Country which aims to remove all skin cancer whilst leaving as much healthy tissue as possible.
- At the time of surgery, clinicians will have access to the pathology department at the Royal Wolverhampton NHS Trust to allow the removed tissue to be analysed within a 15 minute period to ensure all cancer is removed.
- Extensive refurbishment has been done to a building in Wolverhampton for patients across the Black Country, and this service will potentially also become a centre for patients from Staffordshire and Shropshire.
- Training in this specialist surgery is almost complete and the building is ready, and this will come into operation in late summer 2023.
Orthopaedics
Another example of work that has been achieved through the provider collaborative is within the orthopaedic network. The collaborative has successfully won funding as part of the targeted investment funding (TIF) scheme to extend an existing elective orthopaedic surgery.
Walsall Healthcare NHS Trust and The Dudley Group NHS Foundation Trust will now have access to two of the new theatre spaces each as part of the extension, which is due to be in use from 2024. The funding would not have been awarded if the collaborative had not worked together on the bid.
Urology
Work has also been done within the urological network and involves the implementation of robotic surgery.
The clinical leads for urology and colorectal surgery came together to discuss the potential for additional robotic surgical expertise within the Black Country. The collaborative team then looked at how they might mobilise the finances to provide a Da Vinci robot at Sandwell and West Birmingham NHS Trust and The Dudley Group NHS Foundation Trust.
The collaborative was able to raise this funding and the robots have now been delivered to the trusts.
Through the work of the collaborative, Walsall Healthcare NHS Trust agreed that they would not have their own robot but would seek to network with the three other trusts within the system to share the robots as needed. Dr Odum believes that this is a good example of system working that would not have been possible without the collaborative and the clinical networks.
Surgeons are currently being trained on the robots and the opportunity to be part of this new piece of work is drawing specialist clinicians into the Black Country which in turn will give the system a boost not only in terms of workforce and clinical expertise, but also in terms of educational and academic resource.