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www.england.nhs.uk Improving Population Healthcare The power of variation

Matthew Cripps

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www.england.nhs.uk

Improving

Population

Healthcare

The power of

variation

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Inconvenient truths – Diabetes and The Atlas

Opportunity Locator Tool

• 5 Diabetes maps in Atlas 2015 have confidence

intervals

• Of the 211 CCGs (at time of data capture):

13 CCGs are not significant outliers on any of the

diabetes maps

• Or rather:

198 CCGs and their local providers have at least

one significant improvement opportunity in

Diabetes

2-fold..

.

4-fold..

.

Diabetes

‹#›

What is NHS RightCare?

RightCare is a methodological approach to improvement that provides

commissioners with:

• a robust starting point - indicative data

• a means of engaging all stakeholders and galvanising focussed

clinical leadership

• a step-by-step business process for building the case for change

with clear prioritisation and decision making techniques

• clinical pathway redesign tools that enhance implementation

capability

• improved health outcomes, value and financial sustainability

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The beginning of the value journey:

Donabedian’s Point of Optimality

So, where is the Point of Optimal Value?

Necessary appropriate inappropriate futile

High Low Zero Negative

BENEFIT

HARM

ResourcesCLINICAL

ECONOMIC

VALUE

The 1st principle ofCommissioning for Value

Awareness is the first step towards value –

If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place

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Generics of improving population healthcare

M a x i m i s e V a l u eObjective

Principles

Get everyone

talking about

same stuff

Talk

about fix

and future

Demonstrate

viability

Isolate

reasons for

non-delivery

Phases Where to Look What to Change How to Change

Ingredients

C l i n i c a l l e a d e r s h i p

I nd i ca t ive Da t a

Effec t i ve I mpr ovemen t P r oce s se s

Ev i den t i a l Da t a

C l i n i c a l E n g a g e m e n t

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Vale of York

• Adopted RC

• Used approach to focus on circulation, neurology,

cancer and system management improvements:

• Locally specified 136 new clinical guidelines

• Reduced referrals by 17% in targeted specialties

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Practice Level Risk Management - Primary Care

• Risk Stratification in Wigan – led to 6,000 new active

care plans and reduced urgent care

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Helps health economies to tick lots of boxes within

same effort – Blackpool & Fylde CCGs

Advanced paramedic project significantly reduced

frequent calling and delivered -

• Quick win (98% reduction in targeted 999s)

• Parity of Esteem & patient empowerment

• Integrated Care/ multi-agency working

• Care planning & Long Term Conditions

management & care closer to home

• Demand management

• Reduced pressure on urgent care

• Immediate significant saving (£2.2m)

• Further improvement & saving (now £2.7m)

Tools, techniques and benefits

NHS Bradford City CCG

Heart disease pathway of a page – Why Bradford chose CVD

= 95% confidence intervals

Initial contact to end of treatment

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Bradford Healthy Hearts

• Variation - 7th worst mortality rate for CVD <75years old

• 28% of all deaths amongst <75 year olds

• Programme overview - Statin Switches, Hypertension, Stroke

prevention

• Over 6000 on simvastatin with total cholesterol >4 mmol/l or LDL

>2 mmol/l (no direct comparison of simvastatin vs atorvastatin)

• Converted to only two doses of statin (40mg and 80mg

atorvastatin) as per ACC guide (greater benefits since NNT=62

for moderate/high intensity cholesterol management vs. NNT=156

for low intensity)

• Switched 6,000 patients (completed in 3 months)

• Improved mortality – including 60 less deaths last year (pye)

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Slough CCG – Complex Case Management

• Examined causes of non-elective admissions, A&E attends and costs.

• Identified unique cohorts of patients as highest risk of emergency

admission:

CHF & CRF

CHF & COPD

Diabetes, CHF & CRF

Diabetes, IHD & CRF

• Commissioned additional regular primary care contacts for at risk

population and, via system-wide MDTs, developed care plans with the

patient

• 28% reduction in targeted non-elective admissions (34% reduction in

spend)

• 28% reduction in targeted A&E attends (31% reduction in spend)

• £500k saving across CCG

• Now being spread across East Berkshire CCGs and wider STP footprint

Tools, techniques and benefits

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Collective design of treatment guidelines

Ashford CCG

• Variation highlighted MSK referral rates

• Designed and developed local protocols

• Designed and implemented local triage

• Reduced referrals by 30+%!!!

www.england.nhs.uk

Closing the

perception

gap

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Closing the perception gap – a cause of variation

• The perception gap pervades the NHS and drives low value, expensive,

unwarranted decisions

• 70% of breast surgeons believe a primary concern of women with breast

cancer is to keep their breast

o The real number is 7% of informed women

• 95% of people with elective stents think they reduce risk of heart attack

o They don’t (most informed people don’t want one)

• 98% of uninformed men want prostate screening

o Fewer than half of informed men do

• 5x more doctors think patients are the biggest barrier to Shared Decision

Making (SDM) than think medics are

o Cochrane found effective SDM is “physician, not patient, dependent”

• Achieved by understanding patient preference via, e.g: Patient-centred

care; SDM - PDAs; self-management/ care-planning; Cooling-off periods

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Bedfordshire MSK – Outcomes-based system

• Locally designed protocols, locally led triage

• 1 in 5 initial referrals changed

• Shared Decision Making (closing the perception gap)

• 35% of patients change direction of initial referral

• Leading to a shift towards community-based care -

% of Activity within Secondary Care*

% of Activity within Community**

68%

32%

2012

64%

36%

2014

52%48%

Now

48%52%

2018

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NHS RightCare - support out now & coming soon

• Wave 1 roll-out now live (65 health economies via

CCGs)

• Wave 2 December 2016 (everyone else)

• Atlas Opportunities Locator tool

• Commissioning for Value refresh packs

• Focus packs – 11 programmes of care

• LTC and MH packs

• New and refreshed Atlases of Variation (diagnostics

refresh coming soon)

• Optimal Value Pathways

• Repository of Shared Decision Making

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Further information available from -

Email RightCare

[email protected]

Twitter:

@matthew_cripps1

Visit RightCare:

http://www.rightcare.nhs.uk/