Copyright 2011 Right Care
Delivering High Value Pathways
Standard versus Optimal – A typical Long-Term Conditions story and how the NHS Right Care approach can help to achieve optimal
Professor Matthew CrippsNational Programme Director, NHS Right Care
Dr Peter Brambleby, Independent public health consultant & Right Care Associate
Mr. Anthony Lawton – Right Care Associate
Five Key Ingredients:
1. Clinical Leadership
2. Indicative Data
3. Clinical Engagement
4. Evidential Data
5. Effective processes
1 key objective + 3 key phases + 5 key ingredients = COMMISSIONING FOR VALUE
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OBJECTIVE - Maximise Value (individual and population)
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Commissioning for Value - Slough CCG
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Granularity – Population to Patient
Where to Look How to Change
SDMCare
PlanningManage
care out of hospital
CfV Pack
Atlas
Programme Budgets
Populations Systems
What to Change
Individuals
Deep Dive
Path-way
Provider
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Paul’s story – Journey 1
Paul: 45, bricklayer, local employer Smokes 10/day, drinks 4 pints/day, overweightCouncil house, supports Leeds United
Wendy: 42, barmaidDavid: 16, schoolboyGP: small practice, 17 miles from DGHVillage shop: limited food options
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Paul’s journey starts when …..
Prompted by Wendy, sees his GP
2 years of increased urinary frequency and loss of energy GP performs tests and confirms diabetes Initial management with diet, exercise, pills 6 visits per year to practice nurse 6 lab tests per year GP has lower than average prescribing and
referral rates – seen as economical
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Context & Variation
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0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%
Prac
tice
1Pr
actic
e 6
Prac
tice
11Pr
actic
e 16
Prac
tice
21Pr
actic
e 26
Prac
tice
31Pr
actic
e 36
Prac
tice
41Pr
actic
e 46
Prac
tice
51Pr
actic
e 56
Prac
tice
61Pr
actic
e 66
Prac
tice
71Pr
actic
e 76
Prac
tice
81Pr
actic
e 86
Prac
tice
91Pr
actic
e 96
Prac
tice
101
Prac
tice
106
Prac
tice
111
Achievement (%) of patients with diabetes where HbA1c is 7 or less in previous 15 months
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In the local population, who has overall responsibility for:
Preventing diabetes? Raising awareness and screening for diabetes? Quality assurance of diabetes care? Getting best value for money from the investment by
caring agencies in diabetes?
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Paul is now 50
Not smoking but still drinking and has not lost weight; recreation is watching football and pub
Has been on insulin for a year Left leg hurts (vascular problem) Not walking far, not driving, missing work Referred to hospital diabetes service and vascular surgeon
– OPD at hospital Wendy drives him David is at university
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Spot Tool
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Paul is now 52
Leg suddenly goes white and painful; amputated below knee
Significant heart and renal complications Vision deteriorating Loses his job with little chance of retraining Applies for more suitable housing Wendy gives up job David takes a year off university
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The Impact (Economic and Social) – Journey 1
Journey 1 - (less than perfect)Paul 45 Paul 50 Paul 52
Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Yr 9 Yr 10 Yr 11
Economic Costs - - 1,360 576 576 576 576 1,762 1,953 8,948 32,757 49,084
David takes time out of University to assist the family
Council contacted - alternative housing - rent not affordable
Forced to sell car - so Wendy also less mobile
Personal & Emotional Costs
Excessive drinking
ObeseLeft leg - white & very painful (then
amputated)
Loses job
Left leg pain
Missing work days
Stopped exercising
Stopped drivingWendy taking half days off to
drive to treatments / Economic situation of the family
becoming tough
Excessive drinking
Obese
Obese
Smoking
Excessive drinking (reduced)
Obese (but improved)
Smoking (reduced)
Pre Primary Care Review
Increased urinary frequency
Issues around Thirst
Excessively Tired
Excessive drinking
Excessive drinking
Obese
Phase 1 Activity & Treatment Phase 2 Activity & Treatment Phase 3 Activity & Treatment
Economic situation of the family is now extreme
Paul's quality of life now very poor
Both Paul & Wendy depressed
Cant exercise
Cant drive
Wendy taking more time off as carer
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The Economic Impact during 3 of those 11 years
Economic Analysis - Journey 1 Extracts:
Activity Costs Activity Costs Activity Costs
GP Visit 4 30.66 GP Visit 3 23.00 GP Visit 3 23.00
Diet advice 1 17.39 GP Care plan review 1 11.50 GP Care plan review 1 11.50
Exercise advice 1 17.39 Prescription Drugs 1 370.52 Prescription Drugs 1 370.52
Prescription Drugs 1 370.52 Testing Strips 1 9.89 Testing Strips 1 9.89
Testing Strips 1 9.89 Lab Tests 2 252.00 Lab Tests 3 378.00
Lab Tests 6 756.00 Practice Nurse 6 34.78 Practice Nurse 6 34.78
Practice Nurse 6 34.78 Daily insulin injections (Levemir) 1 715.00 Daily insulin injections (Levemir) 1 715.00
District Nurse Visit 0 - Diabetology clinic 1 50.00 Diabetology clinic 1 50.00
Care Plan developed 1 23.00 Diabetes specialist nurse 1 7.73 Diabetes specialist nurse 1 7.73
Retinopathy screening 1 100.00 Referred to vascular clinic (Registrar) 1 235.00
Treatment - Heart disease (investigative procedure) 1 210.00
Retinopathy screening follow up 1 53.00 Treatment - Renal Impairment (initial dialysis - monthly) 1 3,012.00
Treatment - Eye disease (glasses) 1 50.00
Anti depressants prescribed 2 107.76
NHS Transport (Ambulance) 4 854.00 Leg ulcer treatment (septicaemia) 1 3,114.00
1,359.63 1,762.42 8,948.18
Phase 1 - Yr 3 Phase 2 - Yr 8 (Paul at 50) Phase 3 - Yr 10 (Paul at 52)
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Paul’s story: What the CCG have done – Commissioning for Value CCG have used CfV pack, identified Diabetes as a key
improvement priority
Worked with AT and neighbouring CCGs to ensure wider system improvement (whilst not allowing this to slow progress for their own population)
Engaged the right people, conducted a deep dive and service review, identified what needed to change, built the case, took the decisions and implemented the change
What does the next Paul’s journey look like now?
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Paul’s story - Journey 2
NHS Health Check identifies Paul’s condition at the end of year 1 – Case management begins…
Use of specialist clinics for advice on diet and exercise (10x cost of GP advice) and this repeated every 2 years
Care Plan / Medication / Retinopathy Screening brought forward 18 months compared to Journey 1
Self Management – Desmond Programme
Diabetes Patient Support Group set up locally
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The Impact (Economic and Social) J2Journey 2 - (Improved Pathway - Revised Focus)
Pre Primary Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Yr 9 Yr 10 Yr 11
Increased urinary frequency
Excessive drinking (reduced)
Issues around Thirst
Obese (but improved)
Excessively Tired
Smoking (reduced)
Excessive drinking
Obese
Smoking
Economic Costs 23 1,153 607 958 587 958 710 1,084 736 1,210 909 8,936
Phase 1 Activity & Treatment
Support working - Eating well, Exercising, & Drinking Controlled. Keeping work and social life healthy, no depression, no serious interventions:
focus is on Support, Education & Medication.Personal & Emotional Costs
Phase 2 Activity & Treatment Phase 3 Activity & Treatment
Initial pathway = sub-optimal quality, cost £49k, low valuePost-improvement = optimal quality, cost £9k, high value
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Discussion Points
Type two diabetes is a largely preventable disease caused, and controlled, by lifestyle
Better “vertical” integration (along the clinical pathway) and “horizontal” integration (between the parties) could improve outcomes and save substantial costs
Who should take the initiative for the individual and for the population?
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Granularity – Population to Patient
Where to Look How to Change
SDMCare PlanningManage care out of hospital
CfV PackAtlas
Programme
Budgets
Populations
Systems
What to Change
Individuals
Deep Dive
Path-way
Provider
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CURRENTSERVICE
FUTURESERVICE
Fit forPurpose
Efficiencyand
marketoptions
Supplyand
capacityoptions
No/ lowbenefit
Step 1 – define:
Step 3 –
categorise:
Step 2 – define:
Redesign,Contract,Procure
Contract,Procure,Divest
Step 4 –
recommend:
Maintain
Divest
Service Review Pathway – Diagnostic steps
Fit forPurpose
Efficiencyand
marketoptions
Supplyand
capacityoptions
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Respiratory Care in Warrington Health Economy
• 2010/11 –• £1.5M Overspending V. demographic peers• Only 2/3s of asthmatics known• Worst quintiles – COPD rate of em admns, deaths
within 30 days, %age receiving NIV, re-admns
• 2012/13 –• £0.6M UNDER spending V. demographic peers• Delivered by focus on variation – problems fixed or
improving (e.g. 30% less COPD NEL admissions, MDT, 70+ p.m. triaged away from acute sector)
• HSJ Commissioner of the Year
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Where Bradford are now (and where West Cheshire were)…
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Where West Cheshire are now (and where you could be)…
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Number of Circulatory indicators in the bottom quintile of the practice cluster
Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive
comparison of performance.
Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 21-27 for the 3 practices with the highest total number of indicators in the bottom quintile
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Galvanising Clinicians – On the right things
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Change the clinical perspective
Dr Jones is a Derby-based respiratory physician. Last year she saw 346 people with COPD and provided evidence based, patient centred care
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All people with the condition
People receiving the specialist service
She estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit from the knowledge of her team
People receiving the service
People who would benefit most from the service
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Dr Jones is given a day a week for Population Respiratory Health and the local COPD Network and Service helps her to increase population value by:
Working with Public Health to reduce smoking Network development Improving the quality of patient information Professional development of all system staff (e.g. nurse
educators) Production of the Annual Report of the service
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Work through the phases and Commission for Value
Where to Look How to Change
SDMCare
PlanningManage
care out of hospital
CfV Pack
Atlas
Programme Budgets
Populations Systems
What to Change
Individuals
Deep Dive
Path-way
Provider
29
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Where can I find out more?
• The Powerpoint presentation you have seen today, an excel spreadsheet with the underlying data is available on the Right Care website
• You will also find there links to short online learning videos on the Right Care approach and links to some of the tools and packs mentioned in the presentation
• Email Feedback or questions to [email protected]
• Or Visit and follow the link
www.rightcare.nhs.uk/paul_adams
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For more information – contact the team
Professor Matthew Cripps - National Programme Director,
NHS Right Care
Email: [email protected]
Dr Peter Brambleby, Independent public health consultant,
Email: [email protected]
Mr. Anthony Lawton – Right Care Associate
Email: [email protected]
Jules Gaughan - Right Care Associate
Email: [email protected]
Mr. Ian McKinnell - NHS Right Care
Email: [email protected]
