International efforts to improve quality, reduce costs and increase

transparency

On the theme of “shift” in the National Health Service of England

Helen Bevan

Bipartisan Congressional Health Policy Conference

How did we spend our healthcare resources last year?

Acute care

£45bn

Primary care

£15bn

Social care

£12bn

To

tal

exp

end

itu

re:

£72b

n (

$138

bn

)

Social care£12bn

Primary care physicians and other

primary care (including drugs)

£15bn

Community care£10bn

Mental health£7bn

Elective and ambulatory (outpatient)

£12bn

Non-elective and critical care

£14bn

Accident and emergency,

Out of hours, emergency transport

£3bn

How did we spend our resources last year?

Exp

end

itu

re 2

005/

06T

ota

l: £

72b

n (

$138

bn

)

Social care£12bn

Primary care physicians and other

primary care (including drugs)

£15bn

Community care£10bn

Mental health£7bn

Elective and ambulatory (outpatient)

£12bn

Non-elective and critical care

£14bn

Accident and emergency,

Out of hours, emergency transport

£3bn

75%

25%

How will this change in future?E

xpen

dit

ure

200

5/06

To

tal:

£72

bn

($1

38b

n)

Social care£12bn

Primary care physicians and other

primary care (including drugs)

£15bn

Community care£10bn

Mental health£7bn

Elective and ambulatory (outpatient)

£12bn

Non-elective and critical care

£14bn

Accident and emergency,

Out of hours, emergency transport

£3bn

75%

25%

70%

30%

The 2006 White Paper represents an ambitious new direction

• better prevention services with earlier intervention

• a greater proportion of care outside of hospitals and in the home

• more support in the community for people with long term needs

• more choice and a louder voice for service users

• tackling health inequalities and ensuring access to high quality care for all

• integration between health and social care

Shifting location, process and provider of care

focus on treatment

professionally driven care

care in specialist hospital settings

assume care will be provided by a doctor

variation in access, clinical quality, resource utilisation

focus on prevention and early intervention

patient-driven care and self-care

care in local community settings

assume care will be provided by a professional with the right skills

high quality, cost effective care for all

from to

Quality and Outcome Framework: reward and incentive programme for General Practitioners

Established in 2004 as a core component of the new GP Contract

• around 30% of a GP’s compensation package• voluntary• 8,500 practices, covering 53 million patients• at level of practice, not individual GP• via Quality Management and Analysis System

Quality and Outcome Framework: reward and incentive programme for General Practitioners

Covers 4 domains:

• Clinical: 76 indicators in 11 areas: coronary heart disease; left ventricular dysfunction; stroke and transient ischaemic attack; hypertension; diabetes; pulmonary disease; epilepsy; hypothyroidism; cancer; mental health; asthma. Worth up to 550 points

• Organisational: 56 indicators in 5 areas: records and information; patient communication; education and training; medicines management; clinical and practice management. Worth up to 184 points

• Patient experience: 4 indicators in 2 areas: patient survey and length of time with the doctor. Worth up to 100 points

• Additional services: 10 indicators in 4 areas: cervical screening, child health surveillance; maternity services; contraceptive services. Worth up to 36 points

Quality and Outcome Framework: examples of points availability in clinical domain

Disease registers – maintaining a high quality disease register for each disease category (2-6 points)

Asthma – percentage of patients aged 8 and over diagnosed as having asthma with measures of variability or reversibility (6 points)

Depression – in those patients with a new diagnosis of depression in the previous year, the percentage who have had an assessment of severity (appropriate to primary care) at the outset of treatment (25 points)

Mental health – percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review, there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status (23 points)

Stroke – percentage of patients who have had a stroke or TIA in whom the last blood pressure reading (in the last 15 months) is 150/90 or less (5 points)

World class clinical database

Quality and Outcome Framework: results from the first 2 years

Average points per practice

No. of practices scoring the

maximum 1,050 points

Average score in the clinical domain

(of 550 available)

2004/5 2005/6

958.7(91.3% of

available total)

1,010.5(96.2%)

222(2.6% of total)

813(9.7%)

507.7(92.3%)

534.2(97%)

GP compensation

• average salary from NHS <$200,000• significantly higher than average NHS salary for

hospital specialist• GPs have had 40% increase in compensation in 2

years

Case study one:supporting people with long term conditions in the county of Cornwall

People with long term conditions who are at “high risk” are proactively supported in the community by nurses with advanced skills who:

• work as part of the primary healthcare team• refer patients directly to specialist doctors in hospitals• order diagnostic investigations• prescribe medicines and treatments

As a result:• 50% reduction in hospital admissions for this group• growth in emergency admissions down from 9% to 1% (-3% in over 75s)• 72% reduction in no. of visits this group made to their primary care physicians• 61% reduction in home visits• 42% reduction in contacts made with the emergency primary care (“out of

hours”) service• higher patient satisfaction, more “joined up” care, better quality, lower costs

Case study two:East Midlands Ambulance Service “avoidable admissions” project

Aim• to reduce unnecessary hospital admissions amongst patients who dial 999 but

who do not have a life-threatening condition

Action• “core” ambulance crews who answer 999 calls were replaced with paramedics

with advanced skills (“emergency care practitioners” - ECPs)

As a result:• 60-70% reduction in the proportion of patients taken to hospital and

subsequently admitted• a largely elderly group of patients avoid the trauma and knock-on

consequences of hospital admission • no increase in risk; no decrease in patient satisfaction and significant cost

saving from hospital admissions avoided

In addition:• scheme set up with British Red Cross Society to enable ECPs to call in trained

volunteers to watch patients in their homes overnight until they see the GP the next day

Quality and outcomes framework

+•champions prevention and quality• based on evidence• creates good practice across the system:

– high compliance– low variation

• quality of local and national database – basis for decision making• moving towards longer term health and well-being outcomes – the bar is rising• foundation for shift to primary care and other policy directions• enables role redesign and other new ways of working

-• underestimate of baseline performance• rise in GP compensation• administrative workload• GPs taking a higher proportion of practice income as personal income• question some indicators

– not stretching enough– not high impact– need to move to more

outcome focused measures

• focuses on only a minority of patients