Commissioning for Value
How Right Care can support CCGs to get value
for patents and populations
Professor David Colin-Thomé
Independent Health Care Consultant
Member of the Right Care team, Department of Health
www.dctconsultingltd.co.uk
david@dctconsultingltd.co.uk
Copyright 2011 Right Care
CHANGE; Both the bureaucracy and the market
have a part to play but what is needed are
complex adaptive systems because healthcare is
too complex to be managed through the market or
bureaucracy alone
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Liberating the NHS…or bamboozling?
“Design an approach to moderation, conditions and decisions that is
consistent, proportionate, transparent, and legally compliant,
supporting the delivery of an efficient and consistent decision-making
process. The process design will be accompanied by template
documents and conditions to further support efficiency and
consistency.
This rigorous approach will also protect both the NHS
Commissioning Board (NHS CB) and CCGs by ensuring that the
risks of CCGs taking on responsibilities before they are ready to do
so are minimised, whilst maximising the opportunities for full
authorisation.”
“One reason for the conditions will be that groups are required to
demonstrate strong and “credible” operational and service planning
for 2013-14, including how they will achieve financial balance. Few
CCGs are in a position to do so and no framework or guidance is yet
in place.”
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A changing paradigm
20th Century Health
Care
Clinician-centred
Focus on benefits of treatment
Increase quality
Patient as passive complier
Good care for known patients
Hospital as focus
Operates through bureaucracy
Driven by finance
High carbon usage
Challenges met by growth
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21st Century Health Care
Patient-centred
Focus on prevention of disease &
harm
Reduce waste and increase value
Patient as co-producer
Equitable care for populations
Focus on systems
Operates through networks
Driven by knowledge
Low carbon usage
Challenges met by transformation
1948-1972 Free
1980’s Effectiveness
1990’s Cost-effectiveness
2000’s Quality and Safety
2010 and for the rest of the century
VALUE
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Right Care - Commissioning for Value
“Value in any field must be defined around the
customer, not the supplier. Value must also be
measured by outputs, not inputs. Hence it is
patient health results that matter, not the volume
of services delivered. But results are achieved at
some cost. Therefore, the proper objective is..
the patient health outcomes relative to the total
cost (inputs). Efficiency, then, is subsumed in the
concept of value. ”
Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School.
Institute for Strategy and Competitiveness. White Paper.
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Value = Outcomes / Costs
Outcome = Good – Bad
(Outcome= Effectiveness – Harm)
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The Right Care Programme
Right Care is a programme designed to increase the
value from the resources allocated to healthcare
We do this by:
• Highlighting un-warranted variation in quality,
outcomes, activity and spend
• Empowering patients through shared decision making
• Engaging clinicians and commissioners to shift from
“rationing” to “rational commissioning”
• Using information to create insights leading to action
and ensuring these insights are shared
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The six domains underpinning Right Care
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Highlighting un-warranted
variation in quality, outcomes,
activity and spend
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Variations in healthcare
Variations in healthcare exist for many legitimate
reasons. Populations and individuals have distinct needs,
and some of the variation observed is a reflection of the
responsiveness of the service to meeting particular
needs.
However, the degree of variation demonstrated for
instance in the Right Care Atlas of Variation cannot be
explained solely on that basis.
Unwarranted variations are driven not by the needs of the
patient but by the limitations of the healthcare system
and the healthcare professionals within it.
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The NHS Atlas of Variation 2011
Reducing unwarranted variation to increase
value and improve quality
“A good map is worth a
thousand Words…
… cartographers say, and they are right:
because it produces a thousand words: it
raises doubts, ideas. It poses new questions,
and forces you to look for new answers.”
Franco Moretti (1998)
Atlas of the European Novel 1800–1900
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Right Care Themed Atlas Series
Themed atlases focus on specific
conditions or populations in more depth
and are developed as collaborations with
key stakeholders
•
•
•
•
•
Child and Maternal Health (Out now)
Diabetes Care (Out now)
Kidney Care (Out now)
Respiratory Disease (Out now)
Organ Donation and
Transplantation (Dec)
• Liver Disease (Dec)
• Diagnostics (Jan 2013)
…2013/14?
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Examples of Variation in Child Care
Breastfeeding: There is a three-fold variation in breastfeeding rates
for babies aged 6-8 weeks across the country.
Asthma: Variation in the treatment of child asthma has got worse. In
2008/09, there was a four-fold variation in the rate of children
admitted for emergency hospital treatment – now, that has risen
to a five-fold variation.
Epilepsy: There is a four-fold variation in the emergency admission
rate for children with epilepsy.
A&E: There is a 3.5-fold variation in A&E attendance for children
aged 0-4.
Diabetes: There is a 2.6-fold variation in the percentage of children
with diabetes admitted to hospital for diabetic ketoacidosis – a
serious emergency condition that can lead to coma or even death
if Type 1 diabetes is not properly managed
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www.rightcare.nhs.uk/atlas
In print
You can order free printed copies using
the online form on our website
Online
High and Low resolution PDFs are
available for download
Interactive
A fully interactive
InstantAtlastm is available
online
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Empowering patients
through shared decision
making
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Patient Decision Aids –
empower patients, get better decisions
International evidence suggests a 20 per cent reduction
in ‘discretionary surgery’ when Patient Decision Aids are
used (Cochrane Collaboration review)
Research from the Ottawa Hospital Research Institute
also states that patients who don’t have decision support:
• Are 59 times more likely to change their mind
• Are 23 times more likely to delay their decision
• Are five times more likely to regret their decision
• Blame their practitioner for bad outcomes 19%
more often
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Decision Aids reduce rates of discretionary
surgery
0%
25%
50%
75%
CA-Prostatectomy
CAOrchiectomy*
coronary bypass*
coronary bypass
hysterectomy
.
hysterectomy*
mastectomy
back surgery
Standard Care
mastectomy*
D-Aid
bphprostatectomy
bphprostatectomy
O’Connor et al., Cochrane Library, 2009
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RR=0.76 (0.6, 0.9)
Engaging with clinicians and
commissioners to shift from
“rationing” to
“rational commissioning”
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“Dis-investment” to fund innovation?
There has been controversy surrounding “rationing” in the NHS, with
PCTs challenging the use of a range of interventions, sometimes
deemed to be of “low value”, and developing clinical policies to
reduce the level of interventions,
Right Care supports the shift from lower to higher value interventions
to provide the “innovation fund” – achieving consensus around that is
however difficult.
Right Care is working with the Royal College of Surgeons and the
Federation of Specialist Surgical Associations to develop
Commissioning Guidance. Surgical Commissioning Guidance will
support CCG’s to commission evidence-based, cost effective care for
patients with conditions amenable to surgical intervention
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We will do this by…
• the description of evidence based high value care
pathways
• highlighting variation in the provision of surgical services
• describing process and outcome measures that allow
commissioners to make intelligent commissioning
decisions
• providing levers for change within the local healthcare
community
• links to patient and clinician facing information, and
practical examples of high value care pathways that have
been implemented in other healthcare communities
• identifying priority areas for research
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Procedures Explorer
To support the development work
for guidance production, Right
Care has commissioned East
Midlands Quality Observatory to
develop a Procedures Explorer
Tool and populated it with national
SUS data. The tool can be used:
• By commissioners to
understand how commissioning
actions can influence variation
in spend and outcomes at a
granular level
• By providers to understand how
their behaviour can influence
outcomes, which may be
different from those of other
providers across the country
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The PET will be available online in
early 2013.
Using information to create
insights, leading to action and
ensuring these insights are
shared
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NHS Right Care have previously produced “Health Investment Packs” for each of
the 151 Primary Care Trusts in England. The packs used available health
investment tools to highlight areas where outcome was poor compared with
spend, and with other similar PCTs.
http://www.rightcare.nhs.uk/index.php/tools-resources/health-investment-packs/
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Information Available for Commissioners
The products available to commissioners including:
• Programme Budgeting Spreadsheet;
• SPOT (Spend & Outcome Tool);
• Programme Budgeting Atlas;
• NHS Comparators.
• Inpatient Variation Expenditure Tool (IVET)
These tools allow commissioners to compare expenditure and outcomes at disease
level.
To access these tools visit;
www.networks.nhs.uk/nhs-networks/health-investment-network/key-tools
These tools are a starting point for the process of making health investment decisions.
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NHS Comparators
NHS Comparators provided by the IC on the NHS net;
nww.nhscomparators.nhs.uk
Holds data at England, SHA, PCT and Practice level;
Data are timely and frequent – every quarter up to Q3 2009/10
Various sources of data including:
total admissions – activity and expenditure;
non-elective admissions – activity and expenditure
elective admissions – activity and expenditure
prescribing – items and expenditure
better care better value metrics – including low cost statin prescribing
Very powerful for showing variation, and time series – which allows to track
change over time
Outpatient referrals by GP
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Key Findings
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Example SPOT chart – NHS Nottingham City spends more per head on cancer and has a
higher premature mortality rate than similar areas.
Mortality
from all
cancers,
under 75
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NHS Oldham
….uses Programme Budgeting Tools to show
that, when compared to similar PCTs, NHS
Oldham has;
• Above average overall spend for Musculo
Skeletal system problems (MSK) and higher
proportion spent on elective admissions
• Lower health gain for patients receiving hip
replacements than patients in PCTs with similar
pre-op health status. Patients have relatively
low pre-op health status compared to PCTs with
similar deprivation levels
• Average health gain for patients receiving knee replacements compared to
patients in PCTs with similar pre-op health status. Patients have relatively
higher pre-op status compared to PCTs with similar deprivation levels
• High FHS prescription rate for MSK
• Low GP referrals to T&O but high referrals from A&E, MIU & Walk in
Centres and average overall T&O outpatient attendances
• High rate of elective admissions for MSK and long length of stay
• Low rate of emergency admissions for MSK but long length of stay
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NHS Western Cheshire
The result is that demand for acute services is starting to
fall. £7m of the re-investment were delivered in just 6
months.
Western Cheshire took a three stage approach to this
work:
•
Understanding their current expenditure to identify areas to
target
Service reviews of identified areas /health programmes
Implementation of the agreed recommendations from
service reviews
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•
Service reviews identified a range of changes specific to each service, including:
•
•
•
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Service redesign to change a pathway from current to best practice.
Contract management or procurement change to get a service provided to a higher
quality and/ or lower cost.
Decommissioning of a service/pathway because it does not add value or delivers more
capacity than is necessary.
Derby city and Derbyshire county CCGs
Working locally in Derbyshire, Right Care has
facilitated the development of 7
“Commissioning for Value Information packs”
– soon to be 11, covering Derby city and
Derbyshire county CCGs.
The packs have been produced with local
engagement of CCGs and use both national
and local data analysis to generate
recommendations for action in 4 programme
budget areas.
As the Erewash Casebook shows – this has
lead to changes in pathways/systems and real
cash savings for re-investment
Get all these Casebook online at
http://www.rightcare.nhs.uk/index.php/tools-resources/
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Next Steps
Visit the Health Investment Network website:
www.networks.nhs.uk/nhs-networks/health-investment-network
Use the E guides to understand how the tools use in this slidepack work and to
gain a better understanding of expenditure and associated outputs and
outcomes.
Produce versions of this slidepack for other programme budgeting categories.
Download the annual population value review which provides a contextual guide
to the health investment process.
Access a video learning module that explores the definitions, tools and practical
application of Programme Budgeting Marginal Analysis (PBMA)
Find Useful links to other tools, data sources, reports and guidance.
Further information regarding QIPP Right Care can be found at:
www.rightcare.nhs.uk
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