Oldham
Doing It Differently
Dr Hugh Sturgess
Director, Pennine MSK Partnership
Context
• New White Paper
– Root and branch reform of NHS in England
– Unprecedented financial challenge for NHS
• Deep seated failings in the NHS
– Model of Care
– System of Care
What’s wrong with the system?
• System of Care
• “Disintegration!”
• Micro-commissioning complex pathways
• Perverse incentives – PbR
• KPIs process driven not population level
improvement or patient experience
• No effective performance management of care
Variation in MSK Spend
Programme Budget Commissioning
• Different from standard approach
– Commission with the lead accountable provider for
defined programmes of care with a defined budget
– Commissioners have population quality based KPIs
– Lead accountable provider shares responsibility for
care co-ordination, quality and performance
management across the entire pathway
One thing I have always found is that you
have got to start with the customer
experience and work backwards to the
technology.
Steve Jobs 1955-2011
Patients want more involvement
8
9
Analysis: Satisfaction with
Total Knee Replacement (NJR)
Satisfaction questions were completed by
8095 patients
Overall
- 81.8% were satisfied
- 11.2% were unsure
- 7.0% were not satisfied
The OKS varied according to patient
satisfaction (p<0.001)
Source: National Joint Registry
Challenges
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Lack of faith in new system
Lack of interest/support from grass root GPs
Dismantle existing systems
Financial instability
Threat of competition
Ageing population, more expensive treatments,
increasing co-morbidities and LTCs
• Lack of integrated care
– Much spoken of – hardly ever delivered
– Need to shift investment from Acute trusts to community
and primary care
Oldham
Pennine MSK Partnership
• Primary Care based organisation commissioned by NHS
Oldham to provide non admitted care in rheumatology,
orthopaedics and chronic pain
• Consultant led – provide 97% rheumatology and take
patients to point of listing in Orthopaedics
• From May 2011 control £23m programme budget for
MSK using prime vendor model
• Psychological medicine for chronic pain
• 11,000 new referrals a year
• Deliver traditional hospital based services from
community – biologics and infusions
• GP and Specialist training
• Research
Referral triage
Primary care holistic
assessment and care
COMMUNITY
MULTIDISCIPLINARY
SPECIALIST SERVICE
(Pathway Hub)
Referral
Highly specialised,
intensive, episodic
hospital care
Prime contractor
SUBCONTRAC
TING
Hub functions:
•Referral triage
•Skilling up 1’ care
•Specialist Assessment
•Specialist integrated care
•Shared Decision Making
•Personal Health Planning
•Supported Self Care
•Patient & carer support
•Voluntary sector provision
PATHWAY
MANAGEMENT
NHS Oldham Programme Budget
• MSK - £23m - Pennine MSK 1st May 2011
– Primary Care
• Local enhanced services
– Community Care
• Pennine MSK
• Physiotherapy, podiatry
– Secondary Care
• All activity included
Outcomes Of Programme Budget
• We are incentivised to performance manage
the entire pathway
• Invest in Shared Decision Making and Self
Management
• Work with primary care to reduce variation
• Work with secondary care to ensure best
practice is followed
• Work with commissioner – high value care
within budget
Delivering Integration
• Commissioner will focus on clinical outcomes
rather than process metric
• Patients at the centre of our redesign
• Work with third sector
• Use self management and self referral were
clinically appropriate
Challenges and Opportunities
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Acute Trust attitude
Change in commissioning
Financial constraints
GP support
– Initial suspicion
– Wider support as triage spreads to all referrals
• Clinician support
Knee Pathway (O/A)
Triage of Referral
within 24 hours on CaB
– Signpost patient to
NHS PDAs
Face to face
assessment ESP with 2
weeks with diagnostics
– telephone FU if
needed
Listing – after choice –
18 week compliance by
week 7
Shared Decision Making
– Tested and Implemented the AQuA model past 2
years
– Looked at impact of implementing SDM on patient
reported outcomes for those who have had knee
arthroplasty, year before implementation
compared to the two years since
– Already know SDM results in patient expectations
being more realistic
– High dissatisfaction in knee arthroplasty (19% of
patient ambivalent about or regret surgery)
– Joint project with NHS England
Shared Decision Making
Implementation
• Developed and trialed the NHS patient decision
aids
• Staff training
• Organisation changes – standard board reports,
staff induction, measuring decisional conflict
• Patient empowerment – Ask three questions
• AQuA collaborative
• All patients:
– Given A3Q leaflets
– Signposted to PDAs
– All front line staff trained in SDM, many in
Motivational Interviewing too
Better Health Outcomes
Used Patient Reported Outcome Measures (PROMs) data on EQ-5D index to show:
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Oldham’s knee replacement patients received an average health gain of 0.27 in 2009/10 and 0.35
by 2011/12.
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A statistically and clinically significant increase in Oldham’s patients health outcomes.
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The England average health gain was 0.30 throughout the period.
Period of improvement matches the introduction of SDM.
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Involving patients in decision to treat appears to lead to better outcomes.
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Treated increasingly sicker patients in Oldham, but restored to same good health level.
Improvement delivered within financial constraints in period with:
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Arthroscopies growing at 8% in Oldham compared to 12% nationally.
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Musculoskeletal spend per head decreasing by £10 in Oldham compared to an increase of £10
nationally.
Pennine MSK Impact
Reducing per capita cost whilst maintaining quality
Pennine MSK Impact
Reducing per capita cost whilst maintaining quality
Thank You
Dr Hugh Sturgess
Tel: 0161 628 3628
Mob: 0780 893 7788
E-mail: hugh.sturgess@nhs.net