Clinical Directors Forum
Donal O’Donoghue
National Clinical Director

During the recession, government expenditure has continued to grow whilst receipts have fallen:
Expenditure
700
600
500
400
• Highest spending since 1982–83
• Lowest tax burden since 1960–61
• Highest borrowing since WWII
300
200
19
96
-9
7
19
97
-9
8
19
98
-9
9
19
99
-0
0
20
00
-0
1
20
01
-0
2
20
02
-0
3
20
03
-0
4
20
04
-0
5
20
05
-0
6
20
06
-0
7
20
07
-0
8
20
08
-0
9
20
09
-1
0
£154bn borrowing last year
Receipts

The challenge is immense:
Change in real current spending
16%
14%
12%
10%
8%
6%
4%
2%
0%
-2%
-4% public expenditure
NHS expenditure
19
74
-75
19
79
-80
19
84
-85
19
89
-90
19
94
-95
19
99
-00
20
04
-05
20
09
-10
20
14
-15
“Quality, Innovation, Productivity and Prevention (QIPP) productivity gains… will release up to £20 billion more funding into frontline services for patients over the four years [2011/12 to 2014/15].” ( The Operating Framework for the
NHS in England: 2011/12 , December 2010)
“But this will not protect the NHS from the need to secure efficiency savings and to control pay and prices in the NHS. If we can secure those efficiency savings, we can reinvest them in the NHS to deliver improving outcomes for the public.” (Secretary of State, Today , May 2010)

Focus on quality retained following the change of government…
“Building on Lord Darzi’s work, the Government will now establish improvement in quality and healthcare outcomes as the primary purpose of all NHSfunded care”
NICE Quality Standards, Quality Accounts, CQUIN, measuring for quality improvement, the National Quality Board are all key features of the new system

But, an important shift in focus towards outcomes…
Equity and Excellence: Liberating the NHS set out a vision of a NHS that achieves amongst the best outcomes of any health service in the world. To achieve this, it outlined two major shifts:
• A move away from centrally-driven process targets which get in the way of patient care;
• A relentless focus on delivering the outcomes that matter most to people
“All too often, the NHS has been hamstrung by a focus on nationally determined process targets which have had a distorting effect on clinical priorities, disempowered healthcare professionals and stifled innovation. We need to recalibrate the whole of the NHS system so it focuses on what really matters to patients and what we know motivates healthcare professionals
– the delivery of better health outcomes.”
Transparency in Outcomes- a framework for the NHS July 2010

GOAL: Aligned outcomes frameworks for the NHS, public health and adult social care

The NHS Outcomes Framework will set direction and provide enhanced accountability
The framework will be organised around 5 national outcome goals / domains covering the breadth of NHS activity
These will help the public and
Secretary of State for Health to track:
How EFFECTIVE the care provided by the NHS is
What the patient EXPERIENCE is like
How SAFE the care provided is
Domain
1
Preventing people from dying prematurely
Domain
2
Enhancing quality of life for people with long-term conditions
Domain
3
Helping people to recover from episodes of ill health or following injury
Domain
4
Ensuring people have a positive experience of care
Domain
5
Treating and caring for people in a safe environment and protecting them from avoidable harm
Effectiveness
Patient experience
Safety

THE NEW QUALITY LANDSCAPE: How will the NCB deliver the NHS Outcomes Framework?
• How to make change happen in the new system will feel very different.
• Even though many of the levers remain, top down performance management of providers or commissions won’t be a feature of the new system .
• There will be no NHS Headquarters - this is not the role of the NHSCB.
• The focus on outcomes will require a far more sophisticated accountability model than we have had in the past.
• Unlike process measures where it is easier to make black and white judgements about performance, outcome measures are far more complex to understand and interpret - this is a good thing as it will require real understanding of the issues
• There will be a temptation to pull every available lever in an attempt to affect change – the reforms, however, are about liberating the intrinsic motivators of staff to deliver high quality care and better outcomes

The QIPP programme is supporting the NHS to meet the challenge
Characteristics of a sustainable system:
Care closer to home
Earlier intervention
Fewer acute beds
More standardisation
Empowered patients
Reduced unit costs
Areas covered by Quality, Innovation,
Productivity and Prevention (QIPP) programme
Supporting commissioners to commission for quality and efficiency – e.g. through improved clinical pathways, decommissioning poor value care
Provider efficiency – supporting providers to respond to the commissioning changes and efficiency pressures by transforming their businesses
Shaping national policy and using system levers to support and drive change e.g. primary care contracting & commissioning

Thirteen national QIPP workstreams will help local organisations respond to this challenge:
Commissioning and pathways
• Right Care
• Long Term Conditions
• Urgent Care
• End of Life Care
Provider efficiency
• Back Office Efficiency and Optimal Management
• Procurement
• Clinical Support Rationalisation (Pathology)
• Productive Care
• Medicines Use and Procurement
• Safe Care
System enablers
• Primary Care Contracting and Commissioning
• Technology and Digital Vision
• Workforce

1a Mortality from causes considered amenable to healthcare
1b Life expectancy at 75
2 Health-related quality of life for people with long-term conditions (EQ-5D)**
1.1
Under 75 mortality rate from cardiovascular disease*
1.2
Under 75 mortality rate from respiratory disease*
1.3 Under 75 mortality rate from liver disease*
1.4 Cancer survival i One- and ii five-year survival from colorectal cancer iii One- and iv five-year survival from breast cancer v One- and vi five-year survival from lung cancer
1.5 Under 75 mortality rate in people with serious mental illness*
1.6.i Infant mortality*
1.6.ii Perinatal mortality (including stillbirths)
One framework
Five domains
Ten overarching indicators
Thirty-one improvement areas
Fifty-one indicators in total
2.1
Proportion of people feeling supported to manage their condition***
2.2
Employment of people with long-term conditions
2.3.i
Unplanned hospitalisation for chronic ambulatory care sensitive conditions
2.3.ii
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.4
Health-related quality of life for carers (EQ-5D)**
2.5
Employment of people with mental illness
4a Patient experience of primary care
4b Patient experience of hospital care
* Shared responsibility with Public Health England
**EQ-5D ™ is a trademark of the EuroQol Group. Further details can be found on
4.1 Patient experience of outpatient services
4.2 Responsiveness to inpatients’ personal needs
4.3 Patient experience of A&E services
4.4 Access to i GP services and ii dental services
Improving women and their families’ experience of maternity services
4.5 Women’s experience of maternity services
4.6 An indicator needs to be developed based on the survey of bereaved carers
4.7 Patient experience of community mental health services
4.8 An indicator needs to be developed.
3a Emergency admissions for acute conditions that should not usually require
3b Emergency readmissions within 28 days of discharge from hospital***
3.1 Patient-Reported Outcomes Measures ( PROMs) for elective procedures
3.2 Emergency admissions for children with LRTIs
3.3 An indicator needs to be developed.
3.4 An indicator needs to be developed.
3.5 The proportion of patients recovering to their previous levels of mobility / walking ability at i 30 and ii 120 days***
3.6 The proportion of older people (65 and over) who were still at home 91
5a Patient safety incident reporting
5b Severity of harm
5c Number of similar incidents
5.1 Incidence of hospital-related venous thromboembolism (VTE)
5.2 Incidence of healthcare associated infection (HCAI) i MRSA ii C. difficile
5.3 Incidence of newly-acquired category 3 and 4 pressure ulcers
5.4 Incidence of medication errors causing serious harm
5.5 Admission of full-term babies to neonatal care
5.6 Incidence of harm to children due to ‘failure to monitor’

• Testing for CKD
• Progression
• Referral
• BP control
• Anaemia management
• AKI risk management
• Personalised information
• AV fistula
• Immunisation
• HCAIs reduced
• Transport for HD
• Pre-emptive transplants
• Care planning
• Conservative kidney care

The Commissioning of Quality and Innovation (CQUIN) payment framework are one way to achieve quality:
The renal CQUINS cover acute kidney injury and home dialysis. The indicators of quality that have been chosen are:
• Percentage of emergency admissions to have both 1. physiological scoring performed to identify patients at high risk of clinical deterioration (eg MEWS score) and 2. senior review (consultant or equivalent within 12 hours of admission).
•
Percentage of emergency admissions with a major risk factor for AKI to have both: 1. medication review and 2. serum creatinine re-checked within 24 hours of admission.
• Percentage of patients requiring maintenance dialysis to be receiving home haemodialysis, peritoneal dialysis or assisted automated peritoneal dialysis.

Before Changes After Changes
No. on hospital transport
Taxi journeys
Costs
Saving
Volunteer drivers journeys
Costs
66
300-350 approx
£6,000
3,000 approx
£13,350
(£4.45 per journey)
44
0
£0
£6000
1,536
£6,830
Saving
Hospital Car Transport Journeys 11,500 approx
Costs
Saving
£86,250
(£7.50 per journey)
Ambulance (£8,892 per pt per year)
18
£6520
6,300
£47,250
£39,000
6
Costs
Savings
Total Saving
£160,056 £53,352
£106,704
£158,224

Patient complaints reduced
12 patients came off ambulance transport
Productivity:
• Number of journeys reduced by approx 33%
• Number of patients requiring transport reduced from
51% to 34%
• Cost savings in one kidney centre: £158,224
• Potential National savings: £25,500,000

Provided by: Bradford Teaching Hospitals NHS Foundation Trust
NHS Evidence assessment of the degree to which this particular case study meets the criteria is represented in the evidence summary graphic:

Giving intravenous iron in patients homes and community hospitals
Provided by: Royal Cornwall Hospitals Trust
QIPP Evidence provides users with practical case studies that address the quality and productivity challenge in health and social care. All examples submitted are evaluated by NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria of savings, quality, evidence and implementability; each criterion is given a score which are then combined to give an overall score. The overall score is used to identify the best examples, which are then shown on NHS
Evidence as ‘recommended’ or ‘highly’ recommended’.

%HHD prevalence in dialysis pop n
2008
Adapted from Renal Registry 12 th Annual Report 2009

“is a fundamental part of care planning and promotes the best choice in what otherwise can be a complex and overwhelming situation.”
The care team communicates to the patient personalised information about the options, outcomes, probabilities and scientific uncertainties of the various treatments.
The patient communicates his or her values and relative importance he or she places on the potential benefits and harms.

Standard 3
“All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

Haemodialysis tariff prices HRG code
Description Tariff per session £
LD01A
LD02A
LD03A
LD04A
LD05A
LD06A
LD07A
LD08A
Hospital haemodialysis/filtration with access via haemodialysis catheter 19 years and over
Hospital haemodialysis/filtration with access via arteriovenous fistula or graft 19 years and over
Hospital haemodialysis/filtration with access via haemodialysis catheter with blood borne virus 19 years and over
Hospital haemodialysis/filtration with access via arteriovenous fistula or graft with blood borne virus 19 years and over
Satellite haemodialysis/filtration with access via haemodialysis catheter 19 years and over
Satellite haemodialysis/filtration with access via arteriovenous fistula or graft 19 years and over
Satellite haemodialysis/filtration with access via haemodialysis catheter with blood borne virus 19 years and over
Satellite haemodialysis/filtration with access via arteriovenous fistula or graft with blood borne virus 19 years and over
128
159
146
182
128
159
146
182

:
Tariff per day £ Peritoneal dialysis tariff prices HRG code
Description
LD11A
LD12A
Continuous ambulatory peritoneal dialysis 19 years and over
Automated peritoneal dialysis 19 years and over
46
56

• There is currently no capacity to differentiate between APD and assisted APD in the new chapter LD HRG.
• Therefore both aAPD and APD activity will result in the generation of an APD HRG with its associated National Tariff.
• For the next 12 months it will be necessary to agree locally the commissioning and re-imbursement for the ASSISTANCE portion of the costs, and a means of communicating this activity.

• The items in the current NRD which define the current HRG include separately;
– Modality (CAPD, CCPD, Haemodialysis)
– Supervision (Hospital, Satellite, Home, Shared)
• The supervision is currently used to differentiate Home from Satellite and Hospital HD in HRG.
• In the future it is proposed to use the currently un-used “Shared” supervision code to differentiate
– Assisted APD (CCPD+Shared)
– Self administered APD (CCPD+Home)

• A request will be made in May 2011 to revise the current HRG to include aAPD.
• The modest change requested, and the existing items in the NRD make it likely to be a quick modification.
• In preparation providers can collect data on aAPD using the future
(CCPD+shared) scheme now if they wish.
• The current HRG grouper ignores supervision if the modality is
CCPD so it will still result in the same APD HRG, but will allow immediate transition to the new HRG when these are released.

• The ideal is
– A close to real-time record of individual HD treatment sessions for all unit HD patients which includes the access used for the individual treatment session, and the dialysis location (hospital or satellite).
– An electronic treatment prescription which a patient will be self administering if doing a home therapy (CAPD, CCPD,
HHD) containing a minimum of modality and the number of delivered treatments per week.
– An electronic record of a patients blood borne virus status
(mimimum = positivity to one or more of HepBsAg, HepCAb,
HIV test) for all unit HD patients.
– An electronic record of the patients age (<19 v.s >=19yrs).

Data flow
NRD Source extracted from renal unit clinical computer system
.csv file passed through local grouper to convert codes to HRG
Finance divide activity by PCT
Provider invoice for activity by HRG
Finance also provide patient level
Data as part of contract for assurance
PCT pay provider for activity

Data flow
NRD Source extracted from renal unit clinical computer system
.csv file passed through local grouper to convert codes to HRG
Finance divide activity by PCT
Provider invoice for activity by HRG
Finance also provide patient level
Data as part of contract for assurance
ICD-10 and OPCS Source extracted from hospital PAS
PCT pay provider for activity

Data flow
NRD Source extracted from renal unit clinical computer system
.csv file passed through local grouper to convert codes to HRG
Finance divide activity by PCT
Provider invoice for activity by HRG
Finance also provide patient level
Data as part of contract for assurance
ICD-10 and OPCS Source extracted from hospital PAS
NRD data remain in the grouper output file aAPD identified using NRD codes rather than HRG
Invoice for aAPD
PCT pay provider for activity

Data flow
NRD Source extracted from renal unit clinical computer system
ICD-10 and OPCS Source extracted from hospital PAS
.csv file passed through local grouper to convert codes to HRG
Finance divide activity by PCT
Provider invoice for activity by HRG
Finance also provide patient level
Data as part of contract for assurance
Data submitted to SUS for grouping
Provider and commissioner both review same activity data in SUS
PCT pay provider for activity

Nephrology
CONSULTANT-LED
WF01B
First attendance
Single Professional
(£)
WF02B
First attendance
Multi Professional
(£)
WF01A
Follow up Attendance
Single Professional
(£)
WF02A
Follow up Attendance
Multi Professional
(£)
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