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 Cripps
National Programme Director, NHS Right Care
Dr Peter Brambleby, Independent public health consultant & Right Care
Associate
Mr. Anthony Lawton – Right Care Associate
Copyright 2011 Right Care
1 key objective + 3 key phases + 5 key ingredients =
COMMISSIONING FOR VALUE
OBJECTIVE - Maximise Value (individual and population)
Five Key Ingredients:
1. Clinical Leadership
2. Indicative Data
3. Clinical Engagement
4. Evidential Data
5. Effective processes
2
Commissioning for Value - Slough CCG
3
Granularity – Population to Patient
Populations
CfV Pack
Atlas
Programme
Budgets
Where to Look
4
Systems
Deep
Dive
Individuals
SDM
Care
Planning
Provider
Pathway
What to Change
Manage
care out of
hospital
How to Change
Paul’s story – Journey 1
Paul:
45, bricklayer, local employer
Smokes 10/day, drinks 4 pints/day, overweight
Council house, supports Leeds United
Wendy:
David:
GP:
Village shop:
5
42, barmaid
16, schoolboy
small practice, 17 miles from DGH
limited food options
Paul’s journey starts when …..
Prompted by Wendy, sees his GP






6
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
Context & Variation
7
Practice 1
Practice 6
Practice 11
Practice 16
Practice 21
Practice 26
Practice 31
Practice 36
Practice 41
Practice 46
Practice 51
Practice 56
Practice 61
Practice 66
Practice 71
Practice 76
Practice 81
Practice 86
Practice 91
Practice 96
Practice 101
Practice 106
Practice 111
Achievement (%)
of patients with diabetes where HbA1c is 7 or less in previous 15 months
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
8
In the local population, who has overall responsibility for:




9
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?
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
10
Spot
Tool
11
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
12
The Impact (Economic and Social) – Journey 1
Journey 1 - (less than perfect)
Paul 45
Pre Primary Care Review
Yr 1
Yr 2
Personal &
Emotional Costs
Yr 3
Phase 1 Activity & Treatment
Yr 4
Yr 5
Yr 6
Yr 7
Paul 50
Phase 2 Activity & Treatment
Yr 8
Yr 9
Paul 52
Phase 3 Activity & Treatment
Yr 10
Yr 11
Increased urinary frequency
Excessive drinking (reduced)
Excessive drinking
Excessive drinking
Excessive drinking
Issues around Thirst
Obese (but improved)
Obese
Obese
Excessively Tired
Smoking (reduced)
Left leg pain
Obese
Left leg - white & very painful (then
amputated)
Excessive drinking
Missing work days
Loses job
Obese
Stopped exercising
Cant exercise
Smoking
Stopped driving
Wendy taking half days off to
drive to treatments /
Economic situation of the family
becoming tough
Cant drive
Wendy taking more time off as carer
Economic situation of the family is now
extreme
Paul's quality of life now very poor
Both Paul & Wendy depressed
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
Economic Costs
13
-
-
1,360
576
576
576
576
1,762
1,953
8,948
32,757
49,084
The Economic Impact during 3 of those 11 years
Economic Analysis - Journey 1 Extracts:
Phase 1 - Yr 3
Activity
Phase 2 - Yr 8 (Paul at 50)
Activity
Costs
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
1
370.52
Prescription Drugs
1
1
9.89
Testing Strips
1
3
378.00
Lab Tests
6
6
34.78
Practice Nurse
6
1
715.00
District Nurse Visit
0
1
50.00
Care Plan developed
1
1
7.73
Retinopathy screening
1
1
210.00
370.52 Testing Strips
9.89 Lab Tests
756.00 Practice Nurse
34.78 Daily insulin injections (Levemir)
-
1
2
6
1
Diabetology clinic
1
23.00 Diabetes specialist nurse
Referred to vascular clinic
100.00 (Registrar)
1
Retinopathy screening follow up
1,359.63
14
Phase 3 - Yr 10 (Paul at 52)
Activity
Costs
1
1
370.52 Prescription Drugs
9.89 Testing Strips
252.00 Lab Tests
34.78 Practice Nurse
715.00 Daily insulin injections (Levemir)
50.00 Diabetology clinic
7.73 Diabetes specialist nurse
Treatment - Heart disease
235.00 (investigative procedure)
Treatment - Renal Impairment
53.00 (initial dialysis - monthly)
1,762.42
1 3,012.00
Treatment - Eye disease (glasses)
1
50.00
Anti depressants prescribed
2
107.76
NHS Transport (Ambulance)
Leg ulcer treatment
(septicaemia)
4
854.00
1 3,114.00
8,948.18
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?
15
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
16
The Impact (Economic and Social) J2
Journey 2 - (Improved Pathway - Revised Focus)
Pre Primary
Yr 1
Yr 2
Increased
urinary
frequency
Yr 3
Phase 1 Activity & Treatment
Yr 4
Yr 5
Yr 6
Yr 7
Phase 2 Activity & Treatment
Yr 8
Yr 9
Phase 3 Activity & Treatment
Yr 10
Yr 11
Excessive
drinking
(reduced)
Support working - Eating well, Exercising, & Drinking Controlled. Keeping work and
social life healthy, no depression, no serious interventions:
Issues around Obese (but
Thirst
improved)
Excessively
Personal & Tired
Emotional Costs
Smoking
(reduced)
focus is on Support, Education & Medication.
Excessive
drinking
Initial pathway = sub-optimal quality, cost £49k, low value
Post-improvement = optimal quality, cost £9k, high value
Obese
Smoking
Economic Costs
17
23
1,153
607
958
587
958
710
1,084
736
1,210
909
8,936
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?
18
Granularity – Population to Patient
Populations
CfV Pack
Atlas
Programme
Budgets
Where to Look
19
Systems
Deep
Dive
Individuals
SDM
Care
Planning
Provider
Pathway
What to Change
Manage
care out of
hospital
How to Change
Service Review Pathway – Diagnostic steps
Step 1 – define:
CURRENT
SERVICE
20
Step 2 – define:
Step 3 –
Step 4 –
categorise:
recommend:
Fit for
Purpose
Maintain
Efficiency
and
market
options
Redesign,
Contract,
Procure
Supply
and
capacity
options
Contract,
Procure,
Divest
No/ low
benefit
Divest
FUTURE
SERVICE
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
21
Where Bradford are now (and where West Cheshire were)…
22
Where West Cheshire are now (and where you could be)…
23
Galvanising Clinicians – On the right things
Number of Circulatory indicators in the bottom quintile of the practice cluster
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
1
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
24
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
25
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
All people with the condition
People receiving
receiving the
the People
specialist
service service
26
People who
would benefit
most from the
service
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
27
Work through the phases and Commission for Value
Populations
CfV Pack
Atlas
Programme
Budgets
Where to Look
28
Systems
Deep
Dive
Individuals
SDM
Care
Planning
Provider
Pathway
What to Change
Manage
care out of
hospital
How to Change
29
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 rightcare@nhs.net
• 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: rightcare@nhs.net
Dr Peter Brambleby, Independent public health consultant,
Email: p.brambleby@btinternet.com
Mr. Anthony Lawton – Right Care Associate
Email: Anthony.Lawton@ffmi.co.uk
Jules Gaughan - Right Care Associate
Email: juedrop@me.com
Mr. Ian McKinnell - NHS Right Care
Email: ian.mckinnell@btopenworld.com
31