Sir Muir Grey Presentation
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Improving Eye Care through Maximising Value:
the population approach
Sir Muir Gray
Miss Aeesha Malik
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The NHS in a word
1948-Free
1970’s and 80’s- Effectiveness
1990’s-Cost-effectiveness
2000’s-Quality and Safety
2010, and for the rest of the century…
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Value = Outcomes / Costs
Outcome = Good – Bad
(Effectiveness – Harm)
Costs ≠ Money
Costs = Harm + Carbon + Opportunity Lost
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Lower value activities are those which
1. Have clear evidence that they are ineffective or that they do more harm than good.
2. Have no evidence of effectiveness but are not being delivered in the context of research that
would allow evidence to judge effectiveness to be gathered.
3. Have evidence of effectiveness but are being offered to patients whose characteristics are
different from the characteristics of the patients in the research studies which produced the
evidence of effectiveness.
4. Treat a patient who has not been given unbiased information in a way that they can
understand the probability of both benefit and harm of accepting the offer of treatment
Use resources which would produce more value, namely a better balance of benefit to harm, if
invested in some other service
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Commissioning Growth ££
DIAGRAM SHOWING 3 PIE CHARTS
1st one is COMMISSIONING, The Opthalomology piece of commissioning split into another pie
chart showing Cataract, Retinopothy, ARMD and Glaucoma then split into a 3rd pie chart showing
Low Vision Services and Lucentis or Avastin
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DIAGRAM SHOWING SINGLE PIE CHART WITH Lucentis or Avastin
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DIAGRAM SHOWING TWO PIE CHARTS 1ST with Lucentis or Avastin with an arrow towards another
pie chart showing Cataract, Retinopothy, ARMD and Glaucoma
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DIAGRAM 3 Pie Charts of COMMISSIONING, The Opthalomology piece of commissioning split into
another pie chart showing Cataract, Retinopothy, ARMD and Glaucoma then split into a 3rd pie
chart showing Low Vision Services and Lucentis or Avastin
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1. Is the service for people with glaucoma in Manchester better than the service in Liverpool?
2. Who is responsible for the retinopathy service for people in Warrington?
3. How many AMD services are there in England and how many should there be?
4. Which cataract service provides the best value?
5. Which cataract service improved most in the last year ?
6. Who is responsible for publishing the Annual Report on AMD care in England?
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THIS PAGE IS BLANK
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CHART SHOWING THE GROWTH OF OPPTHALMOLOGY OUTPATIENT ATTENDANCES AGAIN YEARS
FROM 2003 TO 2009
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CHART SHOWING Ophthalmology first and subsequent outpatient APPOINTMENTS
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PICTURE showing
Total attendance outpatient expenditure rate, 2009/10
(weighted for age, sex and need - per 1,000 population)
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PICTURE showing Phakoemulsification Cataract Extraction and Insertion of Lens
Inpatient expenditure rate, 2008/9
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PICTURE Measuring Variation
•
•
Outpatient attendances
•
Per 1000 population
•
Follow-up to first attendance ratio
•
First attendances per 1000 population +/- by source of referral
Day case admissions
•
•
Per 1000 population
Cost
•
Out patient costs per 1000 population
•
Number of sight tests
•
Out patient costs per 1000 population
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Sustainable, Accountable Systems
Agreed objectives, standards, outcomes to minimise un-warranted variation and maximise value
in communities
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Eyes and Vision
Programme
Systems Glaucoma, AMD, Emergency Eye Care.
Networks
Patient Pathways
PICTURE OF VISION 2020 EYE CARE NETWORK
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AMD Pathway
Map of Medicine
PICTURE OF AMD MAP OF MEDICINE
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Newborn Screening for Sickle Cell Disorders Programme Standards
GRAPH OF STANDARDS
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The NHS Outcomes framework is organised around five domains that cover all treatment activity
for which the NHS is responsible
These will help the public, NHS Commissioning Board 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
The five domains will cover the range of activities that the NHS should be delivering for all patients
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 that people have a positive experience of care
Domain 5 Treating and caring for people in a safe environment and protecting them from
avoidable harm
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What are the outcomes for our patients?
Have we improved from last year?
How does we compare to others?
PICTURE OF WEBSITE PAGE ‘COMMISSIONERS QUESTIONS ABOUT GLAUCOMA’
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Developing Sustainable Systems

Monitor the service outcomes and value being delivered

Adapt to new integrated pathways

Strong networks to allow people to be treated by right person in right place

Cope with increasing demand

Sustain high quality health service for patients

Reduce inequalities and preventable disease
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Population medicine

Skills development as part of professional development

Developing a role for a ‘clinical lead’ in a population- integrating care with community
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
Why did 1 in 4 people with diabetes who are eligible for diabetic retinopathy screening not
take part in the screening programme?

Why do some PCTs in England have a rate of eye tests more than 3 times higher than in
others?
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Miss Jones estimated from a population based audit that there were a significant number of
people who were not referred who would benefit. There were also meanwhile another large
number of people seen in hospital clinics who didn’t need to be there.
PICTURE
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Miss Jones, the Co-ordinator of the Glaucoma multi professional Network and Service with
leadership and resources to:

Develop Clinical Networks across primary/secondary, health/public health/social care

Localise integrated patient pathways

Advise the Clinical commissioning board

Advise Health and wellbeing boards on ocular public health

Produce the Annual Report of the service
PICTURE
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Population based planning and programme budgeting
Allocating resources optimally using programme budgeting

Use of programme budgeting tools for comparison and to highlight variation

NHS Atlas of variation
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City and Hackney has:

23% of those CVI registered blind/visually impaired are due to Glaucoma (Compared to 8% in
England and Wales)

13% of those registered are due to Diabetic retinopathy (compared to 7% in E+W)

36% of CVI registration is in the working age population (compared to 17% in EW)
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C &H has a lower spend than national average, cluster and host SHA in comparison
PICTURE
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•
Overall trend of lower spend on vision in areas of higher deprivation- inverse care law
•
In comparison to overall total PCT spend as slight increase with increasing deprivation
PICTURE
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City and Hackney has less first outpatient attendances compared to the SHA and national average
PICTURE
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Outcome measures
Vision- total sight tests per 10,000 population
PICTURE
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City and Hackney has a higher than average rate of CVI blindness registration due to Glaucoma and
DR
Right Care Programme Budgeting tools show that compared to similar PCTs it has;

Lower overall spend on Vision

High index of deprivation

Less first outpatient attendances

Similar day surgery admission rate

Lower spend on GP prescribing for eye care medications
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Shared decision making
Creating a culture for patients to actively engage in decision making about their own healthcare
Clinicians

Diagnosis

Cause of disease

Prognosis

Treatment options

Outcome probabilities
Patients

Experience of illness

Social circumstances

Attitude to risk

Values

Preferences
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NHS Direct: Cataract decision
making support tool coming
soon……..
PICTURE OF WEBSITE PAGE
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1. Population based planning and programme budgeting
2. Sustainable, Accountable Systems
3. Better Value Clinical Practice
4. Shared Decision Making
5. Population Medicine
QIPP Right Care
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Conclusions

Increasing demands on Eye care services, which is set to continue

Significant progress through UK Vision strategy, VISION 2020 and Royal College in new
pathways and models

Build on current changes with sustainable accountable systems, networks, pathways spread
across the country

Opportunity for clinicians to take a leading role on planning Eye care services for the 21st
century
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“We can’t solve problems by using the same kind of thinking we used when
we created them”
Albert Einstein