1
Commissioning for Value
Leeds 10th March 2015
Session 2
Commissioning for Value and
population health improvement
Investing in prevention: common ground
for public health and the NHS
Commissioning for Value event, Leeds 10th March 2015
Professor Brian Ferguson
Chief Economist
Ideas
• “The difficulty lies not so much in developing
new ideas as in escaping from old ones”
(John Maynard Keynes)
• “There are few new ideas in NHS reform, just
ones that have found their time”
Take-home messages
• We have a once-in-a-lifetime opportunity to shift the focus to
commissioning for population health
• Commissioning for value is all about culture change
• It requires a sustained focus on outcomes and investing in areas of
proven cost-effectiveness
• It requires us to operate collectively as a system with the right
incentives in place
• We need high-quality and timely intelligence that is also joined-up
across systems
4
A strong and shared case
NHS 5-year forward view
• The health and wellbeing gap: if the nation fails to get
serious about prevention then recent progress in healthy
life expectancies will stall, health inequalities will widen,
and our ability to fund beneficial new treatments will be
crowded-out by the need to spend billions of pounds on
wholly avoidable illness.
6
NHS 5-year forward view: PHE’s priorities
•
Public Health England’s new strategy sets out priorities for tackling obesity,
smoking and harmful drinking; ensuring that children get the best start in
life; and that we reduce the risk of dementia through tackling lifestyle risks,
amongst other national health goals.
•
We support these priorities and will work to deliver them. While the health
service certainly can’t do everything that’s needed by itself, it can and
should now become a more activist change of health-related social change.
That’s why we will lead where possible, or advocate when appropriate, a
range of new approaches to improving health and wellbeing.
7
Wanless got it right
•
Wanless (2007): “Without improvements in productivity and greater efforts
to tackle the causes of ill-health, even higher levels of investment in the
NHS will be required than envisaged by the fully engaged or solid progress
scenarios”
•
‘Fully engaged scenario’: levels of public engagement in relation to their
health are high: life expectancy increases go beyond current forecasts,
health status improves dramatically and people are confident in the health
system, and demand high quality care. The health service is responsive
with high rates of technology uptake, particularly in relation to disease
prevention. Use of resources is more efficient.
8
Diabetes
•
Prevalence rising due to ageing population and obesity levels – new shared
focus on prevention
•
Good control (HbA1C etc) in primary care
•
Getting people screened and achieving consistent screening rates across
the country
•
Avoiding hospital admissions for (e.g.) lower limb amputations
•
PbR system and perverse incentives
•
i.e. we talk about prevention then reward more of the wrong type of activity
9
Commissioning, Value and
Culture
11
Focus of commissioning to date
• Transactional or transformational?
12
Source?
Focus area
Description
3
Proactively seek and build continuous and meaningful
engagement with the public and patients, to shape services
and improve health
4
Lead continuous and meaningful engagement with clinicians to
inform strategy and drive quality, service, design and resource
utilisation
6
Prioritise investment according to local needs, service
requirements and the values of the NHS
7
Effectively stimulate the market to meet demand and secure
required clinical, health and well-being outcomes
8
Promote and specify continuous improvements in quality and
outcomes through clinical and provider innovation and
configuration
11
Make sound financial investments to ensure sustainable
development and value for money
Don Berwick (2001)
•
“….measurement alone does not hold the key to improvement….measuring
could be an asset in improvement if and only if it were connected to
curiosity - were part of a culture primarily of learning and enquiry, not
primarily of judgement and contingency”
•
CfV is an improvement tool – performance management systems lead to
defensive behaviour that is not conducive to a culture of improvement
14
Long-term agreements – a good old idea
•
Marks & Spencer – quality / value / service
•
Regular dialogue with suppliers
•
Detailed technical / quality specifications
•
Length of relationship
•
Focus not all on cash flow
•
Power balance
Could argue that M& S have been ‘commissioning for value’ for years
15
Population health systems: going beyond
integrated care (King’s Fund Feb.’15)
Key features of health systems that focus on population health:
 organisations working together across systems to improve health outcomes for
defined population groups
 population-based budgets to align financial incentives with improving population
health
 systems have developed different strategies for different segments of the populations
they serve
 community involvement in managing their health and designing local services
 integrated health records
 scaled-up primary care systems
 close working with individuals to understand the outcomes and services that matter to
them
 supporting and managing individuals to manage their own health
16
Jönköping and the Triple Aim initiative
1. improve the health of the population
2. enhance the patient experience of care (including quality, access and
reliability)
3. reduce, or at least control, the per capita cost of care
•
"The Jönköping work has been shaped by an agenda focused on quality
and safety which places the citizen at the heart of its services
•
The Jönköping model underlines the strategic role public health plays in
improving the health and wellbeing of a population. The commitment to
embedding quality improvement methodology and ensuring the needs of
local populations are the key priorities for each organisation
•
Jönköping's commitment to partnership working across sectors,
providing an almost seamless pathway for patients, is clearly one of the
many reasons for its success
17
Jönköping: main themes
• The vertical integration of a quality improvement approach to
healthcare. The board receive performance reports that are
generated from systems implemented by staff trained in change
management and who have an ethos of strong quality improvement
as an expectation of their employment
• A corporate approach to systems improvement that enables crossdepartmental process development with notable clinicianmanagement co-operation
• Cohesion and consistency between the delivery of healthcare
and public health and social policy
• A strong link between systems development and the financial
reporting required to service any change in systems reporting that
might result from the improvement work.
18
The concept of value – remember QIPP?
•
Quality
•
Innovation
•
Productivity
•
Prevention
•
Initial focus: allocative efficiency / value for money / cost-effectiveness
•
It became all about cost-cutting
•
Quality improvement itself can save money, and be efficient
19
Value for money vs cashable savings
•
Cost-effectiveness / efficiency / value for money are not the same as costcutting / cost savings
•
Investing in prevention makes economic sense
•
But will it release cash in the short term?
•
Implementing interventions that are deemed cost-effective within NICE
cost/QALY thresholds will not necessarily save money
– most of the public health interventions that have been analysed are
highly cost-effective
– still a need to prioritise
•
Wider return on investment approach is needed
•
CfV needs both a short and long term focus on prevention
20
The NHS has a strong role to
play in prevention
Working with the NHS
•
Population health; public health is not just what PHE does
•
Investing in primary prevention
– tackling obesity, alcohol and the wider determinants
•
Systematic, at scale secondary prevention
– tackling unwarranted variation
– doing what we know works
•
‘Investing’ in prevention does not always need money: it needs energy to be
focused in the right areas
•
Next 2 slides courtesy of Chris Bentley who led the National health
Inequalities Support Team………
22
23
24
So what else is needed?
25
One system working together
• across the NHS, public health and social care
• a focus on individuals - integrated care pathway work
from CfV programme
• integrated budgets and joined-up commissioning
• genuinely commissioning for population health
26
The right supporting environment
•
alignment of incentives
– conflict between ‘Payment by Results’ in the hospital sector while we
encourage more preventative care to keep people out of hospital
– health and social care working together (avoiding cost-shifting)
•
realistic time horizons
– recognising the need for short-term changes without losing focus on
longer-term wider determinants
•
real public engagement in debates about prioritisation
– “It is disappointing that so few boards identified public engagement as a
priority, and there is no evidence of boards being creative in reaching
out to local communities through, for example, social media” (King’s
Fund report on H&WBs, Oct ‘13)
•
permission to be bold about (dis)investment decisions
27
Knowledge & intelligence skills
•
knowledge management expertise to:
– synthesise data and evidence to create timely health intelligence
•
business cases for public health investment (identifying value gained from
resources invested)
•
a ‘common currency’ for assessing impact of health & well-being
•
identifying the impact of cost-effective interventions on health inequalities
•
more focus on quality and outcomes data
•
presenting intelligence effectively to different audiences
•
knowledge transfer skills to make a difference to care / service delivery
•
…..oh, and integrated health records!
28
Spend & Outcome Tool (SpOT)
Atlases of Variation
Spend & Outcome Tool (SpOT)
• Has been produced for several years now for the NHS (previously at
PCT, now CCG, level)
• Essential starting point to know where to look further at areas of
(e.g.) high spend / poor outcome
• Could we develop a similar tool for local government?
• We all know that transport, education and housing contribute to
health and wellbeing – can we start to look at those using a
common framework?
• And look at the NHS-facing information alongside the local
government information – single conversation within Health &
Wellbeing Boards
Programme Quadrant Chart
•
Shows how all programme
budgets in your chosen
organisation perform against
the respective national
averages, using modified zscores plotted on axes.
•
Spend plotted on the
horizontal, outcome on the
vertical.
•
Can be viewed with weighted
analysis (multiple outcome
measures) or unweighted
(single relevant outcome
measures).
Atlases of Variation
• First published in 2010 then 2011
• Followed by a series of six themed atlases covering specific diseases or patient
groups.
• New Atlas of Variation Compendium (a collaboration between Public Health
England, NHS England and Right Care) coming soon.
Summary
• We know what needs to be done; it just needs to be done
systematically and at scale
• Getting incentives right and aligning them across different parts of
the system
• NHS and public health system working together on the investing in
prevention agenda
• Maintaining the focus on long-term outcomes (the time horizon
dilemma)
• The culture of commissioning is far more important than the process
33
Population health systems: going beyond
integrated care (King’s Fund Feb.’15)
• “The permissive framework set out in the NHS five year
forward view, with its emphasis on integrated care and
health improvement, also provides a favourable policy
context for the ideas set out here. Acting on these ideas
should be seen as part of the health and care system’s
efforts to achieve the ‘fully engaged scenario’ outlined by
Derek Wanless more than a decade ago”
34
Real life stories
NHS IQ Long Term Conditions team –
Leena Sevak
Leeds City Council - CVD and
Respiratory – Lucy Jackson
Long term conditions Year of care commissioning Programme
LTC Dashboard …
….a wealth of data
Adding local value to
Commissioning for Value
Lucy Jackson
Consultant in Public Health
Leeds City Council
What did we do with Commissioning
for value?
• Ensured it made sense locally.
• Choose issue for a local reason too.
• Added local data – to add to the pathway and
triangulate.
• Wider footprint of Leeds but local too - 3 CCGs agreed
on the same 2 areas.
• Brought all players together – Clinicians; CCG
commissioners; Local Public Health with PHE. Citywide
and within each CCG to work through.
• Ownership of approach - Conversations with clinical
fora in each CCG – does this make sense , prioritise
actions?
Local Strategic Context –
Leeds Joint Health and Well Being Strategy
Vision - Leeds will be a healthy and caring city
for all ages
Principle - People who are the poorest will
improve their health the fastest
Outcome one - People will live longer and
have healthier lives
Use CFV but also locally what fits - the life
expectancy gap by cause of death
Scarf chart showing the
breakdown of the life
expectancy gap between
Leeds as a whole and
England as a whole, by
cause of death, 2009-2011
46
Local Data: GP audit and healthy living
service referral data summarised by CCG
prevalence
CHD
Health checks uptake
prevalence
Smoking
Obesity
Smokers referred to smoking services
(including prompted self referral)
prevalence
Recorded BMI
>30 referred to weight management service
Short screening (FAST or AUDIT-C)
Completed full AUDIT screening
Alcohol
Screened as positive
(Hazardous/harmful/dependant drinkers)
Brief intervention (in GP practice)
Scoring 20+ on AUDIT who have been referred
for specialist advice for dependant drinking
Leeds
3.3%
3.8%
3.1%
3.4%
60.2%
65.2%
51.5%
57.7%
18.6%
27.0%
22.0%
22.7%
9.0%
9.1%
4.2%
7.0%
19.5%
25.7%
19.9%
21.7%
2.2%
2.1%
1.5%
1.9%
6.3%
7.0%
6.7%
6.7%
1.1%
0.7%
4.1%
2.3%
9.9%
21.5%
34.9%
30.8%
4.5%
6.7%
9.0%
8.7%
1.1%
1.8%
0.4%
0.5%
Local Data
NHS LEEDS
NHS LEEDS SOUTH AND
NORTH CCG EAST CCG
NHS
LEEDS
WEST
CCG
47
Local Data: Obesity prevalence
Obesity prevalence versus % weight management referrals
Low obesity prevalence
High weight
management referrals
High obesity prevalence
High weight
management referrals
Practices which have high obesity
prevalence and low percentage of
weight management referrals :
(For a full list of all practice's see
appendix 5)
Practice
cluster
Low obesity prevalence
Low weight
management referrals
High obesity prevalence
Low weight
management referrals
Practices within the dotted line do not have statistically
different level of obesity prevalence and % of weight
management referrals to the CCG as a whole
GP practice name
% Obese Referrals
Pentagon
21.7%
0.9%
Triangle
22.7%
1.7%
Kite
21.3%
0.4%
Hexagon
20.4%
0.6%
Kite
20.0%
1.7%
Triangle
25.7%
0.4%
Pentagon
19.5%
2.2%
Kite
22.7%
1.6%
Circle
23.1%
0.7%
Hexagon
26.7%*
0.0%
* Statistically different to the CCG
48
Local Data: Smoking prevalence
Low % smokers
High% smokers referred
High % smokers
High% smokers referred
Practices which have a high % of smokers
and low percentage of smokers referred:
(For a full list of all practices see
appendix
5)
Practice
%
Smoking
cluster
Low % smokers
Low% smokers referred
High % smokers
Low % smokers referred
Practices within the dotted line do not have
statistically different level of smoking prevalence
and % of smoking referrals to the CCG as a whole
GP practice name
Smoking referrals
Triangle
30.3%
8.3%
Triangle
33.2%
4.7%
Triangle
29.1%
8.1%
Triangle
34.2%
1.4%
Triangle
34.1%
3.3%
Oval
30.3%
6.6%
Triangle
39.9%
4.6%
Triangle
37.1%
3.4%
Oval
33.2%
1.4%
Circle
33.4%
3.8%
Circle
31.5%
2.0%
Oval
33.6%
5.3%
Triangle
32.3%
6.9%
Triangle
37.4%
4.1%
No cluster
27.8%
3.6%
Local Data
Smoking prevalence versus % smoking referrals
49
Overarching messages for Leeds -CVD
Summary:







Public health focus on prevention; specifically smoking
prevalence (Leeds South & East and Leeds West) smoking
cessation (All) and Obesity (Leeds South & East)
Significant benefit to patients if improvement to Primary
Care management indicators were made (All)
High emergency admissions for CVD (Leeds South & East),
costs (Leeds North and Leeds South & East) and lengths of
stay (All)
High costs for CHD emergency admissions (Leeds North
and Leeds South & East) and high costs for CHD elective
admissions (Leeds South & East)
High emergency admissions for Heart Failure and Stroke
(Leeds South & East and Leeds West)
High costs for Angiography procedures (All), CABG
procedures (All) and Angioplasty procedures (Leeds West)
High lengths of stay for Angiography procedures (Leeds
West)
50
Respiratory Summary






Public health focus on prevention; specifically smoking
prevalence (Leeds South & East and Leeds West) and
smoking cessation (All)
Significant benefit to patients if improvement to Primary
Care management indicators were made (All)
High emergency admissions for Influenza & Pneumonia
(Leeds South & East and Leeds West)
High COPD emergency readmissions (Leeds South & East
and Leeds West)
High costs for Respiratory (All), COPD (Leeds North and
Leeds West), Asthma (Leeds South & East), Upper
Respiratory (Leeds South & East) and Other Acute lower
(Leeds South & East and Leeds West) emergency
admissions
High lengths of stay for Upper Respiratory (Leeds South &
East) and Other Acute Lower (Leeds North and Leeds South
& East)
Significant variation in corticosteroids prescribing between
practices (All)
Summary on a page

51
Actions …………..
• Public Health – challenge to jointly re look at
commissioning of healthy living services key priority for
the Council.
• Primary care – variation target work with key practices
and embed into engagement schemes in each CCG
• Whole pathway – flow and variation – LIQH.
• CCG commissioning – using packs as part of
prioritisation framework
• Transformation work streams -Acute – elective care
value approach; Integrated Care – Pathways work; PYLL
trajectories.
The LIQH approach
LIQH – focussed areas
CVD
□ improving the management of chest pain;
□ optimise outcomes and quality of care for people requiring
interventions/ treatment for suspected/confirmed arrhythmia
and to prevent inappropriate use of secondary services.
□ to improve the physical and psychological health of patients’
post-MI with new or existing anxiety / depression.
COPD
□ support people with COPD to manage their own condition and to
reduce the likelihood and impact of exacerbations;
□ reduction in variation of approach to COPD patients in crisis;
□ Improving the early and accurate diagnosis of COPD whilst
improving patient experience.