10 ways to use your
CfV packs – 1 to 4
1. Use CfV packs to prioritise improvement
programmes – Where to Look
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2. Use the variation highlighted in the CfV packs to
destabilise complacency and define opportunity
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2015 - CVD Focus Pack headlines - Wigan
1.
2.
3.
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Enhance/ redesign/ manage prevention and primary care system to optimise
•
Prevention
(11,100 more with low activity levels than peers, 1,300 more
eating unhealthily)
•
Detection
(600 fewer Stroke patients on registers)
•
Systemise care planning and self/ case management
(1,100 fewer >40yr old patients with BP record, 650 fewer with
<75yr old hypertension patients with brief intervention)
•
Local referrals triage and pathway navigation
Specify whole service and thresholds, with particular attention on
•
Admission rates (CVD – 840 more, CHD – 300, HF – 140)
•
Procedure rates (Angioplasty – 70 more, CABG – 30)
Specify robust discharge thresholds and protocols, in particular to manage
•
LOS
(CVD – 800 more beddays, CHD – 550, Angiography – 650,
Angioplasty – 200, CABG – 200. Total = 2,400 days or 6 beds)
•
Rehabilitation services
(130 fewer stroke patients discharged to usual place of residence)
3. Use CfV to show The Art of the Possible
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Where Bradford are now (and where West Cheshire were)…
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Where West Cheshire are now (and where Bradford could be)
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4. Use CfV as the catalyst for clinicians to design
optimal
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Canterbury & Ashford CCGs – Optimal Design Event
February 2015
• Adopted RightCare December 2014 and in Feb 2015 •
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•
•
100 GPs
40 hospital clinicians
10 tables
5 priority work streams (taken from CfV packs)
• Designing the optimal system for their population
• Prevention to end of life
• Collective design - collective agreement
• Challenge system (including selves) to deliver
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5. Use CfV to identify where in the pathway to focus
clinical engagement
‹#›
Heart disease pathway
= 95% confidence intervals
Initial contact to end of treatment
NHS Bradford City CCG
6. Use CfV to identify peers to find good practice
‹#›
Heart disease pathway
= 95% confidence intervals
Initial contact to end of treatment
NHS North Kirklees CCG
7. Use CfV to galvanise the system into immediate
action
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CfV pack to delivery in 7 months – Hardwick CCG
•
Now implementing –
• Agreed and specified COPD pathway
• Enhanced nebulisers service in primary care
• Primary care COPD audit and support service to implement findings
practice by practice
• Improved promotion of self-management
• Improved self-management support
• Enhanced organisation of Breathe Easy Groups (with British Lung
Foundation)
•
Delivered (so far – only just begun) –
• 30% reduction in emergency admissions
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8. Use CfV to improve primary care whilst
progressing secondary care engagement
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Diabetes in Slough CCG
•
“The Right Care methodology has been successfully applied to the
primary care management of diabetes in Slough” – Slough CCG
Diabetes Lead
•
Following primary care pathway reform –
• Of patients with pre-diabetes whose results are available for evaluation,
100% saw a reduction in their HbA1c levels
• Of the patients with type 2 diabetes, 89% saw a reduction in their
HbA1c levels
• 15 out of 16 practices showed an increase in the number of patients
whose diabetes was controlled
• 15 out of 16 practices saw an increase from 72.25% to 80.06% of
patients whose blood pressure was <140/80
‹#›
9. Use CfV to identify which Patient Decision Aids to
implement first
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Cochrane review update 2014
• 115 studies across 6 countries (>34,000 participants)
• Found good evidence that PDAs
• Increase patient knowledge
• Improve accuracy of patient expectations
• Improve communication between patient and
practitioner
• Reduce volume of elective surgery
• DO NOT worsen health outcomes
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PDAs supporting Cancer, Circulation, Respiratory,
include…
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•
•
•
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COPD
High BP
High cholesterol
Localised prostate cancer
Lung Cancer
Smoking cessation
Stable angina
Stroke prevention for AF
www.sdm.rightcare.nhs.uk
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Patient Decision Aids – Implementation Process
1. Identify best PDAs for local impact
• Use CfV and AoV to id. high use of
discretionary surgery and/ or sub-optimal
primary care condition management (LTCs)
2. Localise with local GP leads and add referrals criteria
and protocols
• C. 50% of unwarranted activity dealt with by
PDAs, 50% by protocols (Capita)
3. Implement in key practices and prove impact
4. Spread across practices
5. Implement more PDAs (in phases or collectively)
Optional (innovative):
6. Design own, use and spread
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10. Use CfV to check you are doing (or did) the right
things
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Stress-testing action and proposals – Blackpool
Stroke review
CfV Pack 1 – Will the recommendations in the local Stroke review lead to:
An increase in the number of stroke patients spending 90% of their time in
hospital on a stroke unit and a reduction in overall admissions?
CfV Pathways on a Page Pack – Will the recommendations lead to:
Increased numbers of stroke/TIA patients with BP < 150/90, cholesterol <
5mmol/l and on anti-platelet agent? Increased numbers of atrial fibrillation
patients with a stroke risk assessment? Reduced elective and nonelective spend? Reduced emergency readmissions?
CVD Focus Pack
Prevention - does the review seek to highlight and/ or tackle the significant
lifestyle drivers of CVD? E.g. smoking, obesity, exercise, healthy eating,
binge drinking, all of which Blackpool is a material outlier for? Until these
issues are confronted, population level impact will not occur.
Detection – does the review tackle the shortfall in identified stroke patients
(100’s fewer on registers in Blackpool than cluster best practice)
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Stress-testing action and proposals – Blackpool
Stroke review
CVD Focus Pack contd.
Primary Care Management – in addition to above, does the review seek to
impact on the primary care management of e.g. flu vaccicinations for
CHD patients and/ or brief intervention numbers for HF patients?
Secondary Care Management – do the recommendations resolve the status
of Blackpool CCG as the least good performer amongst its demographic
peers on emergency admissions and lengths of stay?
Diagnostic AoV
Will the recommendations lead to an increase in the number of stroke
patients receiving a brain image within one hour of arrival in hospital?
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And why are we doing this?
Why act: Patient case study – Long Term Conditions
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Paul Adams is a typical patient in a typical CCG. The following story is seen across the country
in many long term condition pathways. Journey one tells of a standard care pathway. Journey
two tells of a pathway that has been commissioned for value.
Journey One
• At the age of 45, and after 2 years of increased urinary frequency and loss of energy, Paul goes to his
GP. The GP performs tests, confirms diabetes and seeks to manage with diet, exercise and pills. This
leads to 6 visits to the practice nurse and 6 laboratory tests per year
• Paul knows that he is supposed to manage his diet better but is not sure how to do this and does not
want to keep bothering the GP and the practice nurse
• By the age of 50, Paul has given up smoking but continues to drink. His left leg is beginning to hurt. His
GP prescribed insulin a year ago and now refers him for outpatient diabetic and vascular support
• At 52, Paul’s condition has deteriorated further. He has to have his leg amputated and he now has renal
and heart problems. His vision is also deteriorating rapidly. He is a classic complex care patient.
This version of Paul’s patient journey costs £49,000 at 2014/15 prices…
NHS xxxxxxxxxx xxxxxxxxx CCG
Why act: Patient case study – Long Term Conditions
If Paul Adam’s CCG had adopted Commissioning for Value principles and reformed their
diabetes and other long term conditions pathways, what might Paul’s patient journey have
looked like?
Journey Two
• The NHS Health Check identifies Paul’s condition one year earlier, at the age of 44 and case
management begins…
• Paul is referred to specialist clinics for advice on diet and exercise and he has this refreshed every 2
years. He is also referred to a stop smoking clinic and successfully quits
• Paul has a care plan and optimal medication and retinopathy screening begins 18 months earlier
• He is supported in his self management via the Desmond Programme and a local Diabetes Patient
Support Group
Journey One cost £49k and managed Paul’s deterioration
Journey Two costs £9k and keeps Paul well
NHS xxxxxxxxxx xxxxxxxxx CCG
Right Care Impact in Warrington – one
example of one programme
Respiratory Care in Warrington Health Economy
• 2010/11 –
•£1.5M OVER spending V. demographic peers
•Only 2/3s of asthmatics known
•Worst quintiles – COPD rate of em admns, deaths within
30 days, %age receiving NIV, readmns
• 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
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