Transcript Document

Clinical Programmes Gloucestershire
Commissioning for outcomes
Justine Rawlings
Associate Director Clinical Programmes
Introduction
- Clinical programmes:
- Based on 23 programme budgeting categories
- Benchmarked spend and outcomes for these
areas
- Identify priority programme areas for which
we are an outlier
- Priority programmes for our focus in next 2
years
MSK outcomes
• The national SPOT tool suggested the following benchmarked
outcomes:
• MSK: Initially higher spend average outcome. Now higher spend is
decreasing and outcome still average. Note: spend/head has stayed
roughly the same as cluster average
• Trauma: initially higher spend and lower outcome. Spend has
decreased over the years, but outcomes still below average
•
• (Outcomes used by SPOT tool MSK: hip replacement and knee
replacement; EQ-5D Health gain 2010/11; Oxford hip score health
gain 2010/11 (HES online); Trauma: Mortality from accidents DSR;
Mortality from accidental falls DSR, Mortality from fractured NOF,
Mortality from skull fracture and intercranial injury, Mortality from
land transport accidents)
2015/16: Focus to reduce to quartile benchmarked position
CPG Category
High level description
MSK & Trauma
Outpatient general 1st attendances
Outpatient Outpatient
- New/1st - follow-up Elective
Emergency
Cost of
variance
(£000k)
Cost of
variance
(£000k)
Cost of
variance
(£000k)
Cost of
variance
(£000k)
v quartile
v quartile
v quartile
v quartile
800
Outpatient general F/up attendances
1,200
Hips
1,300
Elbows and lower arms
200
Feet trauma
230
Reconstruction (mainly revisions of hip, knees, shoulder)
1,060
Spinal (mainly extradural)
TOTAL by Worktype
250
690
800
1200
3050
TOTAL
Notes:
T&O new OP: 1sts only small % over average
T&O f-up OP: Follow up ratio 2.1 v 1.8
Reconstruction – this in large part relates to reconstruction following initial joint replacement surgery and so cannot be delivered as a
saving until the initial surgery rate is reduced. NB Reconstruction will be 10-15 years after the initial surgery
680
5,730
Service context
• Some evidence of demand management in
areas where there was a physiotherapy
interface service
• Some evidence that patients being referred
that do not require surgery
• Variation in provision/use of of interface and
core physiotherapy service and conservative
management options e.g. weight loss
programmes
CPG set up
• Clinical and managerial representation
commissioners and providers
• JD for consultant and GP lead including
commitment to take back and consult within
organisation and provide overall view
• Layworker rep and healthwatch rep
• Commitment to doing what makes clinical
sense for the patient
Developing criteria and guidelines
• Detailed guidelines developed for all major
joints
• Included advice and best practice for GP,
physio, interface and surgical IFR criteria
• BUT
• Thresholds ambiguous if you wanted to use it
to manage flow/demand manage
Strengthening thresholds
• Clinical workshop review of guidelines and
simplifying:
• what needs to be done prior to surgical
referral
– E.g. conservative management and timescale
– Weight loss
– Patient wants surgery *(shared decision making)
• Clear IFR policies for surgical intervention that
will be auditable and audited
Outcomes
• National outcome measures not
comprehensive
• We need measures for whole pathway not
single providers
• Agreed principles and framework aligned to
National Outcomes Framework
• In first year increased range of PROMs and use
EQ5DL
Principles
Suggested principles for agreed outcome measures are:
• The number of measures should be kept to those that are meaningful, measurable and likely
to be used
• Measures are for the whole MSK population and are NOT the same as provider based
performance measures i.e. one patient may have multiple interventions from multiple
providers which influence the outcome
• The measures should be applied to conditions that can demonstrate:
– Amenability to intervention
– Sensitivity to intervention
• The scope of outcomes measured should include both measures that are patient reported
and service level outcome measures (i.e. no patient input to measure required.)
• Process measures can be used as proxies if useful where no suitable outcome measure exists
(particularly in order to capture intermediate measures where outcomes are longer term)
• Measures, including mode of delivery should be consistent across services and providers
• Measures should be appropriate to an intervention and should include measures for
interventions dealing with prevention, episodic care and interventions for chronic conditions.
• Measures should take account of the whole pathway, ideally across all interventions including
where a patient has declined or not been accepted for an intervention. (e.g. where shared
decision-making has been part of the process)
•
Outcome group
Service level outcome measures/quality and service standards contributing to outcomes
Patient reported outcome measures
Prevention
Reduction in recurrent osteoporotic fractures
Reduction in fracture risk
Prescription of medications for osteoporosis
Limitation of self-reported occurrence of MSK pain
Waiting times for MSK patient between 1st GP attendance and 1st referral for specialist care
Waiting time for rheumatoid arthritis patient between 1st symptomatic presentation at GP
practice and treatment with disease modifying anti-rheumatoid drugs (DMARD)
Acute single
episodes
Episodic conditions
Emergency readmissions within 28 days of discharge
Percentage of patients returning home
Length of stay
Reoperation rates
Surgical complication rates
National joint registry
Surgical site infections
Surgical revisions
Theatre access time
Timeliness of care
Percentage of patients returning to work within n days of episode beginning (where
research is required to define “n”)
Number of days off work amongst people with MSK disorders in contact with health
services over a given time period
Percentage of patients self-reporting changes in pain and mobility after episode
Percentage of patients self-reporting a return to function
Using EQ5DL, national PROMs (hips and knees) and potentially PROMS for other MSK
conditions (CQUIN – GHFT spine) Suggest : spines, foot/ankle and potentially
shoulder in first instance)
Shared decision making
EQ5DL
PROMS
Percentage of patients self-reporting that they have returned to “normality” e.g.:
self-reported return to work, absence of pain, or self-reported return to domicile
Employment support allowance (ESA) claimed per head of MSK population during given
time
ASCOF data
Long term conditions
Percentage of patients returning to work within n days of episode beginning (where
research is required to define “n”)
Number of days off work amongst people with MSK disorders in contact with health
services over a given time period
Disease activity score (DAS) – rheumatoid arthritis
Percentage of patients self-reporting that they have returned to “normality” e.g.:
self-reported return to work, absence of pain, or self-reported return to domicile
Further work
One system one budget
• Care pathways programme
• Single approach to service development
In year programmes to support
• Advice and guidance
• Peer review