Transcript A whole system approach Empowering Commissioners

Improving quality and increasing value
A whole system approach
Dr Alan Nye
Director Pennine MSK Partnership
Associate Medical Director NHS Direct and Pennine Care Foundation Trust
Dr Steve Laitner
Associate Medical Director East of England SHA,
National clinical lead for Shared Decision Making
www.rightcare.nhs.uk
What’s the problem?
Care Model
Wanted more involvement in
treatment decisions
Source: NHS inpatient
surveys
Care Model
• Paternalistic and bio-medical model of care
delivery
• Lack of patient empowerment – poor
understanding of shared decision making
• Lack of integrated care
– Primary – Secondary care
– Health - Social care
– Community based – hospital based care
What’s the problem?
Variation
Practice variation: its rediscovery by
Wennberg
•17-fold variation in tonsillectomy
•6-fold variation in hysterectomy
•4-fold variation in prostatectomy
•“The need for assessing outcome
of common medical practices”
•“Professional uncertainty and the
problem of supplier-induced
demand”
John E. Wennberg, 1973
Slide courtesy of Dr Al Mulley
Foundation for Informed Medical Decision Making
and the Dartmouth Center for Health Care Delivery Science
Variation in MSK Spend
Knee replacement
Shared Decision Making
• Of particular value in “preference sensitive
decision”
– Medical intervention has no clear single right
option
Compared appendectomy to tonsillectomy
• Patient Decision Aids
– Help empower patients and prepare then for
shared decision making
Sharing Decision Making
Clinician
Patient
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Diagnosis
Disease aetiology
Prognosis
Treatment options
Outcome probabilities
Experience of illness
Social circumstances
Attitude to risk
Values
Preferences
What’s the problem?
System
Identifying Primary Care performance to outcomes
QOF registered prevalence and CHD Mortality(<75) in Oldham (MSOAs)
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Index of Multiple Deprivation (2007)
Most deprived areas in Oldham (darker areas)
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Traditional model – methods of controlling
Demand and delivering savings
Population and personal approach to
healthcare
– Understanding variation
– Empowering patients with SDM
– Understanding and addressing deprivation
– Aligning clinical responsibility and financial
accountability
– Performance managing treatment pathways –
addressing poor performance through peer review
and support
– Unified MSK services
Referral triage
Primary care
holistic assessment
and care
Referral
COMMUNITY
MULTIDISCIPLINARY
SPECIALIST SERVICE
(Pathway Hub)
Highly specialised,
intensive, episodic
hospital care
Prime contractor
SUBCONTRACTING
Hub functions:
•Referral triage
•Skilling up 1’ care
•Specialist Assessment
•Specialist integrated care
•Shared Decision Making
•Personal Health Planning
•Supported Self Care
•Patient & carer support
•Voluntary sector provision
PATHWAY
MANAGEMENT
Programme Budgeting Spreadsheet – Expenditure per 100,000 population (weighted by age, sex and need)
Spend on Musculo Skeletal problems is relatively high – 37th out of 151 PCTs
Note: Oldham has a low proportion of spend in category 23x ‘Other Miscellaneous’. This may result in higher reported expenditure in disease specific
categories.
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NHS Oldham’s Model
NHS Oldham Programme Budget’s
• MSK - £23m - Pennine MSK 1st May
• Tendering for
– Ophthalmics
– Sexual Health
– Diabetes – all next 3 months
• Plans for frail elderly
– Spanning primary, community, social and
secondary care
Programme Budget
• Primary Care
– BNF drug chapters
– LES (referral governance
• Community Care
– Pennine MSK
– Podiatry and physiotherapy
• Secondary care
– All MSK/pain PB elements – trauma from 2012
Pennine MSK Partnership
• Primary Care based organisation commissioned by
NHS Oldham to provide non admitted care in
rheumatology, orthopaedics and chronic pain
• Consultant led – provide 97% rheumatology and take
patients to point of listing in Orthopaedics
• From May 2011 control £23m programme budget for
MSK using prime vendor model
• Psychological medicine for chronic pain
• 9,500 new referrals a year
Developing Programme Budget
• A lot harder than expected
– From May 2011 no trauma – add in April 2012
– Add pain budget in June 2011
– Agreement of PCT and GPCC
– Include secondary, community and primary care
element (BNF and local enhanced services)
– Lots of data trawling to define reasonable PB
– Huge challenge to acute trust
Data Requirements for PBs
Pathway Dashboard
Dashboard Metrics
ONS Aging of the UK tool
The proportion of elderly population in Oldham will grow at a slightly slower
rate than the rest of the UK over the next 20 years
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2009/2010 APHO Spend and Outcomes Tool – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average
Oldham has high spend on Musculo Skeletal when compared to similar PCTs. The chart shows average
outcomes, but this is a default position as the current version of SPOT does not have outcome indicators for
Musculoskeletal. Patient Reported Outcome Measures (PROMS) information will be added to future versions.
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2009/2010 Programme Budgeting Spreadsheet – Musculo Skeletal problems expenditure per 100,000 population (weighted by age, sex and need)
Green column shows that Oldham has above average expenditure nationally (blue columns) for
Musculo Skeletal problems and compared to similar PCTs (purple diamonds)
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2008/2009 Programme Budget Atlas – Prescription Expenditure on Musculo Skeletal per 100,000 unified weighted population
Oldham has a high FHS Prescribing volume for Musculo Skeletal Problems compared
to similar PCTs
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NHS Comparators – GP Practice Level Comparison of Trauma & Orthopaedic Outpatient attendances referred by GPs
GP referrals range from 6 to 35 per 1,000 for Trauma & Orthopaedics across practices in
Oldham (2009/10)
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NHS Comparators - Managing variation in surgical thresholds – Lumbar Spine Procedures Admissions
Large variation in number of Lumbar spine procedures between practices across Oldham (note small numbers)
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There are no short cuts to any place worth
going
There are no short cuts to any place worth
going
Beverly Sills
Dr Alan Nye
[email protected]
Dr Steve Laitner
[email protected]