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NHS Yorkshire and the Humber Monthly QIPP resource pack December 2009 Yorkshire and the Humber Quality Observatory Introduction This is the second QIPP Monthly resource pack. The pack has three components: GENERAL PRACTICE ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides more detailed analysis on a subject relevant to QIPP. This month the hot topic is general practice and its impact on the broader healthcare system. The analyses presented here are designed to offer insight and raise questions about variation in performance. They need to be interpreted in the local context. QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter financial climate. We will publish these metrics monthly although some of the indicators will only be updated quarterly. The purpose is to offer insight and improve understanding of how the system delivering with lower growth. The next resource pack will be published week commencing 25th January. The hot topic will be the health and social care interface. If you have any questions or comments on the pack, please contact Ian Holmes. ([email protected]) <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory Better for Less – Care Plans BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes which have been developed locally and have potential to deliver better quality at lower cost. This month the ‘better for less’ example focuses on how the use of care planning in general practice can improve management of long term conditions and reduce emergency admissions. December 2007 Slide 2 1) Healthy Ambitions: Better for Less <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 3 Better for Less – Care planning Why long term conditions care planning? • Over 1m people in the region have a long term condition This figure will rise as a result of the aging population and lifestyle factors. • We spend over £700m on emergency admissions. The majority of which relate to long term conditions and many are avoidable. There are also significant variations in levels of emergency admissions across the patch – a range of 35 per 100 people between the upper quartile and lower quartile practice. • Healthy ambitions pledged to help people across Yorkshire and the Humber ‘live with, not suffer from’ long term conditions. <footer> PricewaterhouseCoopers LLP • The management of long term conditions in the NHS is often not proactive, and usually focuses on single conditions. This means that patients with multiple conditions need to go to several appointments throughout the year rather than single appointments. • This better for less example sets out a more proactive and planned approach to managing patients with long term conditions which we believe will lead to quality and efficiency benefits. Yorkshire and the Humber Quality Observatory Better for Less – Care Plans Personalised care planning in general practice can ensure better outcomes for patients, reduced exacerbations of long term conditions, increased patient satisfaction and financial savings. December 2007 Slide 4 Better for Less – Care planning How can we provide better for less? Patient benefits • Care planning is a much more proactive approach to managing patients with long term conditions which involves: • The shared approach to planning and setting of goals facilitates greater patient engagement and ownership of their condition – and has led to more active self care by the patient. • Practices actively seeking patients with one or more long term conditions • The patient and general practice clinician agreeing a measurable and patient driven set of goals for the patient • General practice clinician and patient monitoring progress towards the agreed set of goals. • This care planning process has been piloted and is currently being deployed across a number of health economies in the Yorkshire and the Humber with positive results. • The principle of care planning should be applied to suit local circumstances, recognising that a single model may not be appropriate for all localities. <footer> PricewaterhouseCoopers LLP • The process helped identify gaps in patients understanding of their conditions and in many instances has led to ‘eureka moments’ which has transformed patients’ whole approach to self care. • Evidence from Bradford found that 61% of patients had greater satisfaction as a result of the care planning process. Quality benefits • This approach leads to more effective practice management and self management of long term conditions. There are quality benefits to the patient in terms of greater control over their condition, more effective management and less need for other services as a result of complications. Yorkshire and the Humber Quality Observatory Better for Less – Care Plans • Practices offering a care planning meeting to all of these patients, covering all of their condition. December 2007 Slide 5 Better for Less – Care plans Financial/ Efficiency benefits • There are potentially significant financial benefits to be had from managing patients long term conditions effectively and avoiding costly and inconvenient secondary care contacts. www.healthyambitions.co.uk Please note that there are also better for less briefings relevant to this pack on: • E-consultations for long term conditions • Local Enhanced Services for care home clients. • The average cost of an emergency admission is approximately £1400, so reaching the upper quartile would generate savings in the region of £290,000 for the poorest performing practices. • The care planning approach can be used as part of a whole system approach to managing emergency admissions against the thresholds as set out in the operating framework. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory Better for Less – Care Plans • The rate of emergency admissions varies considerably across practices (35 admissions per 1000 people between the lower and upper practice in Yorkshire and the Humber), and there is evidence to link this variation back to secondary prevention in general practice. For further information visit: December 2007 Slide 6 2) Hot topic: General Practice <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 7 Contents Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - contents 1) December 2007 Slide 8 Section 1 Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - overview 1) December 2007 Slide 9 Purpose This information pack is the second of a series ‘hot topics’ that will be While recognising that it may raise more questions than answers, we hope it will stimulate thought and debate within organisations and health communities. Clearly the data presented need to be interpreted in the local context. We would be delighted to receive comments on the contents together with any ideas for further general practice analysis. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - overview produced by the SHA to support organisations in developing their understanding of some of the challenges and opportunities presented by the QIPP agenda. December 2007 Slide 10 Foreword from the Primary Care Delivery Board Strong primary care sits at the heart of a strong NHS. Primary care tends to be good, but there are significant variations in care. We know, for example, that chronic disease clusters in areas of deprivation and that too many of our patients living in deprived communities do not receive the quality of care they deserve and that those patients then end up as acute admissions to hospital. This document provides information aimed at improving our understanding of the variations in care patients receive across the region. It clearly demonstrates a number of important relationships that need to be addressed at a local level. • There is significant variation in quality and accessibility of general practice across our region - within PCTs too. • Care and satisfaction with care is often worse for deprived populations and ethnic minorities - particularly young Asian families. The 5 PCTs with large Asian populations should take note. • This in turn is linked to a range of adverse lifestyle factors, and translates to greater demand on secondary care services, with a clear link to emergency admissions. • A focus on smokers with long terms conditions would cut emergency admissions. We believe there is a significant opportunity to address this variation through general practice, by making best use of: • The wealth of practice level information that is available to us through the regional practice profiles, NHS comparators, and the NHS PCC Benchmarking tool. Share the data. • The levers for change, including contracts and practice based commissioning. Consider how PMS can be used to address local issues. • Evidence of good practice locally, for example as set out in the 'better for less' briefings. Adapt, adopt and diffuse. The pathway Board heartily endorses this pack. We believe it begins a set of conversations that will benefit patients, practices and our population health. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - overview We believe that this pack is essential reading for commissioners, PBC Consortia and practices. It should be used to identify key lines of inquiry and start conversations locally to deliver better care for patients. We recommend that a number of key questions should be drawn from it for discussion at a local level linked to these findings: December 2007 Slide 11 The role of general practice in the healthcare system The healthy ambitions programme identified to centrality of strong general practice to an effective healthcare system…. Primary care services continue to deliver very high patient satisfaction. Patient satisfaction with the quality of general practice is over 85%. Stronger primary care is associated with lower health inequalities Studies have shown that access to primary care reduces effects of poverty on self reported health status. In Yorkshire and Humber 99% of people are registered with a GP – this offers great potential to tackle inequalities. Stronger primary care is associated with lower hospital admissions In the UK, an increase in the number of GPs is associated with lower admissions for both acute illness and chronic illness. Stronger primary care is associated with better value for money Countries that have weaker primary care have higher costs across the healthcare system. Within countries, areas that have more primary care physicians are associated with lower spending. However, there is evidence of significant variation in quality, accessibility and demand management across practices in the region which impacts on the care patients receive across the system. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - overview Strong primary care is associated with higher patient satisfaction December 2007 Slide 12 Headline figures Across Yorkshire and the Humber there are: General Practices – NHS Yorkshire and the Humber • 802 general practices • 3,151 FTE GPs and 8,001 FTE general practice staff • £726m expenditure each year on prescribing in primary care • Over 25m contacts between patients and general practice each year <footer> PricewaterhouseCoopers LLP year on GMS, PMS, APMS PCTMS contracts • £831m expenditure each Yorkshire and the Humber Quality Observatory General practice - overview December 2007 Slide 13 Section 2 Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice – variation in provision 1) December 2007 Slide 14 General practice expenditure We also know that PMS expenditure per head of population is significantly higher than GMS expenditure. In some cases there are clear quality and broader health system benefits from this additional investment. In other cases the additional benefits are less clear. PCTs should be aiming to understand these variations and ensuring contracts are delivering value for money. 180 160 140 120 100 80 60 40 20 Yorkshire and the Humber Quality Observatory GMS cost / w eighted pop £ NE .L I E. RI D BR AD NY Y LE ED CA LD W AK E F KI RK TH SH E RO PMS cost / w eighted pop £ NHS Doncaster <footer> PricewaterhouseCoopers LLP N. LI N NC DO BA R N LL Exec Director of quality 200 HU Julie Bolus, PMS/GMS spend per weighted population £'000 We found it helpful to look at the variation in spend in our PMS contracts. We worked with all of our PMS practices to develop additional quality indicators to be included in contracts. We are in our 3rd year of reviewing these contracts and review the quality indicators annually. Lowest spend in more deprived PCTs? General practice – variation in provision Across PCTs in Yorkshire and the Humber there is significant variation in the level of G/PMS. We also know that PMS is generally more expensive that GMS. Key is to understand the impact of this spend on the quality, availability and accessibility of services. December 2007 Slide 15 General practice expenditure <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory NY Y RO TH 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 NE .LI KI RK BR AD CA LD DO NC HU LL SH EF E. RI D LE ED MPIG is related to the size of PCT, but also higher in more affluent and well doctored areas Total MPIG £000 N. LIN BA RN W AK E The Minimum Practice Income Guarantee protects GMS practice income to for core services to the levels of the previous GP contract. To PCTs this could be considered ‘dead money’ as it does not relate to service provision. General practice – variation in provision ‣ December 2007 Slide 16 General practice capacity population is a relatively crude measure of general practice capacity, At September 2008 there was a 50% variation between the most doctored and least doctored PCT in Yorkshire and the Humber. One the whole, more deprived areas tend to be less well doctored. 60.0 50.0 40.0 30.0 20.0 10.0 Sh No ef rth fie Yo ld rk sh ire & Yo rk No rth Ea st Ea st Ri din g Lin co lns hir e Le ed s of Yo r k Br sh ad ire for d& Air ed No ale rth Lin co lns hir e Ki rkl ee s (2 ) Do nc as W te r ak efi eld Di str ict Ro the rh am Hu ll P CT Ca lde rd ale Ba rn sle y 0.0 • There are also significant FTE practice staff per 100,000 population, Sept 2008 England average 200.0 144.6 250.0 150.0 100.0 50.0 le es Li n co No ln rth sh Yo ire rk sh ire Ea & st Yo Ri di rk ng of Yo No rk rth sh ire Ea st Li nc ol ns hi re Ki rk No rth Ai re da le & d Le ed s Ca ld er da le Do nc as te r Br ad fo r Yorkshire and the Humber Quality Observatory Sh ef fie ld PC W T ak ef ie ld Di str ict Ba rn sle y Ro th er Hu ll 0.0 ha m variations in the number of FTE other practice staff across the region. In general, those with low GP numbers also tend to have relatively low practice staff numbers – there is no real evidence of skill mix substitution in low doctored areas. <footer> PricewaterhouseCoopers LLP FTE GPs per 100,000 population, Sept 2008 General practice – variation in provision England 80.0 average 60.5 70.0 • GPs per 100,000 weighted December 2007 Slide 17 Future capacity This analysis from the Yorkshire Deanery risk rates PCT GP capacity based on existing levels of supply and number of training places. If current trends in training continue, the observed inequalities are set to persist. The primary care deliver board will carry out more detailed analyses of workforce issues in primary care which will be published in March. <footer> PricewaterhouseCoopers LLP PCT PCT GP Workforce Supply Risk Status Barnsley Currently below median for practitioners, but with adequate numbers of GPs in training locally Not currently at risk Bradford and Airedale Calderdale Doncaster East Riding of Yorkshire Hull Kirklees Leeds North East Lincs North Lincs North Yorkshire and York Rotherham Sheffield Wakefield District Additional GPR places (premises) 3 Additional Trainers on pathway 1 GPStRs recruited 2009 (Variance from Target) 12 (-1) 13 8 Below median for practitioners and inadequate numbers of GPs in training locally Below median for practitioners and inadequate numbers of GPs in training locally Below median for practitioners and grossly inadequate numbers of GPs in training locally Below median for practitioners and grossly inadequate numbers of GPs in training locally Below median for practitioners and inadequate numbers of GPs in training locally Currently above the median for practitioners, but with inadequate numbers of GPs in training locally Below median for practitioners and inadequate numbers of GPs in training locally Currently above the median for practitioners, but with inadequate numbers of GPs in training locally Not currently at risk 9 10 6 4 10 8 4 4 9 10 10 18 38 (+9) 13 (-7) 23 (-7) 10 (-5) 10 (-6) 19 (0) 37 (-3) 5 3 8 0 23 20 46 (+7) Currently below median for practitioners, but with adequate numbers of GPs in training locally Not currently at risk 11 0 9 (-4) 8 4 Not currently at risk 19 12 38 (+9) 30 (+6) Yorkshire and the Humber Quality Observatory 5 (-4) 5 (-4) General practice – variation in provision Given the role of general practice in the system it is important to understanding future pressures on capacity. December 2007 Slide 18 QOF Exception Reporting 80,000 7.00% 70,000 6.00% 60,000 5.00% 50,000 4.00% 40,000 3.00% 30,000 2.00% 20,000 0.00% A M IR RH SH SH E E TH E W A AS T R C LI N O C AL D O E R LN D ID R ST EA & D R BR RT H A O R D KS FO H AL E G D IN S AL E LE E D AI RE SL EY O R R N D E IR BA AN K Y LE ES LL U H KI R Y N O N O RT H FF KE IE FI LD EL D D IS TR IC D T O NC N O A RT ST H ER LI N C O LN SH IR E 0 E 1.00% K 10,000 PCT averages can mask wide variations at practice level (for example within NHS Calderdale, exception rates vary from under 2% to over 10%), and even PCTs with low overall rates of exceptions should be seeking to explore and tackle unacceptable variations in exception reporting. Exceptions Percentage exceptions QOF Exceptions – NHS Calderdale, 2008-09 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% Source: NHS Information Centre 0.00% 1 <footer> PricewaterhouseCoopers LLP 2 3 4 Yorkshire and the Humber Quality Observatory 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 General practice – variation in provision QOF Exceptions – numbers and percentage, 2008-09 In 2008-09, there were around 484,000 exceptions recorded in general practices in Yorkshire and the Humber. High levels of exception reporting can mean that practices are receiving QOF payments but patients conditions are not being effectively managed. December 2007 Slide 19 Patient Satisfaction We know for example that more deprived and ethnic populations generally have lower satisfaction with general practice and that this influences the way in which they access services – understanding and tackling these variations is key to driving up quality and efficient use of the healthcare system. <footer> PricewaterhouseCoopers LLP 90% 80% 70% 60% quite satisfied 50% very satisfied 40% 30% 20% 10% YO RK YO RK SH IR E EA ST RT H NO AN D RI DI NG S LIN C M RH A TH E NS LE Y RO BA R RD W AL AK E EF IE LD DI ST NO RI CT RT H EA ST LIN CS DO NC AS TE R LE ES CA LD E KI RK LE ED S FF IE LD DF OR D AN D SH E AI RE HU LL DA LE 0% Overall satisfaction – NHS Calderdale NO RT H BR A Patient satisfaction with general practice is generally very high. Patients have a high degree of trust in GPs and are generally happy with their experience of visiting general practice. However these high overall figures mask wider variations at practice level and for certain ethnic group. 120% 100% 80% Fairly satisfied 60% Very satisfied 40% 20% 0% 1 2 3 4 5 24% very satisfied Yorkshire and the Humber Quality Observatory 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 82% very satisfied General practice – variation in provision Overall satisfaction with general practice – Y&H PCTs 100% Source: GP patient survey, DH, 2009December 2007 Slide 20 Out of Hours NHS Primary Care Commissioning team has identified significant variations in the cost per head of general practice out of hours service. Out of Hours Services (including OOHDF) per PCT registered population £18.00 • This data is not routinely available across Yorkshire and Humber PCTs, however based on the variation observed nationally we would anticipate a savings opportunity in the region of £10m across our region. £16.00 £14.00 NHS Average £7.50 NHS Lower Quartile £5.35 £12.00 £10.00 £8.00 £6.00 £4.00 Humber are leading a regional piece of work aimed at exploring the variations that exist in urgent care provision, and making recommendations to improve and streamline the current pathways. <footer> PricewaterhouseCoopers LLP £2.00 £0.00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 AVG • NHS Yorkshire and the Source: NHS Primary Care Commissioning Yorkshire and the Humber Quality Observatory General practice – variation in provision • National work from the December 2007 Slide 21 Supporting effective commissioning - Practice Profiles Health Intelligence practice profiles - example • Practice population health and socio- economic status • Quality of services as recorded through the QOP • Accessibility to services and patient satisfaction with access • The impact on the broader healthcare system – for example emergency admissions. YHPHO will be publishing PCT level profiles in late January. The health intelligence practice profiles are available at: <footer> PricewaterhouseCoopers LLP General practice – variation in provision The Yorkshire and Humber Public Health Observatory have recently published the second edition of the Health Intelligence Practice Profiles. These profiles provide practice level data on a number of topics covered in this pack, including: http://www.yhpho.org.uk/resource/view.aspx?RID=10319) December 2007 Yorkshire and the Humber Quality Observatory Slide 22 Health Intelligence Practice Profiles (2) “NHS Wakefield have used the profiles as part of our annual review of all PMS practices, using them to inform practice objectives for 2010. The profiles have provided us with a greater understanding of the emerging priorities at practice level whether those be for example COPD indicators, smoking prevalence or exceptions rates and have allowed us to determine specific actions for 2010 as a result” Dr Rory O’Connor, Consultant in Public Health, NHS Wakefield. The health intelligence practice profiles are available at: http://www.yhpho.org.uk/resource/view.aspx?RID=10319) <footer> PricewaterhouseCoopers LLP “The practice profiles have given us the impetus to focus on levels of prevalence at practice level. We had already done some initial work locally and have now been in a position to reinforce this with the introduction of the profiles. The profiles have provided us with a baseline and allowed us to identify both COPD and diabetes prevalence within our business plans and to assess progress made over the 2007/08 to 2008/09. The ability to cluster and benchmark practices across the Region has also been incredibly powerful as it has prevented the usual barriers to discussions about how potentially practices seem themselves as different to others”. Simon Hunter, Locality Director (East), Board Lead (Unscheduled Care), NHS Hull Yorkshire and the Humber Quality Observatory General practice – variation in provision The profiles have already been used extensively by PCTs across the region to engage with practices and PBC Consortia: December 2007 Slide 23 Section 3 Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - prescribing 1) December 2007 Slide 24 Prescribing – Overview • As a region we spend over £800m each year on prescribing in primary care. This is more than the total spend on general practice. • Prescribing is an area where we have strong evidence base on cost effective • There is also evidence that a significant proportion (up to 50%) of prescribed drugs are incorrectly taken or not taken at all – and significant quality improvements could be achieved through better management of this. “There is no valid reason for general practice not to pursue evidence based, quality prescribing. When supported by strong prescribing teams in PCTs, significant efficiency savings and better quality outcomes can be achieved through cost effective prescribing” Dr Lis Rodgers, Senior Clinical Leader, NHS Yorkshire and the Humber <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - prescribing treatments – and there are significant quick wins to be had be following this guidance. December 2007 Slide 25 Prescribing – Low cost lipid modification (BCBV) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Productivity opportunity £ Productivity opportunity Across YAH this represents a total productivity opportunity of £11.1M. <footer> PricewaterhouseCoopers LLP 2,500,000 2,000,000 1,500,000 1,000,000 500,000 E HU LL BA RN CA LD NE .L I RO TH DO NC N. LI N SH EF KI RK NY Y E. RI D BR AD LE ED 0 W AK This is the money that would be saved if every PCT achieved the upper quartile (79%) rate of low cost statin prescribing. The average cost for prescriptions for simvastatin and pravastatin together is substituted for the average cost for other statins, to reach 79%. Greater savings will be achieved for larger shifts. Savings are expressed as annualised figures by multiplying by four the savings of the quarter measured. Source: NHS Institute Better care better value Yorkshire and the Humber Quality Observatory General practice - prescribing A high proportion of generic prescribing for simvastatin and pravastatin will mean lower prescribing costs. The indicator measures the percentage of scripts written for simvastatin and pravastatin. % Low cost medicines (Lipid Modification) E.R ID BR AD LE ED N. LIN NY Y KIR K NE .LI CA LD RO TH DO NC EN G AV BA RN SH EF HU LL WA KE The National Institute for Health and Clinical Excellence (NICE) has published comprehensive evidence-based guidance for use of lipid modifying drugs in a range of clinical situations. There are 5 statins approved for use within the UK which vary markedly in price. December 2007 Slide 26 Prescribing – Proton Pump Inhibitors (BCBV) E. RI D DO NC BA RN W AK E KI RK LE ED HU LL NY Y N. LI N NE .L I EN G AV CA LD SH EF TH BR AD The indicator measures the percentage of scripts written for omeprazole and lansoprazole This is given as a percentage of the total volume of PPI prescribing. 100 90 80 70 60 50 40 30 20 10 0 Productivity opportunity <footer> PricewaterhouseCoopers LLP D BR AD LE E NY Y Across YAH this represents a potential productivity opportunity of £3.1M. 500,000 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 CA LD NE .L I N. LI N HU LL BA RN KI RK E. RI D W AK E RO TH DO NC Greater savings will be achieved for larger shifts. Savings are expressed as annualised figures by multiplying by four the savings of the quarter measured. Productivity opportunity £ SH EF This is the money that would be saved if every PCT achieved an upper quartile (92%) rate of low cost PPI prescribing. The average cost for prescriptions for omeprazole and lansoprazole together is substituted for the average cost for other PPIs, to reach 92%. Source: NHS Institute Better care better value Yorkshire and the Humber Quality Observatory General practice - prescribing There are non-proprietary versions of omperazole and lansoprazole, so by prescribing these two drugs generically, clinicians can prescribe more cost-effectively. % Low cost PPIs RO There are five PPIs currently approved for use within the UK for the management of dyspepsia - these drugs vary markedly in price. December 2007 Slide 27 Prescribing – Ace Inhibitor & A2Receptor Antagonists (BCBV) CA LD DO NC RO TH HU LL BA RN SH EF NE .LI W AK E NY Y D E. RI D EN G AV N. LIN Productivity opportunity <footer> PricewaterhouseCoopers LLP 600,000 500,000 400,000 300,000 200,000 100,000 Source: NHS Institute Better care better value Yorkshire and the Humber Quality Observatory D LE E KI RK BR AD 0 NY Y Across YAH this represents a potential productivity opportunity of £1.9M 700,000 HU LL NE .LI RO TH SH EF W AK E DO NC CA LD N. LIN E. RI D Greater savings will be achieved for larger shifts. Savings are expressed as annualised figures by multiplying by four the savings of the quarter measured. Productivity opportunity £ BA RN This is the money that would be saved if every PCT achieved an upper quartile (74%) rate of ACEI prescribing. The average cost for prescriptions for ACEI together is substituted for the average cost for other drugs affecting the renin-angiotensin system, to reach 74%. General practice - prescribing The significant variation in the proportion of ACEI to A2RAs prescribed between PCTs cannot be explained easily on the basis of differences in prevalence or side effects. 78 76 74 72 70 68 66 64 62 LE E There are two classes of drug in common use within this group; angiotension-converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (A2RA) with significant cost differences. % Low cost Medicines (renin-angiotensin system) KI RK Drugs affecting the renin-angiotensin system are used for a wide range of common medical conditions. December 2007 Slide 28 Prescribing: Diabetes testing strips cost per diabetic patient Fig 13e. Yorkshire & the Humber SHA - prescribing costs: blood glucose testing reagents per diabetic patient April 2009 - June 2009 North Yorkshire & York 19.70 Leeds 19.25 East Riding of Yorkshire 18.46 Barnsley 18.21 North Lincolnshire Weighted prescribing costs varied from £13.97/patient in Doncaster to £19.70/patient in North Yorkshire & York. 17.95 Hull Teaching 17.27 England 16.95 Yorkshire & The Humber 16.93 North of England 16.49 Bradford & Airedale 16.46 Wakefield District Adherence to NICE guidance on use of testing strips could significantly reduce this variation. Across our region there are examples of over-testing of patients with a stable condition. 16.44 16.06 North East Lincolnshire Care Trust Plus Rotherham 15.54 15.08 Kirklees Sheffield 14.60 Calderdale 14.59 Doncaster 13.97 0 5 10 15 20 25 NIC/diabetic patient (£) Source: NHS Institute Better care better value <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - prescribing The chart opposite shows the weighted prescribing costs (weighted according to diabetes prevalence from practice QOF registers) from April to June 2009 for blood glucose testing reagents. December 2007 Slide 29 Prescribing - Bronchodilators In April – June 2009, Yorkshire & The Humber SHA spent £8.2m on bronchodilators. Fig 6b. Yorkshire & The Humber SHA - prescribing costs: bronchodilators April - June 2009 Rotherham (8.1%) North East Lincolnshire Care Trust Plus (7.9%) Hull Teaching (7.8%) Doncaster (9%) North Yorkshire & York (7.3%) *(weighted according to chronic obstructive pulmonary disease (COPD) + asthma prevalence from QOF practice registers) since April 2006. Barnsley (8.4%) North of England (8%) North Lincolnshire (7.6%) Yorkshire & The Humber (7.8%) Leeds (7.2%) East Riding of Yorkshire (7.8%) Kirklees (7.4%) Wakefield District (8.9%) Bradford & Airedale (7.7%) Sheffield (7.8%) Thirteen PCTs had prescribing costs above the England average (£17.63/patient), and six PCTS had prescribing costs above the North of England average (£20.23/patient). England (7.2%) Calderdale (7.3%) 0 5 10 25 20 15 NIC(£)/(COPD+asthma) patient Tiotropium Salbutamol Salmeterol Ipratropium Bromide Terbutaline Sulphate Formoterol Fumarate Others Source: NHS Institute Better care better value <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - prescribing In the first quarter of FY 2009/10, weighted* prescribing costs varied 1.4-fold, from £16.78/patient in Calderdale PCT to £23.26/patient in Rotherham PCT. December 2007 Slide 30 Section 4 Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice – wider system 1) December 2007 Slide 31 General practice in the healthcare system This section focuses on: • Presenting variation in emergency admissions, elective activity and referrals from general practice. • Understanding the costs associated with the variation – and the savings that could be addressed by reducing it. • Developing an understanding of the key drivers of the variation <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice – wider system As well as being service providers and the first port of call for the vast majority of people in the region, it also has a role in supporting patients navigate through the rest of the system and managing demand – this gatekeeper role is likely to become increasingly under scrutiny in the new financial environment. December 2007 Slide 32 Avoidable hospital admissions National average performance is 95.00. All but 1 of PCTs in Yorkshire and Humber have a poorer performance than the average. SOURCE: NHS Institute, better care better value 60 40 20 0 Nort h Yorkshire East Riding Nort h East Leeds Kirklees Barnsley Calderdale Lincs Nort h Lincs Bradf ord and Airedale Hull Doncast er Wakef ield Dist rict Rot herham Shef f ield General practice – wider system Better care better value reports on variation in emergency care for 19 Ambulatory conditions that can be managed effectively in primary care. Reducing avoidable emergency admissions for these conditions offers a quality and value for money opportunity to PCTs. The measure used here is the ratio of actual emergency admissions to expected emergency admissions standardised by age and sex. It is estimated that savings in the region of Emergency admissions for 19 Ambulatory Care Conditions: Q4 2008-09 £70m can be derived 160 by bringing those with high emergency 140 admissions down towards the top 120 quartile on these 19 conditions alone. The 100 variation will be wider at practice level. 80 and York <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 33 Outpatient referrals National average is 109.2. All but 2 PCTs are performing above the average. 80 60 40 20 SOURCE: NHS Institute, better care better value <footer> PricewaterhouseCoopers LLP 0 Leeds Wakef ield Bradf ord Nort h Dist rict and Airedale Yorkshire East Riding Nort h East and York Yorkshire and the Humber Quality Observatory Lincs Kirklees Hull Doncast er Barnsley Calderdale Nort h Lincs Rot herham Shef f ield General practice – wider system Better care better value also reports on variation in outpatient referrals by PCT. The indicator measures the actual rate of outpatient appointments relative to the expected rate for the PCT (based on age sex and health need). BCBV does not provide guidance on the ‘right’ level of outpatient referrals for a given population, however managing the variation down appropriately is will be crucial in a tighter financial climate. It is estimated that savings in the region of £14m can be derived Outpatient Referrals: Q4 2008-09 by bringing those with 140 outpatient appointments down to 120 the top quartile. The variation will be wider 100 at practice level. December 2007 Slide 34 Understanding the variation – Emergency admissions Emergency admissions by cluster 120 100 80 60 40 At PBC level, there is a difference of 30 admissions per 1000 population between the upper quartile and the lower quartile, and at practice level the difference is 35 per 1000. DH estimate that the average cost of an emergency admission is around £1,400, therefore moving an average practice (with a list size of 6000) from the lower to upper quartile would general approximately £290,000. * See Annex A for practice cluster groupings. <footer> PricewaterhouseCoopers LLP 20 0 Light green Light blue Dark blue Pink Yellow Emergency admissions by PBC 160 140 120 100 80 60 40 20 0 Yorkshire and the Humber Quality Observatory Dark green Purple Orange Lilac General practice – wider system Emergency admissions per 1000 population vary significantly by practice cluster group* - the rate in the highest (lilac) cluster is almost double that of the lowest (light green) cluster. December 2007 Slide 35 Understanding the variation – Elective admissions Elective admissions by cluster 40 30 20 10 0 1 Light green Dark green Light blue Elective admissions by PBC At PBC level the variation in elective admissions between the upper quartile and the lower quartile is 7 per 1000 – this variation is significantly lower than for emergency admissions. 50 40 30 20 10 0 * See Annex A for practice cluster groupings. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory Purple Dark blue Pink Orange Yellow Lilac General practice – wider system Apart from the ‘light green’ cluster, the variation in elective admissions per 1000 population across practice cluster groups is smaller than for emergency admissions. The ordering is also different apart from the highest and lowest. December 2007 Slide 36 Understanding the variation GP accessibility and deprivation by practice cluster Analysis of deprivation, satisfaction with general practice access and emergency admissions at practice cluster level* demonstrates some quite clear relationships: 90.0% 57 88.0% 127 86.0% 11 • The higher graph shows that satisfaction • The lower graph shows that emergency 82.0% Accessibility with access falls as deprivation increases. 170 Dark blue Dark green Light blue Light green Lilac Orange Pink Purple Yellow 23 3 11 19 80.0% 130 78.0% admissions increase as deprivation increases. 76.0% 74.0% 49 The practice clusters with high ethnic minorities (purple and orange) are also associated with the highest levels of emergency admissions and the lowest levels of satisfaction with access to general practice. 72.0% Social marketing can clearly play a role here, and work carried out in Tower Hamlets has played a significant role in improving the way services are accessed for these populations. 100.0 70.0% 0 10 20 30 40 50 60 Deprivation Emergency admissions and deprivation by practice cluster 120.0 110.0 170 49 * See Annex A for practice cluster groupings. <footer> PricewaterhouseCoopers LLP Emergency Admission Rate 19 11 Dark blue Dark green Light blue Light green Lilac Orange Pink Purple Yellow 233 90.0 130 127 80.0 70.0 57 60.0 11 General practice – wider system 84.0% 50.0 0 10 Yorkshire and the Humber Quality Observatory 20 30 Deprivation 40 50 60 December 2007 Slide 37 Emergency Admissions analysis Age and sex standardised emergency admission rate per 1000 2007/08 - 2008/09 300 250 200 150 100 50 0 • a 10% increase in smoking prevalence in long terms conditions is be associated with a 16 per1000 increase in and emergency admissions – around 90 emergency admissions per average practice per year. • an increase of 10 points the in IMD deprivation score is associated with an 8 per 1000 increase in emergency admissions. 0% 10% 20% 30% 50% 60% Source: HES, NSTS populations and QOF 70% 80% Chart produced by YHPHO Association between deprivation and emergency admissions by GP Practice in Yorkshire and the Humber 300 250 200 150 100 50 0 0 10 20 Low deprivation Source: HES, NSTS populations <footer> PricewaterhouseCoopers LLP 40% Smoking prevalence in people with a LTC 2008/09 Age and sex standardised emergency admission rate per 1000 2007/08 - 2008/09 According to this analysis, all other things being equal: Yorkshire and the Humber Quality Observatory 30 40 Deprivation based on IMD2007 50 60 70 High deprivation General practice – wider system We have carried out a practice level analysis into the key drivers of emergency admissions across Yorkshire and the Humber. Just over 50% of the variation in emergency admissions across the patch can be explained by variation in smoking prevalence of those with long term conditions, and deprivation. Association between smoking prevalence in people with LTCs and emergency admissions by GP Practice in Yorkshire and the Humber Chart produced by YHPHO December 2007 Slide 38 Emergency Admissions analysis - COPD 150 100 50 0 0% 10% 20% 30% 40% 50% 60% 70% 80% Smoking prevalence in people with a LTC 2008/09 prevalence in long term conditions is associated with a 15 per 1000 increase in COPD related emergency admissions; • A 10 point increase in deprivation (IMD) is associated with a 11 per 1000 increase in COPD related emergency admissions; • A 10% increase in COPD prevalence is associated with a 3 per 1000 increase in COPD related emergency admissions. Source: HES, NSTS populations and QOF Chart produced by YHPHO Association between deprivation and emergency admissions for COPD by GP Practice in Yorkshire and the Humber 200 Age and sex standardised emergency admission for COPD rate per 1000 2007/08 2008/09 • A 10% increase in smoking Practices with high deprivation achieving low emergency admissions 150 100 50 0 0 10 20 Low deprivation Source: HES, NSTS populations <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory 30 40 Deprivation based on IMD2007 50 60 70 High deprivation General practice – wider system This analysis has demonstrated broadly similar results - that around 50% of the variation in emergency admissions across the patch can be explained by (in descending order) variation in smoking prevalence of those with long term conditions, deprivation, and COPD prevalence. 200 Age and sex standardised emergency admission for COPD rate per 1000 2007/08 2008/09 We also carried out the analysis specifically for emergency admissions relating to chronic obstructive pulmonary disease. Association between smoking prevalence in people with LTCs and emergency admissions for COPD by GP Practice in Yorkshire and the Humber Chart produced by YHPHO December 2007 Slide 39 Emergency Admissions - LTC smoking prevalence The key for PCTs however is to understand and manage variation at practice level. This information is available in the health intelligence practice profiles. Smoking Prevalence in People with a LTC, 2008/09 25% 20% 15% 19.1% 19.2% 19.3% 19.8% 20.1% 20.1% 20.7% 21.2% Rotherham Leeds Barnsley Doncaster Wakefield District Bradford & Airedale North East Lincolnshire East Riding of Yorkshire 18.1% Kirklees North Yorkshire & York 17.6% North Lincolnshire 14.4% Sheffield 14.1% 18.9% Calderdale 23.9% 10% 5% <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory Hull 0% General practice – wider system The analysis above suggests that smoking in long term conditions is a key driver of emergency admissions. There good evidence to suggest that this can be directly influenced by healthcare services. Smoking prevalence in long term conditions varies considerably across data at PCT level (see table below). December 2007 Slide 40 Section 5 Overview 2) Variation in general practice provision 3) Prescribing 4) Impact on the wider system 5) Annexes <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - annexes 1) December 2007 Slide 41 Annex A: Key Contacts Helen Parkin – Associate Director of Primary Care, NHS Y&H ([email protected]) Lorraine Oldridge – Deputy Director, Yorkshire and Humber PHO ([email protected]) The Primary Care Delivery Board key contact: ([email protected]) <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - annexes Ian Holmes – Associate Director, Economics and System Management, NHS Y&H ([email protected]) December 2007 Slide 42 Annex B: General practice cluster groups Yorkshire and Humber Public Health Observatory (YHPHO) has developed practice-level clusters for the Yorkshire and Humber region. Practice population characteristics have been used to define clusters of practices sharing similar characteristics to aid comparisons of data between practices - these allow for more relevant comparison of practices that are within the same cluster. The characteristics chosen to define the practice-level clusters were: practice list size; age; sex; ethnicity; deprivation and geography (urban/rural). Nine cluster groups have been developed which are: Number Explanation Dark Blue 123 Relatively older and predominately white and urban-town dwelling practice population. Below average levels of income deprivation. Relatively older and predominately white practice population. Light Blue 57 Substantially above average percentage of patients who live in a village, hamlet or isolated dwelling. Below average levels of income deprivation. Orange 48 Relatively young, urban dwelling practice population with substantially above average percentage of patients who are Asian and substantially above average levels of income deprivation. Dark Green 11 Light Green 12 Pink 129 Urban dwelling practice population aged predominantly 15-44 years old. Substantially above average percentage of male patients. Above average percentages of patients who are Asian and Black or of mixed race. Above average levels of income deprivation. Above average list size. A practice population that is predominately aged 15-44 years old and urban dwelling. Above average percentages of patients who are Asian and Black or of mixed race. Below average levels of income deprivation. Above average list size. A predominately white practice population with a slightly above average percentage of patients aged 65 years and over. Below average levels of income deprivation. Purple 21 Lilac 168 Yellow 231 None 2 <footer> PricewaterhouseCoopers LLP Relatively young and urban dwelling practice population with substantially above average percentages of patients who are Asian and Black or of mixed race. Above average levels of income deprivation. Relatively young, predominately urban/town dwelling practice population with average percentages of patients belonging to each ethnic group. Above average levels of income deprivation. Average list size. A predominately white and urban-town dwelling practice population that has average percentages of patients aged 0-14 years old and 65 years and over. Slightly below average levels of income deprivation. Practices which have not been assigned to a cluster Yorkshire and the Humber Quality Observatory General practice - annexes Colour December 2007 Slide 43 Annex C: Primary Care Delivery Board: TOR • Supporting the primary care elements of the individual ‘care’ pathway boards, leading on delivery where appropriate; • Driving improvements in the quality of primary care commissioning and • Providing strategic leadership to accelerate the learning from Practice Based Commissioning (PBC) and ensure clinical leadership of the agenda; and • Translating National Primary Care Strategy into locally meaningful outcomes • Recommending actions and showcasing initiatives that will contribute positively to the quality and productivity challenge (Quality, Innovation, Productivity and Prevention – QIPP) <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory General practice - annexes provision and tackling unacceptable variation; December 2007 Slide 44 3) QIPP Metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 45 QIPP metrics - overview We have developed an initial set of metrics so we can begin to track how health systems are functioning in a tighter financial climate. These focus on productivity, but also on outcomes and other measures of system health. <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory QIPP metrics The dashboard will be developed for next months pack to include non-acute provider information and more PCT analyses. As we develop a time series of data we will also analyse how different metrics interact and impact on each other. If you have any comments on these metrics and how they could be developed please contact [email protected] December 2007 Slide 46 QIPP metrics (1) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 47 QIPP metrics (2) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 48 QIPP metrics (3) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 49 QIPP metrics (4) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 50 QIPP metrics (5) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 51 QIPP metrics (6) QIPP metrics <footer> PricewaterhouseCoopers LLP Yorkshire and the Humber Quality Observatory December 2007 Slide 52 PH1: CO validated quit rate at Stop Smoking Service % IC Omnibus Q1 2009/10 PH2: 15-24 yr olds screened or tested for Chlamydia YTD HPA Sep 2009 PH3: All age all cause mortality males rate per 100,000 ONS Q1 2008/09 PH4: All age all cause mortality females rate per 100,000 ONS Q1 2008/09 PH5: Infants being breastfed at 6-8 week % VSMR - Unify Q2 2009/10 PH6: Alcohol related admissions per 100,000 admissions 2008/9 provisional EASR QIPP metrics - definitions and sources Indicator Units Indicator Source Units Source Activity - Acute trusts Activity - PCTs A1: Emergency Readmission rates - nonelective; within 14 days of discharge % Dr Foster data Q1 2009/10 A1: Emerg Readmission rates - nonelective within 14 days of discharge % Dr Foster data Q1 2009/10 A2: Elective LOS Days Dr Foster data Q1 2009/10 A3: Elective LOS compared to expected LOS Days Dr Foster data Q1 2009/11 A4: Nonelective LOS Days Dr Foster data Q1 2009/12 A5: Nonelective LOS compared to expected LOS Days Dr Foster data Q1 2009/10 A6: Hospital Standardised Mortality Ratio Ratio Dr Foster data Q1 2009/10 A7: Crude hospital-based mortality rates % Dr Foster data Q1 2009/10 A8: Daycase rates - Dr Foster indicator based on CQC groups % Dr Foster data Q1 2009/10 A9: First to Follow up OP Ratio BCBV data for Q1 2009/10 A10: Pre-operative bed day rates % BCBV data for Q4 2008/09 A11: Acute delayed discharges for adults % Unify Jul 2009 A2: Elective LOS (days) Days Dr Foster data Q1 2009/10 A3: Elective LOS compared to expected LOS (days) Days Dr Foster data Q1 2009/10 A4: Nonelective LOS (days) Days Dr Foster data Q1 2009/10 A5: Nonelective LOS compared to expected LOS (days) Days Dr Foster data Q1 2009/10 A6: Hospital Standardised Mortality Ratio (days) Days Dr Foster data Q1 2009/10 A7: Crude hospital-based mortality rates (rate per 100,000) Rate per 100,000 Dr Foster data Q1 2009/10 A8: GP referrals (G&A) - YTD against VS Plans (%) % Unify & Vital Signs Oct 2009 A9: Other referrals (G&A) - YTD against VS Plans (%) % Unify & Vital Signs Oct 2009 Quality & Safety and Prescribing - PCTs P1: Low cost prescribing for ACEI (%) % BCBV data Q1 2009/10 P2: Low cost PPI's vs all PPI's prescriptions (%) % BCBV data Q1 2009/10 P3: Low cost prescribing for statins - all prescriptions (%) % SHA Q1 2009/10 QS1: Hospital acquired Infection rates - Cumulative Rates of C.Diff per 100,000 pop SHA Nov 2009 per 100,000 pop SHA Nov 2009 QS3: 62 day Cancer RTT Waits (%) % Unify Oct 2009 QS4: Patients treated within 18 weeks Admitted (%) % Unify Sep 2009 QS5: Patients treated within 18 weeks Non-admitted (%) % Unify Sep 2009 QS1: Hospital acquired Infection rates - Cumulative Rates of C.Diff per 1000 ord adms SHA Sep 2009 age 2+ QS2: Hospital acquired Infection rates - Cumualtive Rates of MRSA per 1000 bed-days SHA Sep 2009 QS3: 62 day Cancer RTT Waits % SHA Sep 2009 QS4: Patients treated within 18 weeks Admitted % SHA Sep 2009 QS5: Patients treated within 18 weeks Non-admitted % SHA Sep 2009 QS6: A&E 4 hour target % SHA 29/11/2009 QS7: Cancelled ops not treated within 28 days of last min cancellation % SHA Q2 2009/10 WF1: PCT total paybill millions £ ESR Jul-Sep 2009 WF2: PCT total Staff in Post by organisation number iView Sep 2009 WF3: PCT annualised Av Basic Pay per FTE thousands £ iView Q2 2009 WF4: PCT sickness Absence rates % iView Q2 2009 WF5: PCT turnover using FTE % ESR Jul-Sep 2009 WF6: PCT ratio of Clincal to Non-clinical staff Ratio Med & Non-Med Census '08 WF7: Acute trust total paybill millions £ ESR Jul-Sep 2009 WF8: Acute trust total Staff in Post by organisation number iView Sep 2009 WF9: Acute trust annualised Av Basic Pay per FTE thousands £ iView Q2 2009 WF10: Acute trust sickness Absence rates % iView Q2 2009 Workforce - PCTs & Acute Trusts Prevention and Public Health - PCTs PH1: CO validated quit rate at Stop Smoking Service % IC Omnibus Q1 2009/10 PH2: 15-24 yr olds screened or tested for Chlamydia YTD HPA Sep 2009 PH3: All age all cause mortality males rate per 100,000 ONS Q1 2008/09 PH4: All age all cause mortality females rate per 100,000 ONS Q1 2008/09 PH5: Infants being breastfed at 6-8 week % VSMR - Unify Q2 2009/10 PH6: Alcohol related admissions per 100,000 admissions 2008/9 provisional EASR Indicator Units Source Activity - Acute trusts A1: Emerg Readmission rates - nonelective within 14 days of discharge % Dr Foster data Q1 2009/10 WF11: Acute trust turnover using FTE % ESR Jul-Sep 2009 A2: Elective LOS Days Dr Foster data Q1 2009/10 WF12: Acute trust ratio of Clincal to Non-clinical staff Ratio Med & Non-Med Census '08 A3: Elective LOS compared to expected LOS Days Dr Foster data Q1 2009/11 A4: Nonelective LOS Days Dr Foster data Q1 2009/12 A5: Nonelective LOS compared to expected LOS Days Dr Foster data Q1 2009/10 A6: Hospital Standardised Mortality Ratio Ratio Dr Foster data Q1 2009/10 <footer> A8: Daycase rates - Dr Foster indicator based on CQC groups PricewaterhouseCoopers LLP % Dr Foster data Q1 2009/10 % Dr Foster data Q1 2009/10 A7: Crude hospital-based mortality rates A9: First to Follow up OP Ratio Yorkshire and the Humber BCBV data forQuality Q1 2009/10 Observatory QIPP metrics QS2: Hospital acquired Infection rates - Cumualtive Rates of MRSA Quality & Safety - Acute Trusts December 2007 Slide 53