dr declan o'neill: implementing the decision: a story about prioritising
TRANSCRIPT
Implementing the decision Case Study: NHS West Kent prevention
strategy
A Story about Prioritizing
Dr. Declan O’NeillDirector
Public Health Improvement
Experience from a PCT’s Strategic Commissioning Planning Process• It was NHS priorities focused• It was developed through the broadest
consultation• It recognised the importance of prevention• It was technical • It was developed in a system already subject
to significant financial pressure where the first principle of innovative plans is often invest to save.
• It was seen as successful in CQC eyes
Key components of the Planning Process which developed ‘Prevention’ as an integral part of the PCT’s Strategic Commissioning Plan1. A programme budget based SCP2. Adoption of a ‘fully engaged prevention
scenario’3. An ‘economic approach’ to prevention using
predictive model based on attributable fractions for major health risks
4. To be funded in year two of SCP from development monies delivered by year one efficiencies
1. A programme budget based SCPDeliver national, regional &
county commitmentsEliminate wasteEradicate the gap in life expectancy
Improve health, quality of life and patient experience
Deliver national, regional & county commitmentsEliminate wasteEradicate the gap in life
expectancyImprove health, quality of life
and patient experience
£37m
Dental
£32m
Maternity
£39m£45m£45m£46m£91m£17m£40m£ 35m£74m£63m
Priority Programmes Spend Profile 2014/15 (rounded)
Trauma & InjuriesRespiratoryNeurologyMusculo-
SkeletalMental Health
Infectious Diseases
Genito-UrinaryEndocrineCirculationCancers
Tumours
£37m
Dental
£32m
Maternity
£39m£45m£45m£46m£91m£17m£40m£ 35m£74m£63m
Priority Programmes Spend Profile 2014/15 (rounded)
Trauma & InjuriesRespiratoryNeurologyMusculo-
SkeletalMental Health
Infectious Diseases
Genito-UrinaryEndocrineCirculationCancers
Tumours
Programme Investment Strategy*
Programme Investment Strategy*
Prog
ram
me
Stra
tegy
Cancer Market Model
Circulatory Redesign
Diabetes Strategy
Sexual Health
Redesign
MMR Program
Mental Health
Efficiency
Older People
(inc. MSK/Falls)
COPD Redesign
Urgent Care
Model
Neurology Market Model
Asthma Redesign
Primary Prevention
Increasing Independence (self-care and carers)
Mental Health Market Model
End of Life Care
Transforming Community Services
Circulatory Market Model
Commissioning Innovation
Prio
rity
Initi
ativ
es
Op plan year 1
Cancer 2
Infectious Diseases
Dental 1 & 2
Circulation 1
Respiratory 1
Mental health 1
Cancer 2
Infectious Diseases
Dental 1 & 2
Circulation 1
Respiratory 1
Mental health 1
Op plan year 2
Circulation 2
Musculo-Skeletal
Endocrine
Maternity 1 & 2
Genito-Urinary
Neurology
Circulation 2
Musculo-Skeletal
Endocrine
Maternity 1 & 2
Genito-Urinary
Neurology
Op plan year 3
Respiratory 2
Cancer 1
Trauma & Injuries
Mental Health 2
Respiratory 2
Cancer 1
Trauma & Injuries
Mental Health 2
Op plan year 4
IncreasingIndependence
PrimaryPrevention
IncreasingIndependence
PrimaryPrevention
Op plan year 5
Subject to reviewSubject to review
Oper
atin
g Pl
an*
Goal
s
(1) (1) (1)
(2) (2) (2)
(1)
(2)
Maternity Redesign
MIMHS Review
(1)
(2)
ServiceImprovementCommissioningLeversHealth &Wellness
ServiceImprovementCommissioningLeversHealth &Wellness
Award & Monitor Dental
Contracts
Social Marketing
(1)
(2)
*Phasing refers to the year in which the major impact of an initiative is felt; work on Programmes is ongoing
*Neutral = +/- 5%
1995 2000 2005 2010 2015 2020 2025
Year
The financial environment
Funding shortfall
NH
S fu
ndin
g
2. “Fully Engaged Prevention Scenario”Assumes • maximum application of • effective prevention interventions • across the complete range • of opportunities to reduce the risks • associated with avoidable illnessesThereby restraining projected growth in the
demand for treatment of illness
So a “Fully Engaged Prevention Scenario”in West Kent meant modelling against real
costs of care
An ‘economic approach’ to prevention
• Using attributable fraction methods estimate the specific burdens of preventable hospital morbidity (related to smoking, obesity, etc) in the locality
• Cost them• Identify local prevalence of
risks• Identify the cost and impacts
of effective programmes
• Extrapolate programme to prevalence modification target and cost.
• Estimate expected reductions in morbidity and benefits
• Demonstrate returns on investment
• Present rationale to payer• Expand budget in this area• Evaluate impact
% Prevalence trends over time
0
10
20
30
40
50
60
1970 1980 1990 2000 2005 2010 2015 2020
Smoking
Haz Alcohol
Falls
Obesity
Expenditure of NHS WK attributable to preventable ill health vsExpenditure on Prevention
Non-preventabl
e75%
Preventable
25%
Other PCT spend99+%
Spent on Prevention
<1%
To work all this out requires a fairly robust predictive model into which is fed year on year population age groups, prevalence predictions morbidity costs and impacts of prevention.
Out of which comes a projected returns in morbidity savings versus costs of programmes
Enabling you to go to the payer with a prediction of returns on investment from a prevention programme which makes good economic as well as good health sense
For an initial investment of £3.6m, over a 7 year period reflected in the SCP, prevention programmes were predicted to provide a return on investment reducing the burden of ill-health and reducing health care costs as follows:Healthy Weight £1.6mFalls £1mSexual Health £1.3mMental Health £1mAlcohol £0.9m Smoking £1.1m
£6.9m
Short and Longer term
Such programmes are predicted to:• break even in about c. 5yrs • start returning investment around 7
years• Significantly multiply their returns after
10 years
What happened?
• The programme based budgeting SCP led the business of the commissioner.
• It required suites of demand management programmes to be fitted into priority programmes
• The organisation was re-structured around clumps of priorities
• Demand management programmes were delivered
What happened next?
Other demands popped up and consumed the supply at similar rates to
before.
Why?
In our environment the system appears to default to acute care. Is there mal-distribution of care
provision? If so what contributing factors?
• Relatively well-off, aged population • Historically, monolithic hospitals provided majority acute and long term
care• Not much in way of other providers• No vertical integration• Historically differing pressures for those alternative providers Eg.
community services • Informed patients, informed GPs• Exposure to inverse care law common• Falling risk thresholds at hospital front end • GP contract, community matrons, OOHC• Care delivered in 4 hours is a benchmark for one part of the system• 3 PFIs• London nearby
If we think there is mal-distibution of care is it demonstrably inefficient?
Suggested imbalance in distribution of care types which drives default to acute services
Care TypesPrevention Primary Community Acute Social
Addressing Maldistribution or moving care upstream:Bottom line assumption that major change needed at 5 points in system
• Prevention programmes will expand and focus to measurably reduce morbidity and attributable hospitalisation.
• GPCCs will manage patient care upstream in such a way as to reduce referrals and unplanned admissions into secondary care
• Community services will be able to modify and develop services, with primary care, to be available round the clock and able to provide management packages in 4hrs, avoiding acute admission as default.
• Social Services will modify the acute social care interface to expedite alternatives reducing stays in acute beds
• Acute services will find substantial opportunities to manage out inefficient acute care and redundant capacity
Underpinning efficiency - QIPP plans and detailed indicators can demonstrate silos of improved
efficiency, but what about the overall outcomes?
• At the Kent & Medway (County) LevelK&M has established a QIPP Board to oversee the system response to addressing the financial challenge by ensuring delivery and encouraging collaboration. The QIPP Board has the following organisational membership:NHS Medway NHS West KentNHS Eastern & Coastal Kent Medway NHS Foundation TrustDartford & Gravesham NHS Trust Maidstone & Tunbridge Wells NHS TrustEast Kent Hospitals University Foundation Trust Kent & Medway NHS & Social Care Partnership TrustMedway Community Services West Kent Community ServicesEast Kent Community Services Medway CouncilKent County Council South East Coast Ambulance ServiceQueen Victoria Foundation Trust South East Coast SHA
• The SHA has nominated Vanessa Harris, Director of Resource & Investment to sit on the Board as the SHA Executive Lead for Kent & Medway
Bottom line assumptions of major change at 5 points in system
• Prevention programmes will expand and focus to measurably reduce morbidity and attributable hospitalisation.
• GPCCs will manage patient care upstream in such a way as to reduce referrals and unplanned admissions into secondary care
• Community services will be able to modify and develop services, with primary care, to be available round the clock and able to provide management packages in 4hrs, avoiding acute admission as default.
• Social Services will modify the acute social care interface to expedite alternatives reducing stays in acute beds
• Acute services will find substantial opportunities to manage out inefficient acute care and redundant capacity
Imbalance will right itself!(Or possibly move in that general direction?)
Prevention Primary Community Acute Social
Care Types
How would we know if we were moving in that direction?
• If you think there’s an imbalance which can be addressed through capacity modification then start by looking at where the system defaults to and see what is happening there. Look at the acute sector (Quantify inappropriate admissions, inappropriate bed days).
• It should be said that most CEs and Acute Trust Directors will be able to tell you what happens there and why.
• However, actually quantifying and recording today’s reality can allow us to accurately bench mark and provide a possible target for where we might like to be.
Acute Bed Use
• We’ve now done a study with one of our local acute trusts, as an experiment just in advance of the 2011/12 financial year to maximise its potential for use for benchmarking QIPP.
• No hospital has maximal appropriate use of its inpatient services and it has long been observed that available beds become filled beds –(Roemer’s Law) .
• This sort of auditing has the potential to demonstrate the outcome of efficiency initiatives.
• It could be used as a baseline and, (if then repeated), as a benchmarking system to monitor the effectiveness of QIPP initiatives.
WHAT WAS DONE
• A team of clinical auditors undertook a point prevalence (snap shot) study of admission appropriateness and subsequent appropriate use of acute care on a specific day of care, through an audit of 344 contemporary inpatients’ medical records using an updated version of a validated and widely tested instrument AEP.
• All of the notes completed on day of the admission were scanned by the clinical reviewer against a set of ‘admission-day criteria’.
• Similarly, all of the notes completed on a specific (subsequent) day of stay were scanned by the clinical reviewer against a similar, (not the same), set of ‘day of care criteria’.
The study population included the main specialties which experience ‘inappropriateness of acute bed use’.
• STUDY QUESTION 1- What percentage of post 48 hour in-patients in the study warranted admission to an acute care facility, according to audit criteria demonstrable in the patient’s record?
• STUDY QUESTION 2 - What percentage of post 48 hour in-patients in the study warranted continuing acute care in an acute care facility on a specific day, according to audit criteria demonstrable in the patient’s record?
• STUDY QUESTION 3 - What were the main reasons behind the recorded inappropriate admission rates and inappropriate day of care rates?
• This sort of auditing has the potential to demonstrate the outcome of efficiency initiatives. Changes in these outcomes could be used to triangulate and validate assumptions underpinning the efficiency programmes built into local QIPP plans and heads of agreement.
• It can be used as a baseline and followed down. • PAS incorporated systems exist.• Ultimately may provide means of identifying and
managing out redundant acute capacity to redistribute resource elsewhere in the system.
Questions?