Oldham Health Commissioninto fairness

Keynote SpeechDr Ian Wilkinson

GPCC in Oldham: A strategy for an Accountable Care Organisation

Dr Ian Wilkinson (Chair of Oldham GPCC)Denis Gizzi (Exec Director)

3

The current landscape

A focus on:

• Reform – transition to the new system • QIPP

• Maintenance of improvements to date – e.g. referral to treatment times

• Specific improvements in relation to Government priorities - eg health visitors and Family Nurse Partnership schemes.

Equity and excellence: Liberating the NHS

• a new Outcomes Framework for the NHS – where the focus is on the health improvement achieved;

• patient experience – where there needs to be a shift to better collection of and timely action on patient experience and feedback;

• better information – where a new information strategy will set out how local commissioners and the people they serve can be better supported in decision making; • quality accounts – which will be extended to cover community services;

• local publication – where there is greater clarity of how expenditure translates into local achievements.

NHS operating framework

Responsibilities:

Most health care pathways and programme budgets will be held by GP consortia – 70% of the current budget

This will include; elective care, rehab care, urgent and emergency care (inc OOH), most community services, mental health and learning disability services.

Consortia (will not) be responsible for primary medical services, or other family health such as dentistry, pharmacy, ophthalmics or national and regional specialist services (this will be the remit of the NHS Commissioning Board, with influence from GP consortia).

Consortia will manage combined budgets (separate account from core practice accounts). Their duty will be NOT to overspend, to hold suppliers to account and to ‘hold to account to quality outcomes and contribution from general practice

Promote equalities and work within productive partnerships with the local authority

Duty to effectively engage patients and the public within the core commissioning role

Bottom Line:

deliver higher quality, regulated outcomes at lower macro cost and whilst enabling public ownership and informed choices.

GP Consortia: Focus on new responsibilities

The story so far

• COG to continue as a single consortium through the transition and beyond

• Strategic Commissioning Plan• Reform strategies• Transforming Community Services Strategy –

transformational programme in development• Clinically owned QIPP programme• System and Market Management Strategy• Quality improvement programme for Primary Care• Joint commissioning strategy with LA and Health and

Wellbeing Board in place

• Vision – the Triple Aim– To improve population health in total and via

disease group– To improve care provided, and the health

experience of individuals– To lower per capita costs

GPCC in Oldham: A strategy for an Accountable Care Organisation

• Vehicle for delivery – ACO• All members share risk and assume accountability for the

resources spent caring for the population and the quality of that care

• An ethos of no unnecessary waiting , no unnecessary cost and no compromise on quality

• Requires the trust and confidence of the public, the NHS Commissioning Board and the local Health and Well-being Board

• Out to consultation with stakeholders

Our principles

How The NHS WorksUrsula Hussain and

Jade Czuba

Where Does All The Money Go?Steve Sutcliffe

The Financial ChallengeSteve Sutcliffe

How Are Priorities Determined?Denis Gizzi

Triple aim – a tool for prioritisation and review

IHI triple aim principlesImproved capita cost

control

To improve care provided and the

health experience of individuals

To improve population health and

via disease groups

Programme Budgets - A Rational Starting Point

Managing the ‘Whole’ over Time

The ‘IW’ Idea (the Oldham Chocolate Orange)

GPCC will control the whole health care system and therefore the whole programme budgets in line with

Government policy.

In order to hold control and deliver efficiencies and enhanced quality of the whole ‘real’ budget, segments

could be extracted and delegated authority allocated to clinical teams / clusters / firms to take clinical and

management control over a specific clinical budget area.

Each segment (or Programme Budget area) would be set a framework within which to operate.

The GPCC consortia Board would retain macro accountability,potentially with a prime vendor

Within the transition period, GPCC could take control over some ‘segments’ under delegated authority from the PCT

Referenced within 17 Feb Nicholson letter

Managing The ‘Segments’ over Time

The segments represent individual programme budget areas linked to specific clinical domains such as MSK, Respiratory, CVD etc

The idea is based on the concept of local ‘clinical firm’ leadership of segment areas using a common method.

This would provide flexibility for all clinicians to engage.

Step 1:

Programmes which meet the following criteria to be prioritised for full evaluation (starting with programme budgeting categories which meet the highest number of the criteria)

1. Identified as a priority area by PCT (SCP, JSNA or other) 2. Potential for cash-releasing efficiency gain (from BCBV indicators,

NHS comparators or other source) 3. Area of poorer outcomes (from Programme Budgeting or alternative

Public Health data) 4. Identified need to reduce inequality in service access

Step 2:

Divide Programme Budgeting areas into subcategories and map providers, spend, markets and potential entrants

Select services for review based on:

1. Expenditure>£500k for service or pathway 2. Cash releasing efficiency >10% 3. Poor performing on KPI’s 4. Alternative providers in market 5. Poor patient experience 6. Poor clinical experience 7. Need to reduce inequality in service access 8. Services contractually ending < 12 months

Services meeting 6 or more of criteria to be prioritised

Step 3:

Apply investment/disinvestment criteria and follow methodology for investment/disinvestment

Step 4:

If redesign/new service required, follow system reform model, with HMA informing procurement panel decision

Selecting programme and services for review

7 stage health market analysis

ACTION PLAN CHANGE EXPLORE ACCEPTABLE

ASSESSMENT OF PROVIDERS

INSUFFICIENT DATA TO MAKE

JUDGEMENT

AVERAGE QUALITY PROVIDER

HIGH QUALITY PROVIDER

LOW QUALITY PROVIDER

CONTRACT AND PERFORMANCE MANAGEMENT

GO TO THE MARKET

ENGINEER PARNERSHIP

WORKING

INVESTMENT DECISION TOOL

3 m

onth

turn

arou

nd

12 month

turnaround

PRIORITISATION

Process following health market analysis

Service Needed

Service delivering

Yes

Yes

No

No

Continue routine

monitoring

Improvement Plan/

Decommission

Decommission

Decommission

Making investment decisions

PROGRAMME PHASE 1

Opportunity Identification & PrioritisationOpportunity Identification & Prioritisation

Identify Initiatives•Overarching objectives driven by:

• strategic vision, commissioning intentions, needs assessments, national policies/priorities, etc.

•Supported by additional data sources including:

• 'Data Cube', other health intelligence/indicators, etc.

•Further informed by local initiatives• PBC plans, LDP, 'grassroots' initiatives)

•'Long-list' of initiatives must be:• specific projects, not vague• actionable initiatives

Prioritise Projects

•Assess and score initiatives against Importance and Do-Ability dimensions

•Discuss/define importance and do-ability thresholds

Develop Implementation Plan•Further consideration of

interdependencies, themes, capabilities and capacity to plan

Theme AProj AProj BProj C

Theme BProj AProj BProj C

Theme CProj AProj BProj C

Theme DProj AProj BProj C

M: Decision M: Implement

TP: Analysis TP: Implement

TP: Analysis TP: Implement

M: Decision M: Implement

QW: Implement

TP: Analysis TP: Implement

QW: Implement

TP: Analysis TP: Implement

QW: Implement

TP: Analysis TP: Implement

QW: Implement

Year 1 Year 2

QW: Implement

AVOID ALTOGETHER

IMPLEMENT IMMEDIATELY

ASSESS IMPACT AND ACT

DELIVER IF DESIRED

AVOID ALTOGETHER

IMPLEMENT IMMEDIATELY

ASSESS IMPACT AND ACT

DELIVER IF DESIRED

Prioritising potential new developments

The Prioritisation Tool, (co developed with the NHS Institute) is a key component of this phase of activity

The Prioritisation Tool : Importance & Do-ability (+ ability to flex weighting due to macro forces)

DO-ABILITY: 5 dimensions are assessedPatient & Public EngagementHealth Economy Stakeholder AlignmentTechnology/Facilities/WorkforceImpact on efficiency creationMarket Capability

IMPORTANCE:5 dimensions are assessedPatient BenefitClinical BenefitReform/Strategic DirectionOperational ImperativeFinancial Impact

Economic impact & do-abilityFlex weighting

depending on financial scenarios

AVOID ALTOGETHER

IMPLEMENT IMMEDIATELY

ASSESS IMPACT AND ACT

DELIVER IF DESIRED

Aligning Prioritisation Tool with Investment Decision Tool (IDT)(used to determine relative strengths and weaknesses of existing suppliers, services,

programme budget performance)

Existing Market occupants, services, contracts

Health Market

Analysis

Failing Provider

(targets, experience,

equity)

Programme Budgeting

Contract Renewal

Ef f iciency of service

Contextual information/service model/business case provided (formatted to respond to IDT)

Investment Decision tool (IDT) completed with multi-disciplinary team

Follow pathway as described within system map

High level proposal completed

(to respond to questions within the prioritisation tool)

Initiative assessed to consider if further detail should be provided)

Initiative generator informed of the outcome (may include request for further information and/or information why decision not to progress has been made)

Factors considered for IDT application

Next steps for GPCC

The next steps

• Engagement – public, patient and clinical • Managing demand - urgent care, scheduled care

and prescribing• Long Term Condition Management• Performance Management

How will we know if GPCC have succeeded? -Critical Success Factors

Objective Measure

1 Full commitment and engagement of every GP practice in consortia

360 degree feedback/informal networks /delivery of outcomes

2 Improvement in outcomes as per accountability schedules: - finance, patient and public engagement, governance standards, clinical outcomes

Improvement in performance

3 Population with LTC have a health care plan % of patients with Persoanlised Care Plan

4 Strong relationships with the public and partner organisations

360 degree feedback

5 Robust product delivery platform in place to enable effective redesign

Successful delivery of service change

6 Appropriate workforce in place Measurement against organisation framework

7 Established and recognised model of managing suppliers

Internal knowledge and capability to manage supplier relationships

8 Robust contracting process Robust contracts and management processes with all providers

Health Inequalities in OldhamMark Drury

The Wider Determinants of Health

Ill health does not happen by chance or through bad luck. Health is multidimensional and is influenced by many determinants, which may go unnoticed. The collective effect of poor housing, unemployment, social isolation, individual lifestyle factors and the environment in which we live, have enormous influences on health and

wellbeing outcomes

• Oldham is the 42nd/354 most deprived borough in England (2007 IMD)

• The ward of Coldhurst falls into the 1% most deprived wards in England (2007 IMD)

• Oldham is the 39th/354 most Income deprived borough in England (2007 IMD)

• Nearly 70% of children aged 0 to 15 in Coldhurst and over 60% in St. Mary’s live in households experiencing income deprivation according to IDACI.

Factors that Impact on Health & Wellbeing in Oldham

Population

NHS Oldham’s resident population is currently estimated to be around 218,800. (ONS)

MPI of GP registered patients, resident in Oldham is around 224,646

Oldham has a younger age structure than the England and Wales average, with a significantly higher proportion of people aged under 15 years

Around 16.6% of Oldham’s population are from non-white, Black and Minority Ethnic groups (BME), with 7.1% being of Pakistani heritage and 5.4% being of Bangladeshi heritage.

Around 27.5% of children under 15 years are from BME groups

Diversity of Communities in Oldham

• Deprivation from the national average→ 42 most deprived LA in England

Summary of populations across Oldham

• The most densely populated ward is Coldhurst• The least populated ward is Saddleworth South• Overall there is a higher proportion of females in the over

60 age category than males • Coldhurst has the highest male population • St Marys has the highest female population • Coldhurst has the highest youth population• Failsworth West has the highest over 65 population • Chadderton Central has the highest working age

population

Public Health Intelligence

WHAT DO YOU THINK THE IMPLICATIONSTO HEALTH ARE IF THE POPULATION CONTINUES TO AGE

Question?

LifestyleLifestyle

The main contributors to premature mortality in Oldham

AlcoholAlcohol

-

500

1,000

1,500

2,000

2,500 20

02/0

3

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009

/10

DSR

per

100

,000

pop

ulati

on

Admission rate for alcohol-related harm per 100,000 population

Oldham North West England

20.1%

22.1%22.5%

England North West Oldham

Percentage of 'increasing risk' drinking (synthetic estimate) 2005

Source: NWPHO Alcohol profiles 2010 Source: NI39 NWPHO

650.02

370.28

Emergency Hospital Admission Rates (DSR) for Alcohol 2006/09

20% most deprived Rest of Oldham

19.3%

23.3%

27.2%

Synthetic Estimates of Binge Drinking (2007/08

England North West Oldham

Source: NWPHO Alcohol profiles 2010 Source: SUS/CDS through NHS Oldham data warehouse

40 deaths occurred across Oldham in 2009 that were directly attributable to alcohol

Over 38 thousand people are estimated to drink unsafely

Digestive disorders are on the increase

Oldham has significantly higher hospital admission rates for people under 18yrs than the England average

It is clear from the data that people from deprived areas are more likely to be admitted to hospital for alcohol related conditions

Targeted interventions aimed at re-admitted patients need to be implemented.

Prevalence Outcomes

SmokingSmoking

28.0%

23.6%22.2%

Smoking Prevalence (%) 2006/08

Oldham North West England

22.42%

28.55%

15.53%

22.18%

11.33%

Most Deprived 2 3 4 Least Deprived

Successful Quiiters by Deprivation Quintile (2009/10)

Smoking is the single biggest cause of preventable illness and death in the UK

Around 410 people die each year from smoking attributable conditions across Oldham

It estimated that 49,000 people smoke in Oldham (28%) of the population

It is estimated that 1814 people quit smoking in 2009/10 (Oldham) This is below target

People from more deprived backgrounds and those in manual occupations are the largest group of smokers both locally and nationally

Widening access to stop smoking interventions is essential if we are to increase smoking quitters across Oldham

Support to prevent and stop smoking should be part of a generic lifestyle intervention as well as available at a specialist level

Prevalence OutcomesManagement

Information sources: % adults, modelled estimate using Health Survey for England 2006-2008Oldham’s JSNA 2010Stop smoking Services Oldham

ObesityObesityPrevalence OutcomesManagement

9.6% 9.6%

9.0%

Percentage of Reception aged Children Obese (2008/09)

England Northwest Oldham

18.3%

18.8%

19.2%

Percentage of Year 6 aged Children Obese (2008/09)

England Northwest Oldham

Source: NCMP childhood obesity database,Local Health profiles: APHO 2010)NICE

In Children

Targeting parents and children-family based interventions

Multi-faceted family based behaviour modification programmes

Support in the use of laboratory based exercise programmes

In Adults

Dietary interventions

Clinically prescribed low calorie diets

Increased physical activity programmes

Behaviour modification interventions

It is estimated that 41,000 adults in Oldham are obese

Obesity increases the risk of diabetes, CHD, hypertension , osteoarthritis and some cancers

People who are obese die on average 9 years earlier than those of normal weight

Excess deaths (2009) among people with diabetes type II across Oldham was 156

Although nationally obesity is more prevalent in deprived populations, there is an increase obesity levels across all groups.

Determining the cause of obesity is the key to tackling it

23.8%

23.4%

24.2%

Obesity Prevalence (%) 2006/08

Oldham North West England

Physical ActivityPrevalence OutcomesManagement

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2005-06 2007-08 2008-09

Adult participation in 30 minutes moderate intensity sport

Oldham North West National

It is estimated that around 28.3 thousand adults participate in sport across Oldham

Currently 63% of men and 76% of women are not physically active enough to meet national guidelines

People from lower socioeconomic groups are more likely to be inactive

Obesity is strongly linked to physical activity

Is effective in the treatment of clinical depression and has benefits for mental health

20-30 % reduced risk of premature death and up to 50% reduced risk of major chronic disease

Levels of walking and cycling have fallen in the last decade

Children are also increasingly sedentary

49.3%

51.6%

49.6%

Oldham NorthWest England

Children's Participating in 3 Hours of Sport/PE (2008/09)

Increased physical activity programmes

Increased active travel through urban and rural planning

Develop and maintain public open spaces that are safe and accessible and encourage physical activity.

For most people, the easiest and most acceptable forms of physical activity are those that can be incorporated into everyday life

Source: Sport England's Active People Survey and The Child Health Profiles for England 2010

QUESTIONS?

Why do you think people from more deprived backgrounds adopt risky lifestyle behaviours

Should people’s behaviours affect the treatment they receive from the health service?

Life Expectancy, Main Causes of Premature Death and Morbidity

across Oldham

Life Expectancy across OldhamLife Expectancy across Oldham

• Life Expectancy at Birth (2007/09)

• Males: 75.5 years – 306/324 – 18th worst in England

• Females: 79.9 years – 312/324 – 13th worst in England

• Life Expectancy at 65 years (2007/09)

• Males: 16.2 years – 11th worst in England

• Females: 18.8 YEARS – 10TH worst in England

• Best Life Expectancy = 80.2 years(m) & 85.1 years(f)

• Worst Life Expectancy =70.1 years(m) & 75.5 years(f)

Life Expectancy has been steadily increasing across Oldham over the last 10 years, but the gap between Oldham and England does not appear to be narrowing.

Oldham has a diverse range of communities from the very affluent to the very deprived and this will therefore always produce wide inequalities in health outcomes.

Please note: Denominators for life expectancy used 2001 and 2007 respectively mid year population estimates for wards.

Trends in Male Life Expectancy

The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for males. The highest life expectancy is currently better than the national average. The lowest is currently 7.7 years below the national average. The gap between the best and worst life expectancy is currently 10.1 years

606264666870727476788082

1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009

Num

ber o

f yea

rs

Male Life Expectancy

England North West Oldham Highest Ward Life expectancy Lowest Ward life expectancy

Trends in Female Life Expectancy

The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for females. The highest life expectancy is currently better than the national average by 2.8 years. The lowest is currently 7.8 years below the national average. The gap locally between the best and worst life expectancy is 9.6 years

666870727476788082848688

1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009

Num

ber o

f yea

rs

Female Life Expectancy

England North West Oldham Highest Ward Life expectancy Lowest Ward life expectancy

0

50

100

150

200

250

300

DSR P

ER

100,0

00 P

EO

PLE

Age Standardised CVD Mortality Rates 2009

England

CVD conditions include Coronary Heart Disease (CHD), Stroke, Angina and heart failure

Around 700 people die in Oldham each year from Cardiovascular disease

Cardiovascular disease contributes most (31%) to the life expectancy gap

Cardiovascular disease is strongly related to lifestyle

In people under 75 years

0

50

100

150

200

DSR P

ER 1

00,0

00 P

EO

PLE

Age Standardised Cancer Mortality Rates 2009

England

Not all cancers are related to deprivation

• Lung cancer is the major contributor to cancer deaths and is more common in the most deprived communities• Breast and prostate cancer are most common in the least deprived groups• There is no association between deprivation and colorectal cancer

In people under 75 years

COPD(Chronic Obstructive Pulmonary Disease)

0

5

10

15

20

25

30

35

40

DSR

per

100

,000

peo

ple

Age Standrdised Mortality Rates for COPD in People under 75 Years

England

COPD mortality is more common in deprived areas and is strongly associated with smoking prevalence

Around 336 people in Oldham die from COPD each year

So What?...The case for working deliberately, to create more equal outcomes, rather than simply more equal opportunities to become ever more unequal, has two essential rationales – the practical and the moral.

In those countries where health inequalities are greatest, overall health status of the population is lower. It is difficult to lower the coronary heart disease mortality of the population if only part of the population is experiencing improvement.

Lowering health inequalities helps societies become more successful economically – drawing on the talents of all the citizens at a society’s disposal, rather just a section of them – and socially. More equal societies have less crime and less fear of crime.

Inequalities in health that are potentially avoidable are unfair. Social justice is a reason for desiring a reduction in social inequalities in health.

In Oldham there is a particular issue about health inequalities (and wider inequalities) between communities living side by side and social cohesion.

Opinion: what should fairness mean in the NHS?Martin Rathfelder

Andrea Fallon, Consultant in Public Health, NHS Oldham,

16.4.2011.

Using ethics in decision making• Need to have an awareness of the ‘sliding doors’

nature of ethical decision making• May change according to the opinion/views of

those making decision – hence importance to get broad involvement

• An understanding of ethics wont tell us what decision to make …

• But it will help us articulate why a decision has been made. …

• And will help us to explore all the angles, and be better prepared for scrutiny

Context …• Responsibility for the health of the whole

population• Finite resources• ‘Demand’ not same as ‘need’ – as those who

don’t demand may also need …• Duty of care … safe and effective treatment

which seeks benefit and avoids harm …• Legal responsibilities and accountabilities…• Choice and patient views…• Scientific and Clinical expertise and opinion…

Four essential questions …

What should we be doing and why are we doing it?what rights and duties do we have to intervene, what outcomes do we seek and what is the evidence that it will work…(eg example of post bariatric surgery cosmetic surgery)

Who should it be for, and what risks/costs are there to others?the boundary between restricting liberty for some to promote the health of others, and how fair will it be ….

Who should decide?who should have the loudest voice …clinical, political, financial or public, patient

How should we decide?what process should we use, are there precedents, and what legal obligations do we have in ensuring the ‘right’ process us followed.

AutonomyBeneficence

Non-maleficenceJustice

AutonomyAutonomy

– The right to individual self-determination/self-rule– Autonomy of thought, will and action – Moral requirement to respect anothers’ autonomy– But ….Grey areas

• the right to end ones life• Treating recurrent admissions for alcohol

intoxication • treating an overdosed drug addict• The right to refuse treatment for risky pregnancies• The issue of ‘competence’ (Fraser competence for

under 16s who request contraception)

Beneficence• Beneficence

– To do ‘good’ for others ie benefits …– Cant always tell what the benefits are …. Eg

Evidence for how ‘good’ a popular treatment is may be weak…eg Reiki, Bowen therapy, baby massage…, and what if we don’t have evidence for how to solve a problem – we may need to experiment …

– May be benefits for some but harms for others (eg numbers of false positives versus false negatives in a proposed screening programme)

Non-maleficence• Above all … do no harm …(hippocratic oath)

• Avoiding harm versus doing good …(using the evidence)

• Obligation not to harm people greater than obligation to benefit people (eg prostate cancer screening)

• Some patients however may want to take risks in hope of a cure …(eg experimental treatments for degenerative conditions)

• Balancing risks and harms essential (there isn’t a formula/means of calculating this though)

Justice– About Fairness and equity

– ‘deserving’ and ‘undeserving’ poor ( welfare changes)

– ‘deserving’ and ‘undeserving’ ill (eg smokers, obese, drinkers …)

– Acceptance that equity may mean that some will need more at the expense of others in order for all to receive the outcome/benefit.

– Concept of ‘capacity to benefit’ (eg ?triple bypass for smokers)

At population level we can incorporate ‘beneficence and non-maleficence (benefits over harms) into justice as a means of looking at effectiveness, and also utility – ie how to maximise health gain overall …

Some other terms ..

• Utilitarianism– Doing the greatest good for the greatest number

• ‘Rights’ and ‘Duties’– All equal, right not to be killed, right to life …

• Paternalism– Do the best for people and minimise their suffering

• Consent– ‘Informed’, competence, power/vulnerability, communication

• Acts and omissions– Actions resulting in harm considered worse than failure to act

• Ordinary and extra-ordinary means– Blurring of boundaries eg parental feeding, extreme prematurity

Some thoughts/questions …

• Services mainly respond to demand – how can we meet our duty of care for those who don’t present to us

• Why are we treating people whose own behaviours have resulted in illness (eg blood borne viruses in IV drug users, smokers and bypasses, bariatric surgery)

• How do we decide whether someone is an exceptional case …• What if the public and media demand is such that despite the

evidence – central government instructs us to fund a treatment (eg Herceptin)

Andrea Fallon, Consultant in Public Health, 16.4.2011

Why use health economics principles

• Structured approach to decision making in health care where need appears limitless

• Resources always scarce• Decisions and prioritisation always

inevitable• Adds rigour and openness to decision

making

Health Economics and decision making in healthcare commissioning The main ways in which we use the

principles of health economics in decision making are:

• Deciding whether or not to introduce a new service or intervention

• How to compare multiple bids for funding, when there are only

sufficient monies for one or two of these

• The best way to decide how to take investment from one area

(perhaps to reinvest in another)

Stakeholder perspectives

• Providers: look for technical efficiency– Achieving a desired objective at minimal cost

– with many of the objectives set for them (waiting times, numbers to treat etc)

• Commissioners/policy makers seek ‘allocative efficiency’– Maximise population health gain from a fixed

allocation of resources

About Costs …• Direct: medical salaries, tests, drugs• Indirect: disability, illness, reduced

productivity• Intangible: eg pain and suffering• Opportunity: what do we give up buying if

we fund something else.

Four main approaches

Cost minimisation analysisCost effectiveness analysis

Cost utility analysisCost-benefit analysis

Cost minimisation• When all we want to look at is comparing

one or more treatments/interventions on COST alone

Outcomes must be equal: ie …– the number of patients roughly equal– The effectiveness of the treatments are equal– Years of life saved– Quality of life equal

Example might be prescribing around cholesterol …

Cost effectiveness

• This tool is used when we want to compare two different types of treatment/intervention but where the type of outcome is the same (eg extra life years, or deaths prevented)

Where the amount (not type) of outcomes from two interventions are different, then the efficient choice is that which takes least resource to produce a good outcome – sometimes see the term Numbers Needed to Treat (NNT), eg two treatments which both prolong life in breast cancer…

Cost-utility

Where the type and volume of outcomes from two interventions aren’t the same then we look for a ‘common outcome currency ‘ – eg QALYs (quality adjusted life years)

– eg whether to prioritise hip replacements, coronary bypass operations or kidney dialysis – although different procedures, we could try to look at how they compare in improving quality of life – hence using the QALYs measure.

Cost- benefit• Previous three compare one treatment

with another, and use some kind of natural unit to measure their relative success (eg lives saved, QALYs, cost)

• Cost benefit is used to compare ‘doing something’ with ‘doing nothing’, and places a monetary value on the outcomes

Example – one component of assessing the suitability for introduction of a new screening programme.

QALYs and DALYsQuality adjusted life years (years of healthy life lived)

and disability adjusted life years (years of healthy life lost) are two commonly used measures to identify the burden of disease on a population. However, these are value laden and subject to interpretation.

Without treatment ‘a’ With treatment ‘a’

Estimated survival 5 years

Estimated survival 10 years

Est QALY weight (from patient data) 0.5

Est QALY weight (from patient data) 0.7

QALYS =5x0.5 = 2.5 10 x 0.7 = 7

QALY gain from treatment a = 7 – 2.5 = 4.5 QALYS

Other terms …• Programme Budgeting

– Understand current spend

• Marginal Analysis– Where can we spend less so we can spend

more elsewhere

Thoughts and questions …• The types of analysis described are

sometimes not applied in a systematic way (despite best efforts) …

• Sometimes we have good information about services, other times less so – how can we strike a balance between targeting ‘low hanging fruit’, versus the potentially richer pickings at the top of the tree …

Meaningful Patient InvolvementMark Drury

• What do we mean by involvement?

• A brief history of involvement

• Why does this matter?

• Making it fair!

• Going forward in Oldham

What do we mean by involvement?

• Involvement in individual care:– Patient choice– Shared decision making– Owning your own medical records

• Collective involvement in commissioning and delivery of services

• Scrutiny and accountability

• “Nothing about me without me”

Involvement ModelInforming Consulting Negotiating Participating

Goal

Provide balanced and objective information to assist patients/ communities in understanding the problem/ solutions/ alternatives etc.

Obtain community feedback on analysis, alternatives and/or decisions.

Work directly with patients/ communities to ensure concerns and aspirations are consistently understood and considered.

Genuine partnership with community/ patients in each aspect of decision making.

Promise

We will keep you informed.

We will keep you informed, listen to you and feedback on how decisions were influenced.

We will work with you to ensure that your concerns and aspirations are reflected and provide feedback on how decisions were influenced.

We will look for your input in formulating solutions and incorporate your input into decision making to the maximum extent possible.

History

• Paternalism

• Deference

• Unequal relationships

• Lower expectations

Why does this matter?

• Increasing expectations– Consumerism– Accountability

• User involvement = better outcomes– Marketing principles– Evidenced

• Expectations of clinicians

• Legal Compliance – NHS Act etc.

Making It Fair

• Everyone has a voice

• Not 'who shouts loudest'

• Proactive work into marginalised groups

• Continuous dialogues – not 'hit and run'

• Sharing agenda setting

• Influencing each stage of the commissioning cycle

• Honesty – what can be influenced

Methodology

• Governance• Grass roots/ community approach• Communications• Online – breadth of involvement• Face to face – depth of involvement• Opportunities for direct access to decision

makers• Emphasis on listening

Key Outcomes

• People feel listened to, and valued• Timely feedback received by customers • People see evidence of action • Quality of commissioning decision making

improved

Going forward in Oldham

• Public commitment made

• Early work:– Mandate

– Patient Communities

– Musculoskeletal conditions

– GP development

• Developing the architecture:– Strategic (incl governance)

– Thematic

– Experience

Conclusion

• GPCC Commitment

• Co-production

• Breadth of involvement

• Depth of involvement

• Everybody's opinion counts

• Be proactive to be inclusive

• Sustainability

What matters to patients?

Oldham Health CommissionApril 2011

Mandy WearneDirector Service Experience

www.InspirationNW.co.uk

Putting the ‘S’ back in to the NHS!

NHS

More interest less action? 90% of the time, the minuted board action point

on patient experience is to note the report and take no action

Examples where patient experience data is used to spark debate and action were rare, as were examples of non-executive directors challenging performance Intelligent Board series (2010)

Begins with…What matters to patients?Identifies key service areas through ‘recognition

events’ or touch points i.e. what makes a difference to users

Measures it, benchmarks and builds on itRecognises and celebrates it!

Generic themes• feeling informed about condition & available

services• patient involvement in their care & treatment

decisions• staff who listen and take time• the value of support services• efficient processes• being treated as a person, ‘not a number’

What matters most to patients• ‘transactional’ aspects of care (in which

the individual is cared ‘for’), e.g. meets the preferences of the patient as far as timings and locations of appointments are concerned

• ‘relational’ models (where the individual is cared ‘about’), e.g. care that forms part of an ongoing relationship with the patient

Iles V and Vaughan Smith J. (2009) Working in health care could be one of the most satisfying jobs in the world - why doesn’t it feel like that?

http://www.reallylearning.com/

Patient experience is closely related to and influences clinical effectiveness and safety

Patient experience

Clinical effectiveness Safety

• Patient-centred organisations have better clinical outcomes

• Doctor-patient communication leads to greater compliance in taking medication and self-management for people with long-term chronic conditions

• Patient anxiety and fear can delay healing

Getting the basics right!

Get the basics right – don’t leave it to chanceEnsure staff are competent, Don’t loose my notes, Keep the place clean

Fit in to my life – not force me to fit in to yoursMake the service easy to access, Give me convenient options, Don’t waste my time

Treat me as a person – not a symptomListen to me and take me seriously , Understand the wider context of my condition, Treat me with

respect and dignity

Work with me as a partner in my health – not just a recipient of careEncourage me to keep control of the process, Equip me to look after my own health

Give me the support I need

The evidence suggest patients want to feel

better Research shows this is as much

about:-•How they feel about the service

they received (emotional experience) as

•The clinical outcome they were seeking (PROM)

Recognises ..

• Recognise two important dimensions: – What happens to patients and – How they feel about the

experience

Making it personal

Interactive session

Vital Sign Care Card

• ‘Real time’ user led capture of emotional and preferred service experience

• Enable tailored care to clearly signaled patient wishes and direction

• Consistent evidence based statements for comparative benchmarking over time

Principles• Foster meaningful conversation

‘in the moment’/real time about an individuals emotional and preferred service experience

• Enable care providers to offer tailored responses to clearly signaled patient wishes and direction

• User led: (user asked to place the cards in order of importance to them)

• Allow a person to express as many or as few of the 8 statements that apply

• Provide an ‘Open Card’  – to allow for free expression and interpretation

Q. What mattered most to you?

1. Self Confidence

2. Respect

3. Reassurance

4. Effectiveness

5. Safety

6. Comfort

7. Understanding

8. Honesty

Voting via SMS messaging Please TEXT the word ‘CARE’ followed by the number (1-8) to 60095

e.g. If Self Confidence your choice Text: CARE1 to 60095

Q. What mattered most to you?

1. Self Confidence

2. Respect

3. Reassurance

4. Effectiveness

5. Safety

6. Comfort

7. Understanding

8. Honesty

Please TEXT the word ‘CARE’ followed by the number (1-8) to 60095

Experience and the new opportunity

• The challenge is more than just money• Need to invest in a different offer • Reshaping the business processes to

reflect a different offer for the public– New relationship that builds on personal

assets as well as service needs– Patient experience as a driver for NHS

efficiency– GP consortia – a step closer to patient led

commissioning

• Build local reputation and loyalty (by commissioning what matters locally. building reputation/loyalty – spread of the branding, service recovery paradox)

• Improve quality (through personalised care outcomes: -clinical, patient reported and patient experience)

• Improve efficiency (by identifying process improvements and wasted effort, increasing productivity by commissioning for patient experience and not the organisation)

• Improve financial outcomes (e.g. Cost to serve savings, ROI, staff retention, reduction in staff sickness and complaints)

Experience and efficiency

The ‘value’ of experience– Worth - price and cost, – Importance - usefulness, consequence– Appeal - attraction and pull– Measure – quantitative and qualitative

The value of ‘good’ experience– At every level, – Every bit of the journey– For both staff, patients and the public– Across care pathways and agencies

The ultimate business question….

‘Did you get the care that mattered to

you?’