s111 - day 2 - 1315 - innovations that could transform planned care
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S111 - Day 2 - 1315 - Innovations that could transform planned careTRANSCRIPT
Innovations that could transform planned care
Michael Macdonnell & Nick Ville 4th March 2014
What we’re going to talk about
2
The strategic context
The opportunity in elective care
How to seize the opportunity
We forecast a funding gap of £28-44bn by 2021/22 in a “do nothing” baseline case
3
859095100105110115120125130135
Funding £bn
£44bn
£28bn
2021/22 20/21 19/20 18/19 17/18 16/17 15/16 14/15 13/14 12/13 11/12 2010/11
Real terms freeze
Real terms freeze through 2014/15 followed by increase with real GDP (2.4%)
Historical Funding pressures on the NHS in England (~4%)
1 The forecast spend assumes pressures continue to rise in line with patterns observed prior to 2010/11 and that policy-makers and managers take no action to improve efficiency and reduce costs. This estimate is based on the rising pressures on the NHS from 1) Demographics (principal population projection from ONS), 2) Health care activity (Chronic demands on acute 04/05-09/10; MH 08-10/11; primary care 95/96-08/09; prescribing 08/09-11/12) and 3) Health care costs (Pay 2% a year over GDP deflator; drugs in line with GDP). Assumes NHS funding continues to grow with inflation (GDP deflator). Forecast starts at 2010/11 as that is year with most available data for productivity calculations.
2 The funding gap is estimated to be ~£12-28bn by 2021/22 if the potential QIPP and wage savings to 2014/15 are delivered
So where are the improvement opportunities?
IMPROVE CURRENT SERVICES
Provider efficiency
Reduce spend on low value interventions
RIGHT CARE, RIGHT SETTING
Patient self-care
Prevent hospitalisation through integrated care
Shift activity between
care settings
NEW SERVICES
Examples:
- Torrevieja Salud
- CareMore
- Martini-Klinik
4
5
30 6.5-12
2.4-4
1.7-2
5
7-14.4
Gap by 2021/22
Improve current services
Right care, right setting
Innovate new
services
Wage freeze to 2014/15
Remaining challenge
New services
Higher value care models are needed to close the gap
£Bn/ pa
...And this view is shared by many NHS leaders
6
0
10
20
30
40
50
60
70
Technology New care models or types of providers Patient responsibility and self management
% o
f Aud
ienc
e
Which of the following is the most important potential solution to the NHS' future challenges?
Healthy & well
At risk
Episodic needs or single LTC
Polychronic and vulnerable elderly
Severe illness & specialist needs
Acu
ity
Active & engaged patients &
citizens
Wider primary care at scale
Modern models of integrated
care
High value elective
care
Specialist centres of excellence
High quality
urgent & emergency
care networks
Six future models or characteristics
What we’re going to talk about
8
The strategic context
The opportunity in elective care
How to seize the opportunity
A step change in the productivity of elective care
Population For patients who need a planned or elective procedure (e.g. cataract or orthopaedic surgery) but excluding prescribed specialised services.
What is it? Providers rationalise their portfolio to specialise in providing a specific planned care procedure and its aftercare at high volume.
By performing at high volume, providers attract the best people, shift tasks to different grades raising quality, reducing variation and lowering cost
9
Providers choose to specialise, do one or few things very well
Measure clinical outcomes, report transparently
Analyse variations, employ best ‘high volume’ surgeons
Focus on improvement & best practice sharing
Individual care tailored to patient
There are significant clinical and productivity opportunities to deliver better value elective care
10
Clinical benefits Productivity benefits
• Reduced mortality and morbidity associated with higher volume centres
• Reduced complication rates for surgical procedures
• Reduced length of stay (and infection rates?) • Research capability, which in turn is
associated with quality improvements
• Better patient experience?
• Greater asset utilisation; for example, theatres and other capital equipment
• Higher workforce productivity arising from standardisation and potential for task-shifting
• Better job satisfaction and recruitment benefits • Fewer complications, less re-work and
potentially lower litigation costs
• Purchasing / procurement benefits?
Better value (outcomes/costs)
Case study 1 : the Shouldice Center, a dedicated and high volume hernia centre
11
About Shouldice Hernia Center
Shouldice Hernia Center (Toronto, Canada) have a 55 year history in specialising in hernia surgery (80% inguinal hernia)
• Total of >300 000 surgeries performed
• 89 beds and 11 surgeons
Developed own surgical method—"Shouldice repair"
• Short operation time with local aesthetic
• Quick recovering process (the patient leaves the operation theatre un-assisted)
Key success factors
Lower costs—and good outcome • Patients are screened carefully,
mostly standard operations • Short operation time
and recovery due to local aesthetic
Lower fees attracts patients from all over North America
• ~50% lower costs compared to other hospitals1
• ~50% of patients originates from outside Toronto and ~20% outside Canada
Experienced and dedicated surgeons
• Nicholas Obney, chief surgeon for 32 years, annual case load of ~800 surgeries
Outcomes
Volu
me
Reo
pera
tion
rate
(%)
~7500 hernia surgeries
0
1
2
3
4
Sweden mean
-89%
Shouldice
3.2
5 year reoperation rate (%)
0.3
Primary surgery 1985
Primary surgery 1992–2007
1. HBS case study shows that a standard hernia surgery at Shouldice costs ~1500 USD, compared to ~3000 USD at other hospitals Source: Swedish National Hernia registry annual report 2012, E. Byrnes Shouldice, Surgical Clinics of North America, 2003 ; HBS Case study
Case Study 2: the ENDO-Klinik, the largest hip arthroplasty unit in Germany
12
About ENDO-Klinik
Recognised Centre of Excellence within orthopaedics
• ~50% of patients originates from outside Hamburg
• Built a strong brand based on high quality since the start in 1976
• Part of the hospital group Helios, one of the largest private players in Germany
Specialised in hip, knee, shoulder and ankle surgery
• ~7000 patients visit the hospital annually
• Only German hospital that is a member of International Society of Orthopaedic Centres
Specialised in complicated cases
A wide range of cases—including the most complicated
• ~2000 hip and knee revisions annually (highest number in Europe)
• Many other orthopaedic centers in Germany only focusing on standardised surgery
Standardised processes and highly experienced teams
• Operation theatres identically designed
• Experienced surgeons with annual case load >200
• Only elective surgery minimising distractions from acute cases
Outcomes
Volu
me
~2300 hip arthroplasties
0.0
0.5
1.0
Reoperation rate (%)
-13%
Weighted mean for German high
volume units
0.8
ENDO-Klinik Hamburg
0.7
Reo
pera
tion
rate
(%)
1. Antibiotic Loaded Bone Cement Source: AOK Weisse Liste http://weisse-liste.krankenhaus.aok.de/ ; http://www.cementinguniversity.com/centres-of-excellence/endo-klinik/presentation?cookieAccept=true; Interview with surgeon at ENDO-Klinik and former surgeon at Schön Klinik.
Case Study 3: the Schön Klinik Neustadt, a dedicated orthopaedic hospital
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About Schön Klinik Neustadt
Specialised within 8 surgical areas, i.e., orthopaedics, spine surgery and neurology
• The hospital was bought from the municipality in 1995
• Annual case load of ~1500 hip arthroplasties and ~1000 knee arthroplasties
Strong growth and internationally recognised as a Centre of Excellence
• Between 1997 and 2005 annual case load grew at CAGR 6%
• Extensive collaborations with international partners (i.e., Harvard Business School)
• Swedish Global Health Partner and Schön collaborates in developing a spine surgery registry
Key success factors
Extensive focus on quality • Comprehensive documentation,
reporting and follow-up • Developed own process called
QED (Quality empowered by documentation)
Cost-efficiency • Strong focus on identifying
cost drivers and correct allocation of costs
• Continuously streamlining operations by standardisation of processes, without affecting clinical outcomes negatively
Outcomes
Volu
me
Reo
pera
tion
rate
(%)
~1500 hip arthroplasties
0.0
0.2
0.4
0.6
0.8
Reoperation rate(%)
Weighted mean for German high
volume units
0.8
Schön Klinik Neustadt
0.0
Källa: AOK Weisse Liste http://weisse-liste.krankenhaus.aok.de/ ; Schön Kliniks hemsida, http://www.lakartidningen.se/07engine.php?articleId=13843;
An important corollary: measuring mortality is not enough to expose the full benefits of specialisation
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0% 5%
Incontinence Severe urinary dysfunction Severe erectile dysfunction
35%
7%
43%
76%
German hospital average1 Martini-Klinik
Complication rates 1 year post-operation (2012)
1. BARMER GEK insured 2012 Source: Quality report Martini Klinik, Budäus et al., Dtsch Ärztebl 2011; 108, personal communication Prof. Huland, BARMER GEK Krankenhausreport
In surgery at least, there is an experience curve: for every doubling of experience (volume), quality improves by ~15%
15
What could this mean at a macro level? Planned care accounts for more than 30% of acute spend, or about £12.2bn per year
Breakdown of planned tariff income1 £ billion (2012/13)
46%
29%
25%
24% 22% 1% 5% 19% 17% 11% 1%
ELIP medical
0.1
ELIP other
0.6
ELIP surgical
2.3
ELDC other
0.1
ELDC medical
1.3
ELDC surgical
2.1
OPFU
3.0
OPFA
2.7
Total
12.2
3.0 3.6 5.6
58% of all acute spend
42% of all acute spend
Acute
48
28
20
Non-tariff
20
Unplanned tariff
14
Planned tariff
14
29% 29% 42%
Non-tariff Tariff
Breakdown of acute trust income from patient activities1 £ billion (2012/13)
1 Tariff income refers to income from activities subject to the national tariff. Difference in planned tariff income between charts due to coding adjustment SOURCE: Analysis based on FIMS; DoH Annual Report and Accounts 2012-13; and HES 2012/13 (Inpatient and outpatient datasets)
Adjusting for coding errors, estimated at
£12.2bn
A conservative estimate, based on reference cost variation, suggests the overall opportunity is at least ca £0.7-0.9bn
16
Opportunity from reducing cost variability to mean (e.g. shift to efficient providers) £ Million
% of spend (12/13)
5% 8% 5% 9%
Total opportunity
660 – 910
Inpatients
210-310
Day Cases
140-230
OP Follow-Ups
210-230
OP First Attendances
100-140
However, this opportunity is based on expensive providers achieving mean costs. What could be achieved if much more productive models were implemented and
the bar was set by the best performing providers internationally?
SOURCE: Analysis commissioned by Monitor based on 2012/13 Reference Costs
What we’re going to talk about
17
The strategic context
The opportunity in elective care
How to seize the opportunity
Making it happen........
18
0
10
20
30
40
50
60
70
Lack of money Political or policy barriers Cultural resistence to change
% o
f Aud
ienc
e
Which of the following barriers to change is the most important?
Challenges for national organisations
19
Partnership working • Join up our work and enable local health economies to take a
system view
Enabling • Be flexible in our approach and remove barriers
Informing • Promote research and analysis the helps local decision-
makers
Active supporter • Lend our support to local ‘proof of concept’ or pilots
Incentivise • Learn how we can better incentivise innovation and adoption
How can we encourage the emergence of high value elective care centres? Thoughts for local health economies
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Understand what you’re buying • Require quality and cost data as a condition of purchase Allocate resources in search of better value • Move activity to best providers Consider incentives that reward value • Can pricing, CQUIN etc encourage providers to specialise?
Commissioners
Providers
Do real strategy • Portfolio rationalisation (doing what you’re good at) is key Take a health economy perspective • An ecosystem of specialised providers operating at scale Consider innovative risk & reward sharing structures • To grease the wheels of collaboration
This makes it sound easy -- taking patients and the public along will also be critical to successful implementation
Discussion question
What can we do that would support innovation and promote its adoption more widely in the NHS?
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