Sir John Oldham National Clinical Lead Quality and Productivity NHS England Jan 2010

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Gwendoline Garrison
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1 Sir John Oldham National Clinical Lead Quality and Productivity NHS England Jan 2010

2 Long term conditions 70% health and social care cost in UK 76% unscheduled admissions 55% GP consultations 93% Medicare and Medicaid cost in US

3 International Comparison of Spending on Health , 3 Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP U.S. Norway Switzerland Canada Netherlands France Germany Sweden U.K. Italy New Zealand Australia U.S. France Switzerland Germany Canada Netherlands New Zealand Sweden Norway Italy U.K. Australia Source: OECD Health Data 2009 (June 2009)

4 Multimorbidity is common in Scotland Mercer Guthrie and Wyke Univ of Glasgow 2011 The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions More people have 2 or more conditions than only have 1

5 Records of 1.7 million patients showed Only 19% of patients with COPD have just COPD Only 14% of patients with Diabetes have just Diabetes Only 5% of patients with Dementia have just Dementia Mercer Guthrie and Wyke Univ of Glasgow 2011

6 Chronic care - a new approach is advocated Review Labs Access Social/Other Services Reassure Diagnose General Referral Review/Adjust Rx and Tx Traditional Model SICKNESS CARE MODEL Approach - Physician Centric) Counsel re: Lifestyle Changes Consultation 10 minutes Routine Preventive Care Deal with Acute Attack of Disease Reinforce Positive Health Behaviours Modify and/or Negotiate Care Plans Complete Forms R eview Care Plan Review History (Current Talk with Family Chronic Care Model Care is Proactive Care delivered by a health care team Care integrated across time, place and conditions Care delivered in group appointments, nurse clinics, telephone, internet, , remote care technology Self-management support a responsibility and integral part of the delivery system Reproduced with kind permission of Prof Chris Ham King s Fund

7 Key system principles (Ham) The delivery system should focus on prevention and not just treatment Priority should be given to patients to self manage their conditions with support from carers and families Primary care should be at the heart of the delivery system Population health management should be emphasised not just responding to the needs of individual patients Care should be integrated to enable primary care teams to access specialist advice and support Information technology should be used to improve chronic care Care for individual patients needs to be coordinated effectively

8 But.. (Ham) These characteristics need to be linked in a coherent whole as part of a strategic approach to change The evidence shows that it is the cumulative effect of different interventions and actions that makes a difference Reproduced with kind permission of Chris ham and the King s Fund

9 Primary drivers Systematic risk profiling of population Integrated locality care teams including social care, community services, allied health professionals and general practice Maximising number of patients who can self manage through systematic transfer of knowledge, and care planning

10 But... You need to do them all.. And status quo is not an option

Long Term Needs patients eye I want you to deal with the whole of me and for you to work as one team Commissioner E-Learning Self-management is default Remote monitoring Personalisation Disease

11 Long Term Needs patients eye I want you to deal with the whole of me and for you to work as one team Commissioner E-Learning Self-management is default Remote monitoring Personalisation Disease specific pathways Neighbourhood care teams Single point of contact Joint delivery teams, community services, social services, ahp practices,mental health Specialist skills Continuity of personnel for individual patient Care plan Broader skill mix Risk Profiling

12 Paradigm shift Part of care system to whole of care system Healthcare effect on people with long term conditions is only a part of the care system Biomedical model to sociomedical model of care Whole of patient not part of patient Not pilots but large system change

13 Quality Trinity (Oldham 2000) improved clinical outcomes improved patient experience maximise use of resources, human and financial (C) John Oldham 2000

14 The Equation (Oldham J JAMA 04 March2009) System Evidence + + Improvement Human Factors = Outcomes Leadership Values Sir John Oldham and Terema Ltd 2007

15 Long term conditions large system change Make it uncomfortable to do nothing Financial model to reinforce care model Regulatory framework Make it easier to make the change Development programme for care model Create pull effect Voluntary sector to mobilise users to request co-management Patient right of access to their electronic medical record

16 Financial model Year of care tariff Quality and Outcomes framework indicators for GP contract

17 Year of care financial model Level of functional need Complexity of health needs High Medium Low High Medium Low

18 Collaborative Process Participants Planning Group Identify driver Baseline data LW0 LW1 LW2 LW3 Support Coaches Virtual programme (webexes etc) Buddying

19 Risk profiling milestones Choosing, testing and running data searches to populate validated software Operating the risk profiling tool for 50% population, with the results acted upon at least fortnightly by a multidisciplinary team Risk stratification utilised across the whole population by integrated neighbourhood care teams for proactive care.

20 Principles of large system change 1. The reason for change (the message, framing the issue) 2. Engage stakeholders, identify and recruit opinion leaders 3. Shape the environment 4. Communicate communicate the change 5. Systematic transfer of knowledge 6. Discipline and rigour to measuring progress 7. Optimism and agility in overcoming obstacles 8. Communicate success 9. Create infrastructure for spread ; recruit and pollute 10. LEADERSHIP

21 Impact in South Devon Minimal delayed discharges from local hospital and fewest excess bed days in the South West Lowest non-elective LoS in the South West and 4 th lowest in the country Lowest occupied bed days for >75 patients with 2+ admissions Acute beds reduced from 750 to 517

22 Swindon s Integrated Approach Swindon rephrased the 6 stages as your questions 1. Prevention 2. Diagnosis 3. Preparation 4. Intervention 5. Rehabilitation 6. Management How can I give myself the best chances? How am I? What does this mean? What are my options? How can I get to the best I can be? Making the most of my life?

The LTC Year of Care Funding Model

The LTC Year of Care Funding Model Team A Team B Team C Team D? Integrated neighbourhood Care Team Primary drivers Systematic risk profiling of population Integrated locality care teams including social