Using outcomes to transform health and social care systems. Dr Nicholas Hicks FRCP FRCGP FFPH Co-founder and Chief Executive, COBIC

Transcription

1 Using outcomes to transform health and social care systems Dr Nicholas Hicks FRCP FRCGP FFPH Co-founder and Chief Executive, COBIC

2 What is an outcome? The results people care about most including functional improvement and the ability to live normal, productive lives International Consortium for Health Outcome Measurement, 2013

3 Core premise System goal = maximising value value = net benefits (outcomes) achieved /

4 Systems approach: the COBIC triangle Led by commissioners Incentive reform Led by providers Infrastructure reform Individual and population outcomes Driven by patients & carers Service delivery reform Led by professions 4

5 Design principles System goal = maximise value ( outcomes / ) Define value by reference to users ie outcomes that matter most to people Measure outcomes and costs with trasparency Align incentives with system goals ie providers paid accountable for relevant outcomes Organise care around users over full cycle of care eg frailty service

6 Systems approach: the COBIC triangle Led by commissioners Incentive reform Led by providers Infrastructure reform Individual and population outcomes Driven by patients & carers Service delivery reform Led by professions 6

7 Framework purpose Articulate and legitimise system purpose Source of indicators Incentivised Transparent monitoring and dissemination 7

8 Adapted from Constructive Comfort: accelerating change in the NHS. Health Foundation, 2015 Outcomes frameworks are enablers Levers for large scale change: Outcomes framework inspires Type 2: Proactive support Relies on building intrinsic motivation in staff to make the right change to improve Type 1: Prod mechanisms Targets Performance mgt Price & payment incentives Regulation Competition Type 3: People focused Education & training National employment contracts Professional regulation Clinical quality standards Less than 10% of potential for improvement can be delivered through Type 1 change, but the influence of the outcomes framework should extend beyond contract and payment mechanisms Outcomes framework requires

9 Outcome framework terminology Outcome theme Outcome theme Outcome domain Outcome domain Outcome domain Outcome Outcome Outcome Outcome Outcome Outcome Indicator / tool Indicator / tool Indicator / tool Indicator / tool Indicator / tool Indicator / tool Indicator / tool 9

10 Dudley: candidate outcome themes Access, continuity & coordination Empowering People and Communities Population Health Outcomes Framework System and staff 10

11 Dudley: candidate outcome themes and domains Population Health Access, Continuity and Coordination Empowering people and communities System and staff Length of life Experience of relationship with staff Activation Financial sustainablility Quality of life Inequality Health related behaviours Prevention and risk reduction People have timely, convenient access to relevant services Experience of coordination of care Experience of continuity of care Shared decision making Public involvement in service design Staff recruitment, retention and motivation National safety and other clinical quality standards 11

12 Population Health Theme 1: Example domains and Length of life Quality of life outcomes Healthy life expectancy PHOF 0.1i Mortality amenable to health care (NHSOF 1.ai and 1.aii) Disease specific mortality (eg cancer, cardiovascular, suicide, respiratory) EQ5-D or Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) Healthy life expectancy Inequality and fairness Health related quality of life of carers/carer reporte qualtiy of life (NHS OF 2.4/ ASCOF 1D) Slope index of inequality in life expectancy PHOF 0.2 Tooth decay in children aged 5 PHOF 4.02 Healthy lives Prevention and risk reduction Smoking Excess weight in adults/ children PHOF 2.06/ 2.12 Physical activity Alcohol Immunisation Care plan in place (CHS OF) Improving experience of integrated care ASCOF 3E 12

13 Phasing 120 Phasing of indicators for outcomes incentivisation Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Population Health Access, continuity and coordination Empowering people and communities 13

14 Population Access, Continuity & Coordination People & Communities System & Staff

15 Dudley MCP Outcomes Context The following slides describe the development of the Dudley MCP Outcomes Framework and the Local Incentive Payment Scheme. This is the current Dudley proposal. This development has been overseen by the Dudley MCP Project Team and the Dudley MCP Project Board. The Head of Implementation from the national MCP Intensive Support, New care Models Team is a member of the Dudley MCP Project Team. Therefore there has been an iterative process of feeding ideas and developments into the NCM national team and having these critiqued against current national thinking and policy development. However, the Dudley proposal as presented here should not be viewed as national policy, or as a nationally authorised position. There are two key checks and balances going forward that may, and more likely will require (to a lesser or greater extent) modification to the currently proposed Dudley MCP Performance Framework and the Local Incentive Payment Scheme : The Gateway Assurance Process. Checkpoint 1 for the Dudley MCP is in February The Competitive Dialogue with Bidders within the Procurement process. 1

16 Development of the Outcomes Drawing on experience from elsewhere literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate Kaiser Permanente (USA) Capitation via multispecialty medical practice with focus on risk stratification, prevention and self-management, use of technology and population data. Also supports wider pop health through healthy eating programmes in schools. Between 2002 and 2005 in Northern California: Reduced smoking prevalence by 25% (c.f. 7.5% in California as a whole). Reduced heart disease mortality by 26% from 1995 to 2004; members 30% less likely to die from other Californians in Gesundes Kinzigtal Integrated Care, (Germany) 30,000 people in Kinzigtal. Non disease specific, population based integrated care across all health service sectors in the local region. Reduction in morbidity and mortality compared to comparator regions. 3

17 Development of the Outcomes ing available metrics literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate Dudley CCG utilised SSentif a digital data hub delivering benchmarking and performance analysis. This online environment gives access to all nationally published data in one place including CCG, Emergency Services, HES Inpatient Data, Hospital Trust Data, Local Authority Data, Mental Health Trust, and NHS Wide Data: all benchmarkable by type of organisation, ONS Group, organisation size e.g. Medium sized secondary care trusts. We assessed variability, reliability and amenability of these metrics 4

18 Development of the Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate Public Consultation What did the Dudley Public want to see change or improve? Series of events Dedicated sessions with the public on the principle outcomes they would like to see. We received a great number of responses from these sessions and almost without exception these responses fell into 3 main categories. Improvement in Access to Care Improvement in the Continuity of Care for all but especially those with a Long Term Condition Improvement in the Coordination of Care for all but especially the frail elderly 5

19 Development of the Outcomes Socialisation of the Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate 6

20 Development of the Outcomes Socialisation of the Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate 7

21 Development of the Outcomes Socialisation of the Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate 8

22 Dudley MCP Outcomes Framework - Population Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate Example Outcome Metrics 9

23 Dudley MCP Outcomes Framework - Population Outcomes literature and draw experience from elsewhere engagement with public and system comments and feedback Consolidate 10

24 Incentive Scheme Principles The incentivised items within the local Dudley MCP Outcomes Framework will feed into the IPS (see diagram above) and will be allocated a top sliced 7.5% of the total MCP Contract value. 11

25 Incentive Scheme Principles Contractually the scheme will be housed within the Particulars: Schedule Incentive Scheme. Proposed that the scheme will be top sliced 10% of the Contract Value. Financial risk ameliorated through target setting approach Apportionment of the 10% incentive across the Outcome Framework themes will change over the course of the MCP Contract. Phasing of incentive reward across 15 years shown as a percentage 11

26 Dudley MCP Incentive Payment Scheme Example Average RTT Ophthalmology Currently the average wait in weeks is 5.96 and a statistically significant reduction would be 1.69 weeks, giving a target of 4.27 weeks. By using the historic monthly data, Monte Carlo simulations yield the likelihood of achievement going forward. This is illustrated in the diagram below which shows there is a 90% likelihood of achieving 7.65 weeks, therefore 90% of the IPS reward has been allocated to the achievement of this figure. If the MCP achieve the current wait performance of 5.96 weeks the MCP will receive 95% of the available reward for this goal. By calibrating the IPS reward as follows: 80% to 90% for achievements between 8.99 weeks and 7.65 weeks 90% to 95% for achievements between 7.66 weeks and 5.96 weeks 95% to 100% for achievements between 5.97 weeks and 4.27weeks 95% of values will fall below this level 12

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