Health Policy in 2018: The President s Guest Lecture: Oxford Orthopaedic Trauma Research Improving Quality in Emergency Care in the NHS by use of Economic Incentives Keith Willett Professor of Orthopaedic Trauma Surgery Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford Medical Director for Acute Care And Emergency Preparedness NHS England
Demographics 64.9m Total population (millions of people) 5.2m 17.4% Percentage of population over 65 years of age 15.8% Health System Statistics $ 4,094 Health care spending per capita $ 6,432 $ 586 Out-of-pocket health care spending per capita $ 882 $ 11,663 Hospital spending per discharge $ 13,923 2.8 Number of practicing physicians per 1,000 population 4.4
Oxford State Orthopaedic Taxation/Insurance Trauma Research funding model: Group UK and Norway (tax) both 9.3 9.9% GDP Australia, New Zealand, Canada (insurance) Payer government or government managed body Some out-of-pocket and private cover NHS user charges (prescriptions, dental treatment) 1.2% UK private health insurance coverage 10.6% FOR: Equitable, efficient, strong incentives to control cost by government or regulators AGAINST: Pressure on public funding as costs rise, politicized
How the government funding and performance model works in the English National Health Service Oxford Orthopaedic Trauma Research Group National Clinical Audits HQIP Financial and Performance Regulator NHS Improvement National Clinical Standards NICE National Performance Standards NHS England Locally (GP) or nationally Commissioned CCG Services Medicines and Devices Procurement NHS England National Research Programmes NIHR Quality Regulator CQC Nationally mandated: Payment by results Activity National Access Standards Evidence-based interventions ** Quality premiums Best practice tariff QOF (GPs) Improvement incentives CQUINs Pathways of Care Bundle payments Cost-effective Value based medicine
Over the age of 75, half of patients have 3 or more medical co-morbidities
Medicine is increasingly about complex and multiple interventions in chronically sick and often elderly patients with marginal improvement R Smith BMJ
Age Heath Cost Curve 7
NHS financial reality - 30bn GAP by 2022 Funding b 135 130 125 120 115 110 105 100 95 90 85 Historical Funding pressures on the NHS in England (~4%) Real terms freeze through 2014/15 followed by increase with real GDP (2.4%) Real terms freeze 2010/11 11/12 12/13 13/14 14/15 15/16 Five Year Forward View - how to innovate? 16/17 17/18 18/19 19/20 20/21 30bn 44bn 2021/22 SOURCE: Nuffield Trust: The funding pressures facing the NHS from 2010/11 to 2021/22: A decade of austerity? McKinsey & Company 8
NHS - defining and designing for QUALITY QUALITY: clinical effectiveness, patient safety, experience of patients Bring clarity to quality Measure quality Publish quality Reward quality Leadership for quality Innovate for quality Safeguard quality Compelling evidence that it is possible to change professional behaviour to improve quality of care, reduce cost.. for better VALUE
Health systems are like an amoeba
Bring clarity to quality First, identify the key interventions in the care pathway that will really improve care and outcomes
Changing practice for quality improvement in healthcare at scale Review of all current evidence and guidelines Multiprofessional clinical and patient/public consensus group key impact interventions Measurable commissionable aligned payments Activity data from registries and Hospital cost-effective government NICE standards health economics operational delivery workforce 13
Measure quality Secondly, agree the metrics by which care can be appropriately judged by patients and all clinicians NHS Hospital Episode/Activity Statistics data do not measure quality
Clinical Databases and Registries
Hip Fracture - agreed best practice metrics Time to surgery (<36 hours) 1. Arrival in Emergency Dept (or diagnosis if an inpatient) to start of anaesthesia Involvement of the multi-professional team: 2. Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon 3. Admitted using an assessment protocol agreed by geriatrics medicine, orthopaedic surgery and anaesthesiology 4. Assessed by a Geriatrician in the perioperative period Consultant or senior resident within 72 hours of admission 5. Postoperative Geriatrician-directed: 1. Multiprofessional rehabilitation team 2. Fracture prevention assessments (falls risk and bone health) 6. Dementia Assessment: Mental test score at admission and prior to discharge by nurses
Publish quality National Clinical Audit / Registry
Reward quality Thirdly incentivise the clinical behaviour and patient flow changes in the care pathway money follows the right patient care..
For hip fracture how the tariff works Payment per patient Tariff price Original base tariff Best practice tariff structure Base tariff for each HRG Additional payment for best practice Reduction in base tariff for current compliance rate 2-part tariff for best practice (4450 8900 NOK) 13350 of 68000 NOK Base tariff set below national average cost Sum of base tariff and BPT higher than national average cost 19
100% Improvement in Hip Fracture Care 2010-2014 Best Practice Tariff: percentage attained for each criteria; all criteria 24 to 64% national experiment on >250,000 patients 16 quarter-on-quarter improvement Admitted under joint geriatric/anaesthetic protocol increased from 64 to 97%; Surgery within 48 hours rising from 65 to 77% in 36 hours, to 87% in 48hrs; Seen acutely by a Geriatrician up from 48 to 90%; bone health assessment up 72 to 97%
Improved hospital productivity and resource use in bed-days days 28 26 24 25.9 Bed days saved: 354,000 per year Overall total spend fell from 320m to 315m 22 20 18 21.2 19.8 2009-10 2010-11 2011-12 2012-13 2013-14 year
Too difficult to solve for 25 years.... MAJOR TRAUMA MAJOR TRAUMA Life threatening or life-changing serious physical injury often multiple Typified by delay, inappropriate care, avoidable death and disability 22
Patients to MTC ISS 9+ 76% of all ISS 16+ Patients 15,000 10,000 5,000 Direct to MTC 17,808 Transfer to MTC 8,578 13,360 26,490 2011 2012 2013 Year 2014 2015 2016
25% increase in odds of survival MAJOR TRAUMA NETWORKS INTRODUCED
-10-5 0 5 10 Before Major Trauma Centre Designation University teaching hospitals before designation as a Major Trauma Centres.5 1 1.5 2 2.5 precision (1/seWs) Ws +2SD -3SD -2SD target +3SD
University teaching hospitals after designation as a Major Trauma Centres After Major Trauma Designation -10-5 0 5 10 21326 pts, 47% ISS >15 0.5 1 1.5 2 2.5 precision (1/seWs) Ws +2SD -3SD -2SD target +3SD
Innovate for quality Safeguard quality Continuous assurance, reappraisal, comparison and sharing. public reporting and peer review
What the hospital, public and commissioners can see Evidence Based Measures Other Hospitals Your Hospital Run Chart Your Hospital performance over 8 quarters Bullet Chart Your Hospital compared to national average
Network Pre-hospital Reception/resus Definitive care Rehab Measures Measures Measures Measures Measures
Cost-effectiveness Regional Trauma Networks are cost effective at the current NICE threshold of 20,000 with close to 100% probability of being cost-effective with a cost per QALY of approximately 5,500 University of Sheffield 2015
The role of Best practicetariff incentives:
Key Performance Indicator focussed reimbursement in NHS Incentive Payments and options: Differing views on whether the payment system should lead innovation by creating new financial incentives or, if it should enable innovation and, over time, incentivise the adoption of proven models of care Alzira What does success look like? Gesundes Kinzigtal Tower Hamlets Diabetes Veterans Health Association
KPI focussed reimbursement in the NHS Incentive Payments and options: CONTRACTS and SANCTIONS Embed Clinical Standards in National or Local Contracts - broad provision issues : 7-day service provision and safety events Cl Difficile, MRSA INCENTIVE PAYMENTS What does success look like? CQUINs national and local top slicing of total contract value for hospital providers for a few key transformation/improvement items drive specific service change implementation - innovate to set new levels of ambition - VTE prevention Best Practice Tariffs - directly focussed on clinical-led pathway improvement or transformation Quality Premium similar but applied to commissioners allocations (GPs-CCGs) - reducing avoidable admissions to hospital ACSC Quality Outcomes Framework (QOF) accumulate points for elements of care in General Practice - health promotion and prevention hypertension checks, diabetes
Quality of life EQ-5D measure: (mobility, self care, usual activities, pain, anxiety and depression) percentage of improvement or worsening health by procedure groin hernia hip replacement knee replacement varicose veins
Proposed new payment model A coordinated and consistent payment approach across all parts of urgent care pathways Making use of three elements: Capacity - Core Fixed in-year cost always on Volume variable - categorical future-proofed towards outcome based acting throughout payment Core Quality Facilities and service standards national contract Volume - Process measures formative not summative Incentives and Sanctions - Patient outcome measures (ToC, PROMs) Patient safety and experience measures (mortality, SAEs, PREMs) 35
The English NHS is moving to Integrated Care Systems Alliance model Prime Provider model Umbrella alliance agreement, not a commissioning contract Documents agreed outcomes, governance, decision-making process Documents agreed shared payment and incentive regime Fosters collaboration: shared leadership, responsibility, accountability Time-consuming and costly to implement Single commissioning contract with one provider for delivery of whole UEC package That prime or lead provider subcontracts some or all elements of UEC services to other providers Prime/lead could be one of the providers, or a corporate vehicle established by the providers for that purpose
We need to move healthcare systems from summative assessment.. (based on performance and fiscal targets) to clinically credible and formative assessment and for whole pathways of care across health and social care economies
Leadership for quality The role of management is to create a culture and reward system that guides thousands of decisions in the direction of better quality and service at reduced cost A Enthoven
Service specifications Payment systems Payer risk Operational risk Provider risk Clinical risk Professional standards Quality assurance
Leadership is the capacity to turn vision into reality LESSON 1 Clinical teams in a universal healthcare system can be trusted to design and commission best practice and best value services and select the measures by which their services should be fairly judged Warren Bennis
Leadership is the capacity to turn vision into reality LESSON 2 Linking payment for performance and public reporting through a national registry is key and ensures government buy-in We must not be naïve
Bring clarity to quality Measure quality Publish quality Reward quality Leadership for quality Innovate for quality Safeguard quality