NHS RightCare - Tools and techniques

Technique Don t mention the money! Talk about variation & value, quality & outcomes, the patient and the population Deal with these and will deliver the money 2

3 Technique Use Variation to Focus Attention

The NHS Atlases of Variation Reducing unwarranted variation to increase value and improve quality Awareness is the first step towards value If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place

Advanced Paramedic Practitioner - Blackpool & Fylde Proactive targeting of top 50 frequent callers and attenders Bespoke care and support package developed with patient Drives integrated care NHS, Social Care, Police, Education all engaged Outlay 1 Advanced Paramedic Practitioner Saving - 2.2m FYE across 2 CCGs (300k popn) Next steps frequent callers 51-100 & new Hospital Liaison Worker to support #

# Technique Use Variation to destabilise complacency

2015 - CVD Focus Pack headlines 1. Enhance/ redesign/ manage prevention and primary care system to optimise Prevention (11,100 more with low activity levels, 1,300 more eating unhealthily) Detection (600 fewer Stroke patients on registers) Systemise care planning and self/ case management (1,100 fewer >40yr old patients with BP record, 650 fewer with <75yr old hypertension patients with brief intervention) Local referrals triage and pathway navigation 2. Specify whole service and thresholds, with particular attention on Admission rates (CVD 840 more, CHD 300, HF 140) Procedure rates (Angioplasty 70 more, CABG 30) 3. Specify robust discharge thresholds and protocols, in particular to manage LOS (CVD 800 more beddays, CHD 550, Angiography 650, Angioplasty 200, CABG 200. Total = 2,400 days or 6 beds) Rehabilitation services (130 fewer stroke patients discharged to usual place of residence) 7

Tool - Prioritisation to support delivery Most health economies try to do too much NHS RightCare supports need to prioritise using principles, tools and subprocesses, e.g: Variation Decision Trees Phasing Phasing to manage sustainability e.g. net-savers first, critical path, etc. Supported by Decision Trees (used to decide projects and order of delivery) - Locally determined criteria (i.e. what matters to you?); - Deal-breakers; - Prioritisers, and; - Mandate use. #

Ideas & Cases Decision Tree for prioritising reform proposals High Priority RoI* > 250k Are there any health benefits? Yes Is it a must do? No Does it save money? Yes No No Yes* Yes Do not proceed No Does it increase value*? Rate of Return <12 months Rate of Return >12 months Prioritise Medium Priority RoI* > 100k Low Priority RoI* < 100k High Priority RoI* > 500k Medium Priority RoI* > 250k Low Priority RoI* < 250k Set Timetable for completion of case outline* Can it be delivered? Yes No Yes Can it be made deliverable? No Do not proceed *See additional slides at end

Technique - Decision Tree Design Workshop Key Steps: 1. Agree criteria; 2. Categorise criteria in to 'deal-breakers' and 'prioritisers 3. Place deal breakers at the front of the decision tree and prioritisers at the end. 4. Mandate use to drive optimal improvement 10

Canterbury DT workshop Deal-breakers Does it (the change idea) improve or maintain health outcomes? If no, is it a candidate for restrictive protocols in the context of finite resource and currently unsustainable services? Will it deliver a net saving? Is there (likely to be) evidence of impact? Prioritisers Is it fast AND easy to implement? If not, is it fast OR easy? How quickly does it save money (rate of return)? How much does it save (return on investment)? 11

Canterbury & Coastal CCG Draft 1 Idea Does it improve or maintain health outcomes? YES Is there a net saving? YES Evidence of impact? YES Fast AND easy? NO Fast? NO Easy? NO NO NO NO YES YES YES Case for clinical policy? Add 25K to thresholds NO YES Rate of return: NOW Rate of return: 0-2 years Rate of return: > 2 years Do not proceed Do not proceed Develop clinical policy Do not proceed Analyse/ do not proceed > 75K > 125K > 175K High priority > 40K > 75K > 100K Medium priority < 25K < 50K < 75K Low priority: DNP

Technique use what you already have: Service Specifications in the Contract Technical Guidance Para.25 Service specifications Para.25.1 The service specifications are one of the most important parts of the contract, as they describe the services being commissioned and can, therefore, be used to hold the provider to account for the delivery of the services, as specified. 13

SPECIFIED CONTRACTS Clauses from the National Contract 2014/15: SC7.2 "The provider may reject a referral on the grounds: SC7.2.1 Of any service limitations in the service specifications" 14

Tool specs, guidelines and filters VoY CCG adopted RC in 2013 to deliver 11m QIPP and shift balance of power from provider to commissioner Used approach to focus on circulation, neurology, cancer and system management improvements: Have specified 136 new clinical guidelines Implemented referrals triage and support service Impact includes 17% reduction in reviewed OP referrals (now expanding system to optimise impact) 15

Tool - Assumption-based Impact Assessment Case Management Example Central Manchester The average number of admissions for the type of patient affected by this project is 2.16 per year, at a length of stay of 16.7 per admission. The caseload for the new proposed advanced practitioners will be 700. With a projected 6% avoidance of admissions this leads to the forecast of 4 beds saved (2.16 admissions * 16.7 bed days * 700 caseloads * 6% / 365 days = 4.2 beds). 16

Steps for Assumption-based Impact Assessment 1. Clinical leads and commissioning managers carried out an audit of the identified type of patient the reform is intended to case manage. The admissions trend for these patients was then analysed. This analysis highlighted that the average number of admissions per relevant patient was 2.16 and that the average length of stay for each admission was 16.7 days. 2. The likely caseload for the 14 advanced practitioners that the reform would employ was agreed by staff already working in similar fields to be 50 patients each. Therefore the overall caseload would be 700. 3. Evidence from elsewhere, where active case management already existed, showed that 6% of relevant admissions are avoidable. Hence: 2.16 * 16.7 * 700 * 0.06 = 1,515. 17

Steps for Assumption-based Impact Assessment 5. 1,515 bed days = 4 beds per annum (1,515 / 365). 6. Clinical leads from both the commissioner and the provider then agreed the types of spells that the caseload patients would likely be admitted to. This was informed by the actual spells from the audit of known relevant patients but was also added to via discussion between the primary and secondary care clinicians. 7. The average cost of the identified spells, plus the cost of the required number of excess bed days to bring the total length of stay to the identified average of 16.7, was then calculated on this basis. 18

Steps for Assumption-based Impact Assessment 8. The results supplied the provider with the necessary information to assess the costs it no longer needed to incur (spells avoided and beds no longer required) and the commissioner and the provider with the level of funds that would cease to flow. 9. The commissioner was then able to set the assumed level of avoided expenditure against the projected costs of the new service to establish its net cost/ saving. 10. This information was used to inform decision makers and allowed them to make a robust decision. 19

20 Tool - Referrals Audit Impact Assessment

Steps to Referrals Audit Impact Assessment 1. Model the current and future pathways. 2. Draw up protocols for each referral stage in the future service. 3. Carry out a clinical audit and map the actual pathways of the audited patient journeys, from GP referral to final pathway discharge. 4. Map what will happen to the same cohort of patients under the new pathways and protocols. 5. Use the results of 4. to determine the resources required within the new pathways. 6. Cost the resources required within the new pathways. 21

Steps to Referrals Audit Impact Assessment 7. Use the variation between 3. and 4. to assess the physical resources and costs from the primary and community care services that are saved under the new pathways, or that can transfer to it. 8. Use the variation between 3. and 4. to assess the physical resources and costs from the non-pbr elements of the secondary care service that are saved under the new pathway, or that can transfer to it. 9. Use the variation between 3. and 4. to assess the cost of Payment by Results activity avoided. 10. Collate the net costs of the new service. 22

Pathways Audit Assessment Financial Impact Case Study West Cheshire Clinical Commissioning Group Shared Decision Making Business Case Financial Impact Summary Knee Replacement Hip Replacement Prostatectomy Transurethral resection prostate Mastectomy Current procedures 367 345 21 118 104 per annum PbR Tariff (11/12) 5224 5227 4604 2030 2385 Total Cost 1,917,208 1,803,315 96,684 239,540 248,040 Saving (5% 95,860 90,165 4834 11,977 12,402 reduction) Saving (10% 191,720 180,331 9,668 23,954 24,804 reduction) Saving (15% reduction) 287,581 270,497 14,502 35,931 37,206 23

24 Tool - Patient Decision Aids

Decision Aids reduce rates of discretionary surgery RR=0.76 (0.6, 0.9) O Connor et al., Cochrane Library, 2009 25

Cochrane review update 2014 115 studies across 6 countries (>34,000 participants) Found good evidence that PDAs Increase patient knowledge Improve accuracy of patient expectations Improve communication between patient and practitioner Reduce volume of elective surgery DO NOT worsen health outcomes 26

Patient Decision Aids 36 NHS PDAs available sdm.rightcare.nhs.uk Including; Stable angina Stroke prevention High cholesterol Smoking cessation Some sit in primary care, some in secondary care There are dozens more internationally 27

Patient Decision Aids Implementation Process 1. Identify best PDAs for local impact Use DD, CfV, AoV, PLCV, local enthusiasm, etc 2. Localise with local GP lead and add referrals criteria and protocols C. 50% of unwarranted activity dealt with by PDAs, 50% by protocols 3. Implement in key practices and prove impact 4. Spread across practices 5. Implement more PDAs (in phases or collectively) Optional (innovative): 6. Design own, use and spread 28

2014/15 National Contract SC10.1 "The Provider must employ Shared Decision-making in planning and reviewing the care or treatment which a Service User receives Contract Definitions Shared Decision Making: The process of discussing options and the risks and benefits of various actions and courses of care or treatment based on the needs, goals and personal circumstances of the Service User, with a Service User A range of tools are available to support this, including Patient Decision Aids. 29

# Technique Deep Dive Service Review

Service Review Pathway Diagnostic steps Step 1 define: Step 2 define: Step 3 categorise: Step 4 recommend: Fit Fit for for Purpose Maintain CURRENT SERVICE Efficiency and and market options Supply and and capacity options Redesign, Contract, Procure Contract, Procure, Divest FUTURE OPTIMAL SERVICE No/ low benefit Divest 31

CfV pack to delivery in 7 months Hardwick CCG Now implementing Agreed and specified COPD pathway Enhanced nebulisers service in primary care Primary care COPD audit and support service to implement findings practice by practice Improved promotion of self-management Improved self-management support Enhanced organisation of Breathe Easy Groups (with British Lung Foundation) Delivered (so far only just begun) 30% reduction in emergency admissions 2 per capita saving (from initial impact much more to come) 32

# Technique Show the Art of the Possible

Where Bradford are now (and where West Cheshire were) 34

Where West Cheshire are now (and where Bradford could be) 35

Heart disease pathway = 95% confidence intervals Initial contact to end of treatment NHS Bradford City CCG

Heart disease pathway = 95% confidence intervals Initial contact to end of treatment NHS North Kirklees CCG

Technique - Storytelling Paul s Story version 1 Paul: 45, bricklayer, local employer Smokes 10/day, drinks 4 pints/day, overweight Council house, supports Leeds United Wendy: David: GP: Village shop: 42, barmaid 16, schoolboy small practice, 17 miles from DGH limited food options 39

Paul s journey starts when.. Prompted by Wendy, sees his GP 2 years of increased urinary frequency and loss of energy GP performs tests and confirms diabetes Initial management with diet, exercise, pills 6 visits per year to practice nurse 6 lab tests per year GP has lower than average prescribing and referral rates seen as economical 40

Paul is now 50 Not smoking but still drinking and has not lost weight; recreation is watching football and pub Has been on insulin for a year Left leg hurts (vascular problem) Not walking far, not driving, missing work Referred to hospital diabetes service and vascular surgeon OPD at hospital Wendy drives him David is at university 41

Paul is now 52 Leg suddenly goes white and painful; amputated below knee Significant heart and renal complications Vision deteriorating Loses his job with little chance of retraining Applies for more suitable housing Wendy gives up job David takes a year off university 42

The Impact (Economic and Social) Journey 1 Journey 1 (less than perfect) Paul 45 Paul 50 Paul 52 Pre Primary Care Review Phase 1 Activity & Treatment Phase 2 Activity & Treatment Phase 3 Activity & Treatment Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Yr 9 Yr 10 Yr 11 Economic Costs 1,360 576 576 576 576 1,762 1,953 8,948 32,757 49,084 Increased urinary frequency Excessive drinking (reduced) Excessive drinking Excessive drinking Excessive drinking Personal & Emotional Costs Issues around Thirst Excessively Tired Excessive drinking Obese (but improved) Smoking (reduced) Obese Obese Left leg pain Missing work days Obese Left leg white & very painful (then amputated) Loses job Obese Stopped exercising Cant exercise Smoking Stopped driving Wendy taking half days off to drive to treatments / Economic situation of the family becoming tough Cant drive Wendy taking more time off as carer Economic situation of the family is now extreme Paul's quality of life now very poor Both Paul & Wendy depressed David takes time out of University to assist the family Council contacted alternative housing rent not affordable Forced to sell car so Wendy also less mobile 43

Paul s story: What the CCG have done Commissioning for Value CCG have used CfV pack, identified Diabetes as a key improvement priority Worked with AT and neighbouring CCGs to ensure wider system improvement (whilst not allowing this to slow progress for their own population) Engaged the right people, conducted a deep dive and service review, identified what needed to change, built the case, took the decisions and implemented the change What does the next Paul s journey look like now? 44

Paul s story - Journey 2 NHS Health Check identifies Paul s condition at the end of year 1 Case management begins Use of specialist clinics for advice on diet and exercise (10x cost of GP advice) and this repeated every 2 years Care Plan / Medication / Retinopathy Screening brought forward 18 months compared to Journey 1 Self Management Desmond Programme Diabetes Patient Support Group set up locally 45

The Impact (Economic and Social) J2 Journey 2 (Improved Pathway Revised Focus) Pre Primary Phase 1 Activity & Treatment Phase 2 Activity & Treatment Phase 3 Activity & Treatment Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Yr 9 Yr 10 Yr 11 Economic Costs 23 1,153 607 958 587 958 710 1,084 736 1,210 909 8,936 Increased urinary frequency Issues around Thirst Excessive drinking (reduced) Obese (but improved) Support working Eating well, Exercising, & Drinking Controlled. Keeping work and social life healthy, no depression, no serious interventions: Excessively Personal & Tired Emotional Costs Excessive drinking Obese Smoking (reduced) focus is on Support, Education & Medication. Initial pathway = sub-optimal quality, cost 49k, low value Post-improvement = optimal quality, cost 9k, high value Smoking 46

Respiratory Care in Warrington Health Economy 2010/11 1.5M Overspending V. demographic peers Only 2/3s of asthmatics known Worst quintiles COPD rate of em admns, deaths within 30 days, %age receiving NIV, re-admns 2012/13 0.6M UNDER spending V. demographic peers Delivered by focus on variation problems fixed or improving (e.g. 30% less COPD NEL admissions, MDT, 70+ p.m. triaged away from acute sector) HSJ Commissioner of the Year 47

48 Tool Engagement AID

Engagement AID in Wigan The NHS RightCare Process Phase 1 RESEARCH Identify Variation (Triangulate) Research Guidance & Toolkits, Best Practice, Service Specifications & Case Studies to improve variation Align research with variation & share with stakeholders Phase 2 ENGAGEMENT Run engagement event: Split into (x-section) groups & rotate around subject areas Facilitator explains variation & showcases research Group challenge (AID) Adopt, Improve or Defend Phase 3 DELIVERY Agree long-list (from Phase 2) Prioritise via decision tree Deliver through business process/ contract management / programme approach 49

Engagement AID in Wigan: The engagement event produced 200 possible actions. This number was prioritised down to a manageable number and made up the bulk of the 2013/14 improvement programme Each prioritised reform was overseen by a project manager and a lead clinician The financial impact of the whole played a significant part in the CCG s 18m savings plan Each reform improved healthcare Increased Clinical Engagement 4-fold 50

The best tool and techniques of all? Employing a systemised methodology, underpinned by a robust and effective business process, that drives the entire improvement agenda, utilising all of the best tools and techniques at the right time, in the right way and with the right people 51

1key objective + 3key phases + 5key ingredients = COMMISSIONING FOR VALUE OBJECTIVE - Maximise Value (individual and population) Five Key Ingredients: 1. Clinical Leadership 2. Indicative Data 3. Clinical Engagement 4. Evidential Data 5. Effective processes 52

Service Reviews NHS RIGHTCARE HEALTHCARE REFORM PROCESS Contracts Clinical Policy Development and Decommissioning GP Member Practices Public Engagement Partners and Stakeholders Miscellaneous (e.g. Commissioning Annual Plan) Research Reform Ideas Ideas Decision Group Reform Proposals Case Outlines Clinical Executive Group Mechanism Decision Process Implementation Full Business Case Governing Body Procurement Primary Care Development 53

So much more www.rightcare.nhs.uk And remember Don t mention the money! 54