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2
Inconvenient truths – Diabetes and The Atlas
Opportunity Locator Tool
• 5 Diabetes maps in Atlas 2015 have confidence
intervals
• Of the 211 CCGs (at time of data capture):
13 CCGs are not significant outliers on any of the
diabetes maps
• Or rather:
198 CCGs and their local providers have at least
one significant improvement opportunity in
Diabetes
‹#›
What is NHS RightCare?
RightCare is a methodological approach to improvement that provides
commissioners with:
• a robust starting point - indicative data
• a means of engaging all stakeholders and galvanising focussed
clinical leadership
• a step-by-step business process for building the case for change
with clear prioritisation and decision making techniques
• clinical pathway redesign tools that enhance implementation
capability
• improved health outcomes, value and financial sustainability
5
So, where is the Point of Optimal Value?
Necessary appropriate inappropriate futile
High Low Zero Negative
BENEFIT
HARM
ResourcesCLINICAL
ECONOMIC
VALUE
The 1st principle ofCommissioning for Value
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
9
Generics of improving population healthcare
M a x i m i s e V a l u eObjective
Principles
Get everyone
talking about
same stuff
Talk
about fix
and future
Demonstrate
viability
Isolate
reasons for
non-delivery
Phases Where to Look What to Change How to Change
Ingredients
C l i n i c a l l e a d e r s h i p
I nd i ca t ive Da t a
Effec t i ve I mpr ovemen t P r oce s se s
Ev i den t i a l Da t a
C l i n i c a l E n g a g e m e n t
10
Vale of York
• Adopted RC
• Used approach to focus on circulation, neurology,
cancer and system management improvements:
• Locally specified 136 new clinical guidelines
• Reduced referrals by 17% in targeted specialties
11
Practice Level Risk Management - Primary Care
• Risk Stratification in Wigan – led to 6,000 new active
care plans and reduced urgent care
12
Helps health economies to tick lots of boxes within
same effort – Blackpool & Fylde CCGs
Advanced paramedic project significantly reduced
frequent calling and delivered -
• Quick win (98% reduction in targeted 999s)
• Parity of Esteem & patient empowerment
• Integrated Care/ multi-agency working
• Care planning & Long Term Conditions
management & care closer to home
• Demand management
• Reduced pressure on urgent care
• Immediate significant saving (£2.2m)
• Further improvement & saving (now £2.7m)
Tools, techniques and benefits
NHS Bradford City CCG
Heart disease pathway of a page – Why Bradford chose CVD
= 95% confidence intervals
Initial contact to end of treatment
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Bradford Healthy Hearts
• Variation - 7th worst mortality rate for CVD <75years old
• 28% of all deaths amongst <75 year olds
• Programme overview - Statin Switches, Hypertension, Stroke
prevention
• Over 6000 on simvastatin with total cholesterol >4 mmol/l or LDL
>2 mmol/l (no direct comparison of simvastatin vs atorvastatin)
• Converted to only two doses of statin (40mg and 80mg
atorvastatin) as per ACC guide (greater benefits since NNT=62
for moderate/high intensity cholesterol management vs. NNT=156
for low intensity)
• Switched 6,000 patients (completed in 3 months)
• Improved mortality – including 60 less deaths last year (pye)
15
Slough CCG – Complex Case Management
• Examined causes of non-elective admissions, A&E attends and costs.
• Identified unique cohorts of patients as highest risk of emergency
admission:
CHF & CRF
CHF & COPD
Diabetes, CHF & CRF
Diabetes, IHD & CRF
• Commissioned additional regular primary care contacts for at risk
population and, via system-wide MDTs, developed care plans with the
patient
• 28% reduction in targeted non-elective admissions (34% reduction in
spend)
• 28% reduction in targeted A&E attends (31% reduction in spend)
• £500k saving across CCG
• Now being spread across East Berkshire CCGs and wider STP footprint
Tools, techniques and benefits
16
Collective design of treatment guidelines
Ashford CCG
• Variation highlighted MSK referral rates
• Designed and developed local protocols
• Designed and implemented local triage
• Reduced referrals by 30+%!!!
18
Closing the perception gap – a cause of variation
• The perception gap pervades the NHS and drives low value, expensive,
unwarranted decisions
• 70% of breast surgeons believe a primary concern of women with breast
cancer is to keep their breast
o The real number is 7% of informed women
• 95% of people with elective stents think they reduce risk of heart attack
o They don’t (most informed people don’t want one)
• 98% of uninformed men want prostate screening
o Fewer than half of informed men do
• 5x more doctors think patients are the biggest barrier to Shared Decision
Making (SDM) than think medics are
o Cochrane found effective SDM is “physician, not patient, dependent”
• Achieved by understanding patient preference via, e.g: Patient-centred
care; SDM - PDAs; self-management/ care-planning; Cooling-off periods
19
Bedfordshire MSK – Outcomes-based system
• Locally designed protocols, locally led triage
• 1 in 5 initial referrals changed
• Shared Decision Making (closing the perception gap)
• 35% of patients change direction of initial referral
• Leading to a shift towards community-based care -
% of Activity within Secondary Care*
% of Activity within Community**
68%
32%
2012
64%
36%
2014
52%48%
Now
48%52%
2018
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NHS RightCare - support out now & coming soon
• Wave 1 roll-out now live (65 health economies via
CCGs)
• Wave 2 December 2016 (everyone else)
• Atlas Opportunities Locator tool
• Commissioning for Value refresh packs
• Focus packs – 11 programmes of care
• LTC and MH packs
• New and refreshed Atlases of Variation (diagnostics
refresh coming soon)
• Optimal Value Pathways
• Repository of Shared Decision Making
21
Further information available from -
Email RightCare
Twitter:
@matthew_cripps1
Visit RightCare:
http://www.rightcare.nhs.uk/