1. Implementing the decision
Case Study: NHS West Kent prevention
strategy
A Story about Prioritizing
Dr. Declan O’Neill
Director
Public Health Improvement

2. Experience from a PCT’s
Strategic Commissioning Planning Process
• It was NHS priorities focused
• It was developed through the broadest
consultation
• It recognised the importance of prevention
• It was technical
• It was developed in a system already subject
to significant financial pressure where the first
principle of innovative plans is often invest to
save.
• It was seen as successful in CQC eyes

3. Key components of the Planning
Process which developed ‘Prevention’
as an integral part of the PCT’s
Strategic Commissioning Plan
1. A programme budget based SCP
2. Adoption of a ‘fully engaged prevention
scenario’
3. An ‘economic approach’ to prevention using
predictive model based on attributable
fractions for major health risks
4. To be funded in year two of SCP from
development monies delivered by year one
efficiencies

4. 1. A programme budget based SCP
Goals
Improve health, quality of life Eradicate the gap in life Deliver national, regional &
Eliminate waste
and patient experience expectancy county commitments
Priority Programmes Spend Profile 2014/15 (rounded)
Programme Strategy
Cancers Genito- Infectious Mental Musculo- Trauma &
Circulation Dental Endocrine Maternity Neurology Respiratory
Tumours Urinary Diseases Health Skeletal Injuries
£63m £74m £37m £ 35m £40m £17m £32m £91m £46m £45m £45m £39m
Programme Investment Strategy*
           
*Neutral = +/- 5%
(1) (1) (1)Award & (1) (1) Mental Older (1)
Priority Initiatives
Cancer Sexual Neurology Urgent
Circulatory Monitor Diabetes MMR Maternity People COPD
Market Health Health Market Care
Redesign Dental Strategy Program Redesign (inc. MSK/ Redesign
Model Redesign Efficiency Model Model
Contracts Falls)
(2) (2) (2) (2) (2) Mental (2)
Circulatory
End of Social MIMHS Health Asthma
Market
Life Care Marketing Review Market Redesign
Model
Model
Primary Prevention
Service Increasing Independence (self-care and carers)
Improvement
Commissioning Transforming Community Services
Levers
Health &
Wellness Commissioning Innovation
Operating Plan*
Op plan year 1 Op plan year 2 Op plan year 3 Op plan year 4 Op plan year 5
Mental health 1 Neurology
Circulation 1 Maternity 1 & 2 Mental Health 2
Primary
Dental 1 & 2 Endocrine Trauma & Injuries Prevention
Subject to review
Infectious Diseases Musculo-Skeletal Cancer 1 Increasing
Respiratory 1 Genito-Urinary Respiratory 2 Independence
Cancer 2 Circulation 2
*Phasing refers to the year in which the major impact of an initiative is felt; work on Programmes is ongoing

5. The financial environment
Funding shortfall
NHS funding
1995 2000 2005 2010 2015 2020 2025
Year

6. 2. “Fully Engaged Prevention Scenario”
Assumes
• maximum application of
• effective prevention interventions
• across the complete range
• of opportunities to reduce the risks
• associated with avoidable illnesses
Thereby restraining projected growth in the
demand for treatment of illness
So a “Fully Engaged Prevention Scenario”
in West Kent meant modelling against real
costs of care

7. An ‘economic approach’ to
prevention
• Using attributable fraction • Extrapolate programme to
methods estimate the prevalence modification
specific burdens of target and cost.
preventable hospital • Estimate expected
morbidity (related to reductions in morbidity and
smoking, obesity, etc) in the benefits
locality • Demonstrate returns on
• Cost them investment
• Identify local prevalence of • Present rationale to payer
risks • Expand budget in this area
• Identify the cost and impacts • Evaluate impact
of effective programmes

8. % Prevalence trends over time
60
50
Smoking
40
Haz
30 Alcohol
Falls
20
Obesity
10
0
1970 1980 1990 2000 2005 2010 2015 2020

9. Expenditure of NHS WK attributable to
preventable ill health vs
Expenditure on Prevention
Spent on
Prevention
Preventabl
<1%
e
25%
Non-
Other PCT spend
preventabl
99+%
e
75%

10. To work all this out requires a fairly robust predictive model into
which is fed year on year population age groups, prevalence
predictions morbidity costs and impacts of prevention.

11. Out of which comes a projected returns in
morbidity savings versus costs of programmes

12. Enabling you to go to the payer with a
prediction of returns on investment from a
prevention programme which makes good
economic as well as good health sense
For an initial investment of £3.6m, over a 7 year period
reflected in the SCP, prevention programmes were
predicted to provide a return on investment reducing the
burden of ill-health and reducing health care costs as
follows:
Healthy Weight £1.6m
Falls £1m
Sexual Health £1.3m
Mental Health £1m
Alcohol £0.9m
Smoking £1.1m
£6.9m

13. Short and Longer term
Such programmes are predicted to:
• break even in about c. 5yrs
• start returning investment around 7
years
• Significantly multiply their returns after
10 years

14. What happened?
• The programme based budgeting SCP led
the business of the commissioner.
• It required suites of demand management
programmes to be fitted into priority
programmes
• The organisation was re-structured around
clumps of priorities
• Demand management programmes were
delivered

15. What happened next?
Other demands popped up and
consumed the supply at similar rates to
before.
Why?

16. In our environment the system appears to default
to acute care. Is there mal-distribution of care
provision? If so what contributing factors?
• Relatively well-off, aged population
• Historically, monolithic hospitals provided majority acute and long term
care
• Not much in way of other providers
• No vertical integration
• Historically differing pressures for those alternative providers Eg.
community services
• Informed patients, informed GPs
• Exposure to inverse care law common
• Falling risk thresholds at hospital front end
• GP contract, community matrons, OOHC
• Care delivered in 4 hours is a benchmark for one part of the system
• 3 PFIs
• London nearby

17. If we think there is mal-distibution of care
is it demonstrably inefficient?
Care Types
Prevention Primary Community Acute Social
Suggested imbalance in distribution of care types
which drives default to acute services

18. Addressing Maldistribution or moving care upstream:
Bottom line assumption that major change needed at
5 points in system
• Prevention programmes will expand and focus to
measurably reduce morbidity and attributable
hospitalisation.
• GPCCs will manage patient care upstream in such a way
as to reduce referrals and unplanned admissions into
secondary care
• Community services will be able to modify and develop
services, with primary care, to be available round the
clock and able to provide management packages in 4hrs,
avoiding acute admission as default.
• Social Services will modify the acute social care interface
to expedite alternatives reducing stays in acute beds
• Acute services will find substantial opportunities to
manage out inefficient acute care and redundant capacity

19. Underpinning efficiency - QIPP plans and detailed
indicators can demonstrate silos of improved
efficiency, but what about the overall outcomes?
• At the Kent & Medway (County) Level
K&M has established a QIPP Board to oversee the system response to addressing the financial challenge by ensuring delivery and encouraging collaboration.
The QIPP Board has the following organisational membership:
NHS Medway NHS West Kent
NHS Eastern & Coastal Kent Medway NHS Foundation Trust
Dartford & Gravesham NHS Trust Maidstone & Tunbridge Wells NHS Trust
East Kent Hospitals University Foundation Trust Kent & Medway NHS & Social Care Partnership Trust
Medway Community Services West Kent Community Services
East Kent Community Services Medway Council
Kent County Council South East Coast Ambulance Service
Queen Victoria Foundation Trust South East Coast SHA
• The SHA has nominated Vanessa Harris, Director of Resource & Investment
to sit on the Board as the SHA Executive Lead for Kent & Medway

20. Bottom line assumptions of major
change at 5 points in system
• Prevention programmes will expand and focus to
measurably reduce morbidity and attributable
hospitalisation.
• GPCCs will manage patient care upstream in such a way
as to reduce referrals and unplanned admissions into
secondary care
• Community services will be able to modify and develop
services, with primary care, to be available round the
clock and able to provide management packages in 4hrs,
avoiding acute admission as default.
• Social Services will modify the acute social care interface
to expedite alternatives reducing stays in acute beds
• Acute services will find substantial opportunities to
manage out inefficient acute care and redundant capacity

21. Imbalance will right itself!
(Or possibly move in that general direction?)
Care Types
Prevention Primary Community Acute Social

22. How would we know if we were
moving in that direction?
• If you think there’s an imbalance which can be addressed through
capacity modification then start by looking at where the system defaults
to and see what is happening there. Look at the acute sector (Quantify
inappropriate admissions, inappropriate bed days).
• It should be said that most CEs and Acute Trust Directors will be able to
tell you what happens there and why.
• However, actually quantifying and recording today’s reality can allow us
to accurately bench mark and provide a possible target for where we
might like to be.

23. Acute Bed Use
• We’ve now done a study with one of our
local acute trusts, as an experiment just
in advance of the 2011/12 financial year
to maximise its potential for use for
benchmarking QIPP.

24. • No hospital has maximal appropriate use of its
inpatient services and it has long been observed
that available beds become filled beds –
(Roemer’s Law) .
• This sort of auditing has the potential to
demonstrate the outcome of efficiency initiatives.
• It could be used as a baseline and, (if then
repeated), as a benchmarking system to monitor
the effectiveness of QIPP initiatives.

25. WHAT WAS DONE
• A team of clinical auditors undertook a point prevalence (snap shot)
study of admission appropriateness and subsequent appropriate use of
acute care on a specific day of care, through an audit of 344
contemporary inpatients’ medical records using an updated version of a
validated and widely tested instrument AEP.
• All of the notes completed on day of the admission were scanned by
the clinical reviewer against a set of ‘admission-day criteria’.
• Similarly, all of the notes completed on a specific (subsequent) day of
stay were scanned by the clinical reviewer against a similar, (not the
same), set of ‘day of care criteria’.

26. The study population included the main specialties which experience
‘inappropriateness of acute bed use’.
• STUDY QUESTION 1- What percentage of post 48 hour in-patients
in the study warranted admission to an acute care facility, according
to audit criteria demonstrable in the patient’s record?
• STUDY QUESTION 2 - What percentage of post 48 hour in-patients
in the study warranted continuing acute care in an acute care facility
on a specific day, according to audit criteria demonstrable in the
patient’s record?
• STUDY QUESTION 3 - What were the main reasons behind the
recorded inappropriate admission rates and inappropriate day of
care rates?

27. • This sort of auditing has the potential to demonstrate the
outcome of efficiency initiatives. Changes in these
outcomes could be used to triangulate and validate
assumptions underpinning the efficiency programmes
built into local QIPP plans and heads of agreement.
• It can be used as a baseline and followed down.
• PAS incorporated systems exist.
• Ultimately may provide means of identifying and
managing out redundant acute capacity to redistribute
resource elsewhere in the system.

28. Questions?