Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event. Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development. This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being. More information is available online: www.expo.nhs.uk

1. Better value in the NHS:
Lessons from the past and opportunities
for the future
Prof John Appleby
Chief Economist
The King’s Fund
www.kingsfund.org.uk/bettervalue

3. • Generic prescribing
• Lengths of stay
• Day case surgery

4. Percentage of primary care prescribed items by
generic/proprietary prescribing and dispensing: England,
1976/7 to 2013/14.

5. Estimated saving in 2013 total net ingredient cost due to
increases in generic prescribing and dispensing between
1976 and 2013
£7.1bn
Saving by
2013/14 of
increased
generic
prescribing
since 1976

6. Variation in generic prescribing by GP practice: England
2013/14

7. Trends in acute medical and surgical patient lengths of
stay: English NHS: 1974-2014
11%
(Extra beds that
wouldhave been
needed in 2013 if
no reductionin LOS
since 1998)
61%
(Increase inbed
throughput
1998-2013)

8. International comparisons of average length of stay (all
types of patient): OECD countries

9. +1.3 m
Proportion of all patient activity carries out as day
cases: England 1974-2014
Rollout of PbR

10. Two key lessons from the past
1. The drivers of change are multiple and overlapping
Common drivers:
› Health technology developments
› Clinical/managerial culture
› Patient pathway design
› Data and information
› Frontline support to enable change
› Financial incentives
› Financial pressures/support
2. Improvement takes time and occurs through a series of
small steps rather than giant leaps forward

11. Opportunities
for the future

12. Variations in clinical practice
By PCT/CCG*:
• Diagnosis of coronary heart disease ranges from 52 to 89%
• Diagnostic tests:1000-fold difference in rate GPs order blood glucose tests
• Prescribing practice: 25-fold difference number of anti-dementia drug
prescriptions
• Management of chronic disease: patients with COPD who had review in past 15
months ranges from 77 to 87%
• Rates of clinical procedures: rate of elective tonsillectomy in children ranges
from 145 to 424 per 100,000 <17 years
• Length of stay in hospital: 11-folddifferencein elective breast surgery LoS
• Health outcomes: mortality rate from pneumonia in 75+ ranges from 4 to 11 per
100,000 population

13. Overuse
• Monitor estimated £0.2 – £0.6 a year potential saving
from by stopping low-value elective procedures like
knee washouts and tonsillectomies.
Overtreatmentin
hospitals
• NICE estimate that following their prescribing policy for
antibiotics for respiratory tract infections would reduce
prescribing by £3.7m
Overprescribing
• Eliminating inappropriate pathology testing could save
the NHS £1 billion a year
Overdiagnosisand
use of diagnostic
tests

14. Underuse
•In 2012/13 only 60 per cent of people with
diabetes received all eight recommended care
processes
Underuseof
effective
interventions
•1 in 8 people over 35 has COPD butremains
undiagnosedUnderdiagnosis
•Between a third and half of drugs prescribed
for long-term conditions are not taken as
recommended
Medicines not
taken properly

15. Misuse (preventable harm)
• Additional days in hospital as a result of adverse events
are estimated to cost the NHS in England and Wales £1
billion each year
• Direct cost of falls in hospital estimated to be £15 million
in 2007
Adverse
events in
hospital
• Estimate based on 10 GP practices found error rate of
around 7%
Adverse
events outside
hospital

16. Care of long-term conditions
Opportunities for:
• Earlier detection and diagnosis
• Involving patients in decision
about their care
• Supporting patients to manage
their own health
• Care co-ordination
• Integrated approaches to mental
and physical health needs

17. Care of older people living with frailty and
complex needs
Opportunities for:
• Avoiding preventable and
inappropriate hospital
admissions
• Improving the patient flow
within hospitals
• Better discharge and reablement

18. End of life care
Opportunities for:
• Reducing time in hospital at the
end of life
• Better care co-ordination
• Training generalist staff in end-
of-life care

19. Agenda for action

20. Frame the productivity debate around
quality and outcomes

21. Hugh Alderwick Ruth Robertson Phoebe Dunn David Maguire
More information: www.kingsfund.org.uk/bettervalue

22. @jappleby123
www.kingsfund.org.uk