CNO Summit 2017, Day 1, 16.45pm Michelle Mello, Deputy National Director, NHS RightCare Phil DaSilva, Co Founder, NHS RightCare

1. Using the Power of Variation to
Transform Care
Michelle Mello
Deputy National Director NHS RightCare
Phil DaSilva
Co Founder NHS RightCare

2. A postcard from Anytown CCG
Dear All
As nurses we know there is no new
money – yet we try hard to find some,
thinking that is the answer to our
financial problems and fragmented
care- we often think more is better.
We believe that all the service s we
provide are of high quality and all are
needed, but we also being told they are
no longer affordable and we constantly
reorganise the services around our teams
and organisations, not always the need
of our population..….
….WISH YOU WERE HERE ??
Patients and Visitors
Some Town Population
Anytown Trust
England

3. Variation – ‘It’s just a buzzword’
Variation is not a new phenomenon – it has been highlighted as an
issue since the beginning of the NHS in 1948…
indeed it has been around since Glover’s seminal paper in
1938…
… but it continues to puzzle policy makers, politicians,
professionals and our patients and has been highlighted, yet again,
in 4 key documents with a call for the NHS to take action to identify
and reduce unwarranted variation.

4. Variation in Healthcare
The prevalence of variation is well documented. Not all variation is
bad.
Some variation is inevitable, as well as random, and perhaps an
outcome of innovation and improvement, which are essential pillars of
a modern health care system. However much of the observed variation
is unwarranted.
Variation in the differences in care (costs, activity or outcomes) which
cannot be explained by public health needs or patient needs and is
often a result of clinicians, managers or whole organisations simply
doing things differently, often based on historical patterns of care and
local preferences.

5. The Context
Health systems across the world are rising to the challenge, many
backed up through the development of a centre, or alliance, between
state partners to drive this agenda.
In England, beyond the NHS England “RightCare” programme, there is
little coordination, creation of knowledge, training or sharing of good
practice between organisations and no clear systematic approach to
addressing unwarranted variation.
There is opportunity, and need, to go further, including in co-ordinating
and understanding where the best impact can be gained through the
application of national, technical, political and regulatory drivers to enable
the system to reduce unwarranted variation.
The solution requires a focal point where knowledge and wisdom can be
harnessed and shared.

6. Addressing Variation – more calls for action
The NHS E document ‘the 5 year Forward View’
www.england.nhs.uk/ourwork/futurenhs/
The PHE strategy document ‘From Evidence to Practice’
www.gov.uk/government/publications/from-evidence-into-action-opportunities-
to-protect-and-improve-the-nations-health
The Carter review – declaring that NHS Providers take decisive action to
reduce unwarranted variation
www.gov.uk/government/news/review-shows-how-nhs-hospitals-can-save-
money-and-improve-care
Leading Change, Adding Value a framework for nurses,
midwives and care staff *
www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf

7. Looking for unwarranted variation
Population
Focus
Referred
Patients
Most in need
Most seen

8. Exploring variation
When faced with variation data, don’t ask:
How can I justify or explain away this variation ?
Instead ask:
“Does this variation present an opportunity to improve ?”

9. Awareness is the first step
If the existence of clinical and
financial variation is unknown,
the debate about whether it is
unwarranted cannot take place.

10. 10
First Atlas 2010
34 maps of variation
11 disease areas
Series now covers 7
themed Atlases & 3
Compendium (2015)

11. 11
Some useful Tools to Help
Awareness is the first
important step in addressing
unwarranted variation; if the
existence of variation is
unknown, the debate about
whether it is unwarranted
cannot take place
Shared Decision
Making: 36 PDAs
27 pieces of surgical
commissioning
Guidance with FSSA
and RCS
211 CfV packs & Pathways
on a Page

12. Stroke Care
Stroke is the third biggest cause of death and single biggest cause of
adult disability in England
As with all NHS services, there are significant variations in the
quality of stroke care across the country

13. Some Questions to Consider
• How much do we spend on stroke care?
• Do we know if the care is better in Northampton, Nottingham or
Newcastle – is it equitable?
• How much do we allocate to preventative Care?
• How many admissions for stroke did we have last year?
• How much waste and duplication is there in the system?
• How can we release funds and direct them to better value health
care?
Why don’t we know?...

14. LOWER VALUE =
BUREAUCRACY
BASED CARE
HIGHER VALUE
=
PERSONALISED
AND
POPULATION
BASED CARE
Design and
Deliver Care
through
Systems – not
organisations
Develop clinical
focus on
populations –
including
unidentified
patient need
Search for
unwarranted
variation –
eliminate
waste and
duplication
Personalised
care
planning-
shared
decision
making
Culture
Change –
Transformati
on
Programme

15. How do you use your CfV pack

16. Principles of NHS RightCare approach
Ingredients
Indicative data
Atlas of
variation
Cf Value Packs
Evidential data
Locally sensitive
data to build a
Case for Change
BPE
Clinical leadership
& Engagement
Nursing is
perfectly
positioned to
design and lead
transformation

17. Understand the data
• CfV packs
• Opportunity areas
• Analytical team/support
• Managing data deniers
• Demographic peers

18. Getting the full picture
Population
Focus
Referred
Patients
Most in need
Most seen

19. • Delivery Partner
• Local Clinical Leads
• Commissioners/Providers/LA
• 3rd sector
• STP
• Buddy up
Connectionsand Networks

20. Leadership
• Focus on quality and outcomes as well as finance
• Creating the right culture and relationship building
• STP system transformation
• Linking initiatives so the focus is on value and outcomes
• Making RightCare business as usual
• Professional networks

21. RightCare & the Nursing Profession
Adopt and enhance the Right Care approach, to help health systems in
maximising value as part of their transformation programmes
Generate a cadre of experienced people to support improvement
Take a lead role in working with national organisations and Arm’s Length
Bodies to understand and enhance the co-ordination and the application of
national technical, political and regulatory drivers to reduce unwarranted
variation
AND
Enhance the prestige and kudos for the Profession as it develops national and
international collaboration and becomes a focal point on this important policy
issue

22. Increasing value
Value to the
Individual
Value to the
Population
Value to the
Professions
• Engage
• Organise &
• Transform
RightCare
Designing
And
Delivering
Optimal
Value

23. A postcard from Anytown CCG
Patients and Visitors
Some Town Population
Anytown Trust
England
Dear All
We now know that we have to use the
resources differently, we do have to ‘stop
starting and start stopping’ those things
that don’t add value. So, we will focus on
population health care, thinking about the
whole system, not just organisations and
traditional ways of working.
To do that we will look at how and where we
allocate our resources and how we share our
knowledge to re-design better ways of
providing care.
That feels right so ….
we really do WISH YOU WERE HERE!!

24. i
NHS RightCare is a programme of NHS England
For more information and support about how to
use the NHS RightCare approach to get best value
for your population, go to
www.england.nhs.uk/rightcare/
or email us at rightcare@nhs.net