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Oldham Health Commission


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A citizens jury into fairness in NHS Commissioning. These are the presesntations fo the expert witnesses.

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Oldham Health Commission

  1. 1. Oldham Health Commission into fairness
  2. 2. Keynote Speech Dr Ian Wilkinson
  3. 3. GPCC in Oldham: A strategy for an Accountable Care Organisation Dr Ian Wilkinson (Chair of Oldham GPCC) Denis Gizzi (Exec Director)
  4. 4. The current landscape
  5. 5. <ul><li>A focus on: </li></ul><ul><li>Reform – transition to the new system </li></ul><ul><li>QIPP </li></ul><ul><li>Maintenance of improvements to date – e.g. referral to treatment times </li></ul><ul><li>Specific improvements in relation to Government priorities - eg health visitors and Family Nurse Partnership schemes. </li></ul>Equity and excellence: Liberating the NHS
  6. 6. <ul><li>a new Outcomes Framework for the NHS – where the focus is on the health improvement achieved; </li></ul><ul><li>patient experience – where there needs to be a shift to better collection of and timely action on patient experience and feedback; </li></ul><ul><li>better information – where a new information strategy will set out how local commissioners and the people they serve can be better supported in decision making; </li></ul><ul><li>quality accounts – which will be extended to cover community services; </li></ul><ul><li>local publication – where there is greater clarity of how expenditure translates into local achievements. </li></ul>NHS operating framework
  7. 8. Responsibilities: Most health care pathways and programme budgets will be held by GP consortia – 70% of the current budget This will include; elective care, rehab care, urgent and emergency care (inc OOH), most community services, mental health and learning disability services. Consortia (will not) be responsible for primary medical services, or other family health such as dentistry, pharmacy, ophthalmics or national and regional specialist services (this will be the remit of the NHS Commissioning Board, with influence from GP consortia). Consortia will manage combined budgets (separate account from core practice accounts). Their duty will be NOT to overspend, to hold suppliers to account and to ‘hold to account to quality outcomes and contribution from general practice Promote equalities and work within productive partnerships with the local authority Duty to effectively engage patients and the public within the core commissioning role Bottom Line: deliver higher quality, regulated outcomes at lower macro cost and whilst enabling public ownership and informed choices. GP Consortia: Focus on new responsibilities
  8. 9. The story so far <ul><li>COG to continue as a single consortium through the transition and beyond </li></ul><ul><li>Strategic Commissioning Plan </li></ul><ul><li>Reform strategies </li></ul><ul><li>Transforming Community Services Strategy – transformational programme in development </li></ul><ul><li>Clinically owned QIPP programme </li></ul><ul><li>System and Market Management Strategy </li></ul><ul><li>Quality improvement programme for Primary Care </li></ul><ul><li>Joint commissioning strategy with LA and Health and Wellbeing Board in place </li></ul>
  9. 10. <ul><li>Vision – the Triple Aim </li></ul><ul><ul><li>To improve population health in total and via disease group </li></ul></ul><ul><ul><li>To improve care provided, and the health experience of individuals </li></ul></ul><ul><ul><li>To lower per capita costs </li></ul></ul>
  10. 11. GPCC in Oldham: A strategy for an Accountable Care Organisation <ul><li>Vehicle for delivery – ACO </li></ul><ul><li>All members share risk and assume accountability for the resources spent caring for the population and the quality of that care </li></ul><ul><li>An ethos of no unnecessary waiting , no unnecessary cost and no compromise on quality </li></ul><ul><li>Requires the trust and confidence of the public, the NHS Commissioning Board and the local Health and Well-being Board </li></ul><ul><li>Out to consultation with stakeholders </li></ul>
  11. 12. Our principles
  12. 13. How The NHS Works Ursula Hussain and Jade Czuba
  13. 14. Where Does All The Money Go? Steve Sutcliffe
  14. 15. The Financial Challenge Steve Sutcliffe
  15. 16. How Are Priorities Determined? Denis Gizzi
  16. 17. Triple aim – a tool for prioritisation and review IHI triple aim principles Improved capita cost control To improve care provided and the health experience of individuals To improve population health and via disease groups
  17. 18. Programme Budgets - A Rational Starting Point Managing the ‘Whole’ over Time The ‘IW’ Idea (the Oldham Chocolate Orange) GPCC will control the whole health care system and therefore the whole programme budgets in line with Government policy. In order to hold control and deliver efficiencies and enhanced quality of the whole ‘real’ budget, segments could be extracted and delegated authority allocated to clinical teams / clusters / firms to take clinical and management control over a specific clinical budget area. Each segment (or Programme Budget area) would be set a framework within which to operate. The GPCC consortia Board would retain macro accountability,potentially with a prime vendor Within the transition period, GPCC could take control over some ‘segments’ under delegated authority from the PCT Referenced within 17 Feb Nicholson letter Managing The ‘Segments’ over Time The segments represent individual programme budget areas linked to specific clinical domains such as MSK, Respiratory, CVD etc The idea is based on the concept of local ‘clinical firm’ leadership of segment areas using a common method. This would provide flexibility for all clinicians to engage.
  18. 19. Selecting programme and services for review
  19. 20. 7 stage health market analysis
  20. 21. Process following health market analysis
  21. 22. Making investment decisions
  22. 23. Prioritising potential new developments The Prioritisation Tool, (co developed with the NHS Institute) is a key component of this phase of activity PROGRAMME PHASE 1 Opportunity Identification & Prioritisation Identify Initiatives <ul><li>Overarching objectives driven by: </li></ul><ul><ul><li>strategic vision, commissioning intentions, needs assessments, national policies/priorities, etc. </li></ul></ul><ul><li>Supported by additional data sources including: </li></ul><ul><ul><li>'Data Cube', other health intelligence/indicators, etc. </li></ul></ul><ul><li>Further informed by local initiatives </li></ul><ul><ul><li>PBC plans, LDP, 'grassroots' initiatives) </li></ul></ul><ul><li>'Long-list' of initiatives must be: </li></ul><ul><ul><li>specific projects, not vague </li></ul></ul><ul><ul><li>actionable initiatives </li></ul></ul>Prioritise Projects <ul><li>Assess and score initiatives against Importance and Do-Ability dimensions </li></ul><ul><li>Discuss/define importance and do-ability thresholds </li></ul>Develop Implementation Plan <ul><li>Further consideration of interdependencies, themes, capabilities and capacity to plan </li></ul>
  23. 24. The Prioritisation Tool : Importance & Do-ability (+ ability to flex weighting due to macro forces) DO-ABILITY: 5 dimensions are assessed Patient & Public Engagement Health Economy Stakeholder Alignment Technology/Facilities/Workforce Impact on efficiency creation Market Capability IMPORTANCE: 5 dimensions are assessed Patient Benefit Clinical Benefit Reform/Strategic Direction Operational Imperative Financial Impact Economic impact & do-ability Flex weighting depending on financial scenarios AVOID ALTOGETHER IMPLEMENT IMMEDIATELY ASSESS IMPACT AND ACT DELIVER IF DESIRED
  24. 26. Next steps for GPCC
  25. 27. The next steps <ul><li>Engagement – public, patient and clinical </li></ul><ul><li>Managing demand - urgent care, scheduled care and prescribing </li></ul><ul><li>Long Term Condition Management </li></ul><ul><li>Performance Management </li></ul>
  26. 28. How will we know if GPCC have succeeded? -Critical Success Factors Objective Measure 1 Full commitment and engagement of every GP practice in consortia 360 degree feedback/informal networks /delivery of outcomes 2 Improvement in outcomes as per accountability schedules: - finance, patient and public engagement, governance standards, clinical outcomes Improvement in performance 3 Population with LTC have a health care plan % of patients with Persoanlised Care Plan 4 Strong relationships with the public and partner organisations 360 degree feedback 5 Robust product delivery platform in place to enable effective redesign Successful delivery of service change 6 Appropriate workforce in place Measurement against organisation framework 7 Established and recognised model of managing suppliers Internal knowledge and capability to manage supplier relationships 8 Robust contracting process Robust contracts and management processes with all providers
  27. 29. Health Inequalities in Oldham Mark Drury
  28. 30. The Wider Determinants of Health
  29. 31. Ill health does not happen by chance or through bad luck. Health is multidimensional and is influenced by many determinants, which may go unnoticed. The collective effect of poor housing, unemployment, social isolation, individual lifestyle factors and the environment in which we live, have enormous influences on health and wellbeing outcomes
  30. 32. <ul><li>Oldham is the 42 nd/ 354 most deprived borough in England (2007 IMD) </li></ul><ul><li>The ward of Coldhurst falls into the 1% most deprived wards in England (2007 IMD) </li></ul><ul><li>Oldham is the 39 th/ 354 most Income deprived borough in England (2007 IMD) </li></ul><ul><li>Nearly 70% of children aged 0 to 15 in Coldhurst and over 60% in St. Mary’s live in households experiencing income deprivation according to IDACI. </li></ul>Factors that Impact on Health & Wellbeing in Oldham
  31. 33. Population
  32. 34. NHS Oldham’s resident population is currently estimated to be around 218,800. (ONS) MPI of GP registered patients, resident in Oldham is around 224,646 Oldham has a younger age structure than the England and Wales average, with a significantly higher proportion of people aged under 15 years Around 16.6% of Oldham’s population are from non-white, Black and Minority Ethnic groups (BME), with 7.1% being of Pakistani heritage and 5.4% being of Bangladeshi heritage. Around 27.5% of children under 15 years are from BME groups Diversity of Communities in Oldham <ul><li>Deprivation from the national average </li></ul><ul><li>42 most deprived LA in England </li></ul>
  33. 35. Summary of populations across Oldham <ul><li>The most densely populated ward is Coldhurst </li></ul><ul><li>The least populated ward is Saddleworth South </li></ul><ul><li>Overall there is a higher proportion of females in the over 60 age category than males </li></ul><ul><li>Coldhurst has the highest male population </li></ul><ul><li>St Marys has the highest female population </li></ul><ul><li>Coldhurst has the highest youth population </li></ul><ul><li>Failsworth West has the highest over 65 population </li></ul><ul><li>Chadderton Central has the highest working age population </li></ul>Public Health Intelligence
  34. 37. Lifestyle The main contributors to premature mortality in Oldham
  35. 38. Alcohol <ul><li>40 deaths occurred </li></ul><ul><li>across Oldham in 2009 </li></ul><ul><li>that were directly attributable </li></ul><ul><li>to alcohol </li></ul><ul><li>Over 38 thousand people are </li></ul><ul><li>estimated to drink unsafely </li></ul><ul><li>Digestive disorders are on the </li></ul><ul><li>increase </li></ul><ul><li>Oldham has significantly </li></ul><ul><li>higher hospital admission </li></ul><ul><li>rates for people under 18yrs </li></ul><ul><li>than the England average </li></ul><ul><li>It is clear from the data that </li></ul><ul><li>people from deprived areas </li></ul><ul><li>are more likely to be admitted </li></ul><ul><li>to hospital for alcohol related </li></ul><ul><li>conditions </li></ul><ul><li>Targeted interventions aimed </li></ul><ul><li>at re-admitted patients need </li></ul><ul><li>to be implemented. </li></ul>Prevalence Outcomes Source: NWPHO Alcohol profiles 2010 Source: NI39 NWPHO Source: NWPHO Alcohol profiles 2010 Source: SUS/CDS through NHS Oldham data warehouse
  36. 39. Smoking <ul><li>Smoking is the single biggest cause of preventable illness and death in the UK </li></ul><ul><li>Around 410 people die each year from smoking attributable conditions across Oldham </li></ul><ul><li>It estimated that 49,000 people smoke in Oldham (28%) of the population </li></ul><ul><li>It is estimated that 1814 people quit smoking in 2009/10 (Oldham) This is below target </li></ul><ul><li>People from more deprived backgrounds and those in manual occupations are the largest group of smokers both locally and </li></ul><ul><li>nationally </li></ul><ul><li>Widening access to stop smoking interventions is essential if we are to increase smoking quitters across Oldham </li></ul><ul><li>Support to prevent and stop smoking should be part of a generic lifestyle intervention as well as available at a </li></ul><ul><li>specialist level </li></ul>Prevalence Outcomes Management Information sources: % adults, modelled estimate using Health Survey for England 2006-2008 Oldham’s JSNA 2010 Stop smoking Services Oldham
  37. 40. Obesity Prevalence Outcomes Management <ul><li>In Children </li></ul><ul><li>Targeting parents and children-family </li></ul><ul><li>based interventions </li></ul><ul><li>Multi-faceted family based behaviour </li></ul><ul><li>modification programmes </li></ul><ul><li>Support in the use of laboratory based </li></ul><ul><li>exercise programmes </li></ul><ul><li>In Adults </li></ul><ul><li>Dietary interventions </li></ul><ul><li>Clinically prescribed low calorie diets </li></ul><ul><li>Increased physical activity programmes </li></ul><ul><li>Behaviour modification interventions </li></ul><ul><li>It is estimated that 41,000 adults </li></ul><ul><li>in Oldham are obese </li></ul><ul><li>Obesity increases the risk of </li></ul><ul><li>diabetes, CHD, hypertension , </li></ul><ul><li>osteoarthritis and some cancers </li></ul><ul><li>People who are obese die on </li></ul><ul><li>average 9 years earlier than those </li></ul><ul><li>of normal weight </li></ul><ul><li>Excess deaths (2009) among </li></ul><ul><li>people with diabetes type II </li></ul><ul><li>across Oldham was 156 </li></ul><ul><li>Although nationally obesity is </li></ul><ul><li>more prevalent in deprived </li></ul><ul><li>populations, there is an increase </li></ul><ul><li>obesity levels across all groups. </li></ul><ul><li>Determining the cause of obesity </li></ul><ul><li>is the key to tackling it </li></ul>Source: NCMP childhood obesity database, Local Health profiles: APHO 2010) NICE
  38. 41. Physical Activity Prevalence Outcomes Management <ul><li>It is estimated that around 28.3 </li></ul><ul><li>thousand adults participate in sport </li></ul><ul><li>across Oldham </li></ul><ul><li>Currently 63% of men and 76% of </li></ul><ul><li>women are not physically active </li></ul><ul><li>enough to meet national </li></ul><ul><li>guidelines </li></ul><ul><li>People from lower socioeconomic </li></ul><ul><li>groups are more likely to be </li></ul><ul><li>inactive </li></ul><ul><li>Obesity is strongly linked to physical </li></ul><ul><li>activity </li></ul><ul><li>Is effective in the treatment of </li></ul><ul><li>clinical depression and has </li></ul><ul><li>benefits for mental health </li></ul><ul><li>20-30 % reduced risk of </li></ul><ul><li>premature death and up to 50% </li></ul><ul><li>reduced risk of major chronic </li></ul><ul><li>disease </li></ul><ul><li>Levels of walking and cycling </li></ul><ul><li>have fallen in the last decade </li></ul><ul><li>Children are also increasingly </li></ul><ul><li>sedentary </li></ul><ul><li>Increased physical activity </li></ul><ul><li>programmes </li></ul><ul><li>Increased active travel through </li></ul><ul><li>urban and rural planning </li></ul><ul><li>Develop and maintain public </li></ul><ul><li>open spaces that are safe </li></ul><ul><li>and accessible and encourage </li></ul><ul><li>physical activity. </li></ul><ul><li>For most people, the easiest and </li></ul><ul><li>most acceptable forms of physical </li></ul><ul><li>activity are those that can be </li></ul><ul><li>incorporated into everyday life </li></ul>Source: Sport England's Active People Survey and The Child Health Profiles for England 2010
  39. 42. QUESTIONS? Why do you think people from more deprived backgrounds adopt risky lifestyle behaviours Should people’s behaviours affect the treatment they receive from the health service?
  40. 43. Life Expectancy, Main Causes of Premature Death and Morbidity across Oldham
  41. 44. Life Expectancy across Oldham <ul><li>Life Expectancy at Birth (2007/09) </li></ul><ul><li>Males: 75.5 years – 306/324 – 18 th worst in England </li></ul><ul><li>Females: 79.9 years – 312/324 – 13 th worst in England </li></ul><ul><li>Life Expectancy at 65 years (2007/09) </li></ul><ul><li>Males: 16.2 years – 11 th worst in England </li></ul><ul><li>Females: 18.8 YEARS – 10 TH worst in England </li></ul><ul><li>Best Life Expectancy = 80.2 years(m) & 85.1 years(f) </li></ul><ul><li>Worst Life Expectancy =70.1 years(m) & 75.5 years(f) </li></ul>Life Expectancy has been steadily increasing across Oldham over the last 10 years, but the gap between Oldham and England does not appear to be narrowing. Oldham has a diverse range of communities from the very affluent to the very deprived and this will therefore always produce wide inequalities in health outcomes.
  42. 45. Please note: Denominators for life expectancy used 2001 and 2007 respectively mid year population estimates for wards. Trends in Male Life Expectancy The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for males. The highest life expectancy is currently better than the national average. The lowest is currently 7.7 years below the national average. The gap between the best and worst life expectancy is currently 10.1 years
  43. 46. Trends in Female Life Expectancy The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for females. The highest life expectancy is currently better than the national average by 2.8 years. The lowest is currently 7.8 years below the national average. The gap locally between the best and worst life expectancy is 9.6 years
  44. 47. In people under 75 years
  45. 48. In people under 75 years
  46. 50. So What?... The case for working deliberately, to create more equal outcomes , rather than simply more equal opportunities to become ever more unequal, has two essential rationales – the practical and the moral . In those countries where health inequalities are greatest, overall health status of the population is lower . It is difficult to lower the coronary heart disease mortality of the population if only part of the population is experiencing improvement. Lowering health inequalities helps societies become more successful economically – drawing on the talents of all the citizens at a society’s disposal, rather just a section of them – and socially. More equal societies have less crime and less fear of crime. Inequalities in health that are potentially avoidable are unfair. Social justice is a reason for desiring a reduction in social inequalities in health. In Oldham there is a particular issue about health inequalities (and wider inequalities) between communities living side by side and social cohesion .
  47. 51. Opinion: what should fairness mean in the NHS? Martin Rathfelder
  48. 52. Andrea Fallon, Consultant in Public Health, NHS Oldham, 16.4.2011 .
  49. 53. Using ethics in decision making <ul><li>Need to have an awareness of the ‘sliding doors’ nature of ethical decision making </li></ul><ul><li>May change according to the opinion/views of those making decision – hence importance to get broad involvement </li></ul><ul><li>An understanding of ethics wont tell us what decision to make … </li></ul><ul><li>But it will help us articulate why a decision has been made. … </li></ul><ul><li>And will help us to explore all the angles, and be better prepared for scrutiny </li></ul>
  50. 54. Context … <ul><li>Responsibility for the health of the whole population </li></ul><ul><li>Finite resources </li></ul><ul><li>‘ Demand’ not same as ‘need’ – as those who don’t demand may also need … </li></ul><ul><li>Duty of care … safe and effective treatment which seeks benefit and avoids harm … </li></ul><ul><li>Legal responsibilities and accountabilities… </li></ul><ul><li>Choice and patient views… </li></ul><ul><li>Scientific and Clinical expertise and opinion… </li></ul>
  51. 55. Four essential questions … What should we be doing and why are we doing it? what rights and duties do we have to intervene, what outcomes do we seek and what is the evidence that it will work…(eg example of post bariatric surgery cosmetic surgery) Who should it be for, and what risks/costs are there to others? the boundary between restricting liberty for some to promote the health of others, and how fair will it be …. Who should decide? who should have the loudest voice …clinical, political, financial or public, patient How should we decide? what process should we use, are there precedents, and what legal obligations do we have in ensuring the ‘right’ process us followed.
  52. 56. <ul><li>Autonomy </li></ul><ul><li>Beneficence </li></ul><ul><li>Non-maleficence </li></ul><ul><li>Justice </li></ul>
  53. 57. Autonomy <ul><li>Autonomy </li></ul><ul><ul><li>The right to individual self-determination/self-rule </li></ul></ul><ul><ul><li>Autonomy of thought, will and action </li></ul></ul><ul><ul><li>Moral requirement to respect anothers’ autonomy </li></ul></ul><ul><ul><li>But ….Grey areas </li></ul></ul><ul><ul><ul><li>the right to end ones life </li></ul></ul></ul><ul><ul><ul><li>Treating recurrent admissions for alcohol intoxication </li></ul></ul></ul><ul><ul><ul><li>treating an overdosed drug addict </li></ul></ul></ul><ul><ul><ul><li>The right to refuse treatment for risky pregnancies </li></ul></ul></ul><ul><ul><ul><li>The issue of ‘competence’ (Fraser competence for under 16s who request contraception) </li></ul></ul></ul>
  54. 58. Beneficence <ul><li>Beneficence </li></ul><ul><ul><li>To do ‘good’ for others ie benefits … </li></ul></ul><ul><ul><li>Cant always tell what the benefits are …. Eg Evidence for how ‘good’ a popular treatment is may be weak…eg Reiki, Bowen therapy, baby massage…, and what if we don’t have evidence for how to solve a problem – we may need to experiment … </li></ul></ul><ul><ul><li>May be benefits for some but harms for others (eg numbers of false positives versus false negatives in a proposed screening programme) </li></ul></ul>
  55. 59. Non-maleficence <ul><li>Above all … do no harm … (hippocratic oath) </li></ul><ul><li>Avoiding harm versus doing good … (using the evidence) </li></ul><ul><li>Obligation not to harm people greater than obligation to benefit people (eg prostate cancer screening) </li></ul><ul><li>Some patients however may want to take risks in hope of a cure … (eg experimental treatments for degenerative conditions) </li></ul><ul><li>Balancing risks and harms essential (there isn’t a formula/means of calculating this though) </li></ul>
  56. 60. Justice <ul><ul><li>About Fairness and equity </li></ul></ul><ul><ul><li>‘ deserving’ and ‘undeserving’ poor ( welfare changes) </li></ul></ul><ul><ul><li>‘ deserving’ and ‘undeserving’ ill (eg smokers, obese, drinkers …) </li></ul></ul><ul><ul><li>Acceptance that equity may mean that some will need more at the expense of others in order for all to receive the outcome/benefit. </li></ul></ul><ul><ul><li>Concept of ‘capacity to benefit’ ( eg ?triple bypass for smokers) </li></ul></ul><ul><ul><li>At population level we can incorporate ‘beneficence and non-maleficence (benefits over harms) into justice as a means of looking at effectiveness, and also utility – ie how to maximise health gain overall … </li></ul></ul>
  57. 61. Some other terms .. <ul><li>Utilitarianism </li></ul><ul><ul><li>Doing the greatest good for the greatest number </li></ul></ul><ul><li>‘ Rights’ and ‘Duties’ </li></ul><ul><ul><li>All equal, right not to be killed, right to life … </li></ul></ul><ul><li>Paternalism </li></ul><ul><ul><li>Do the best for people and minimise their suffering </li></ul></ul><ul><li>Consent </li></ul><ul><ul><li>‘ Informed’, competence, power/vulnerability, communication </li></ul></ul><ul><li>Acts and omissions </li></ul><ul><ul><li>Actions resulting in harm considered worse than failure to act </li></ul></ul><ul><li>Ordinary and extra-ordinary means </li></ul><ul><ul><li>Blurring of boundaries eg parental feeding, extreme prematurity </li></ul></ul>
  58. 62. Some thoughts/questions … <ul><li>Services mainly respond to demand – how can we meet our duty of care for those who don’t present to us </li></ul><ul><li>Why are we treating people whose own behaviours have resulted in illness (eg blood borne viruses in IV drug users, smokers and bypasses, bariatric surgery) </li></ul><ul><li>How do we decide whether someone is an exceptional case … </li></ul><ul><li>What if the public and media demand is such that despite the evidence – central government instructs us to fund a treatment (eg Herceptin) </li></ul>
  59. 63. Andrea Fallon, Consultant in Public Health, 16.4.2011
  60. 64. Why use health economics principles <ul><li>Structured approach to decision making in health care where need appears limitless </li></ul><ul><li>Resources always scarce </li></ul><ul><li>Decisions and prioritisation always inevitable </li></ul><ul><li>Adds rigour and openness to decision making </li></ul>
  61. 65. Health Economics and decision making in healthcare commissioning <ul><li>The main ways in which we use the principles of health economics in decision making are: </li></ul><ul><li>Deciding whether or not to introduce a new service or intervention </li></ul><ul><li>How to compare multiple bids for funding, when there are only sufficient monies for one or two of these </li></ul><ul><li>The best way to decide how to take investment from one area (perhaps to reinvest in another) </li></ul>
  62. 66. Stakeholder perspectives <ul><li>Providers: look for technical efficiency </li></ul><ul><ul><li>Achieving a desired objective at minimal cost – with many of the objectives set for them (waiting times, numbers to treat etc) </li></ul></ul><ul><li>Commissioners/policy makers seek ‘allocative efficiency’ </li></ul><ul><ul><li>Maximise population health gain from a fixed allocation of resources </li></ul></ul>
  63. 67. About Costs … <ul><li>Direct : medical salaries, tests, drugs </li></ul><ul><li>Indirect : disability, illness, reduced productivity </li></ul><ul><li>Intangible : eg pain and suffering </li></ul><ul><li>Opportunity : what do we give up buying if we fund something else. </li></ul>
  64. 68. Four main approaches <ul><li>Cost minimisation analysis </li></ul><ul><li>Cost effectiveness analysis </li></ul><ul><li>Cost utility analysis </li></ul><ul><li>Cost-benefit analysis </li></ul>
  65. 69. Cost minimisation <ul><li>When all we want to look at is comparing one or more treatments/interventions on COST alone </li></ul><ul><li>Outcomes must be equal: ie … </li></ul><ul><ul><li>the number of patients roughly equal </li></ul></ul><ul><ul><li>The effectiveness of the treatments are equal </li></ul></ul><ul><ul><li>Years of life saved </li></ul></ul><ul><ul><li>Quality of life equal </li></ul></ul><ul><ul><li>Example might be prescribing around cholesterol … </li></ul></ul>
  66. 70. Cost effectiveness <ul><li>This tool is used when we want to compare two different types of treatment/intervention but where the type of outcome is the same (eg extra life years, or deaths prevented) </li></ul><ul><li>Where the amount (not type) of outcomes from two interventions are different, then the efficient choice is that which takes least resource to produce a good outcome – sometimes see the term Numbers Needed to Treat (NNT), eg two treatments which both prolong life in breast cancer… </li></ul>
  67. 71. Cost-utility Where the type and volume of outcomes from two interventions aren’t the same then we look for a ‘common outcome currency ‘ – eg QALYs (quality adjusted life years) – eg whether to prioritise hip replacements, coronary bypass operations or kidney dialysis – although different procedures, we could try to look at how they compare in improving quality of life – hence using the QALYs measure.
  68. 72. Cost- benefit <ul><li>Previous three compare one treatment with another, and use some kind of natural unit to measure their relative success (eg lives saved, QALYs, cost) </li></ul><ul><li>Cost benefit is used to compare ‘doing something’ with ‘doing nothing’, and places a monetary value on the outcomes </li></ul><ul><li>Example – one component of assessing the suitability for introduction of a new screening programme. </li></ul>
  69. 73. QALYs and DALYs Quality adjusted life years (years of healthy life lived) and disability adjusted life years (years of healthy life lost) are two commonly used measures to identify the burden of disease on a population. However, these are value laden and subject to interpretation. Without treatment ‘a’ With treatment ‘a’ Estimated survival 5 years Estimated survival 10 years Est QALY weight (from patient data) 0.5 Est QALY weight (from patient data) 0.7 QALYS =5x0.5 = 2.5 10 x 0.7 = 7 QALY gain from treatment a = 7 – 2.5 = 4.5 QALYS
  70. 74. Other terms … <ul><li>Programme Budgeting </li></ul><ul><ul><li>Understand current spend </li></ul></ul><ul><li>Marginal Analysis </li></ul><ul><ul><li>Where can we spend less so we can spend more elsewhere </li></ul></ul>
  71. 75. Thoughts and questions … <ul><li>The types of analysis described are sometimes not applied in a systematic way (despite best efforts) … </li></ul><ul><li>Sometimes we have good information about services, other times less so – how can we strike a balance between targeting ‘low hanging fruit’, versus the potentially richer pickings at the top of the tree … </li></ul>
  72. 76. Meaningful Patient Involvement Mark Drury
  73. 77. <ul><li>What do we mean by involvement? </li></ul><ul><li>A brief history of involvement </li></ul><ul><li>Why does this matter? </li></ul><ul><li>Making it fair! </li></ul><ul><li>Going forward in Oldham </li></ul>
  74. 78. What do we mean by involvement? <ul><li>Involvement in individual care: </li></ul><ul><ul><li>Patient choice </li></ul></ul><ul><ul><li>Shared decision making </li></ul></ul><ul><ul><li>Owning your own medical records </li></ul></ul><ul><li>Collective involvement in commissioning and delivery of services </li></ul><ul><li>Scrutiny and accountability </li></ul><ul><li>“ Nothing about me without me” </li></ul>
  75. 79. Involvement Model Informing Consulting Negotiating Participating Goal Provide balanced and objective information to assist patients/ communities in understanding the problem/ solutions/ alternatives etc. Obtain community feedback on analysis, alternatives and/or decisions. Work directly with patients/ communities to ensure concerns and aspirations are consistently understood and considered. Genuine partnership with community/ patients in each aspect of decision making. Promise We will keep you informed. We will keep you informed, listen to you and feedback on how decisions were influenced. We will work with you to ensure that your concerns and aspirations are reflected and provide feedback on how decisions were influenced. We will look for your input in formulating solutions and incorporate your input into decision making to the maximum extent possible.
  76. 80. History <ul><li>Paternalism </li></ul><ul><li>Deference </li></ul><ul><li>Unequal relationships </li></ul><ul><li>Lower expectations </li></ul>
  77. 81. Why does this matter? <ul><li>Increasing expectations </li></ul><ul><ul><li>Consumerism </li></ul></ul><ul><ul><li>Accountability </li></ul></ul><ul><li>User involvement = better outcomes </li></ul><ul><ul><li>Marketing principles </li></ul></ul><ul><ul><li>Evidenced </li></ul></ul><ul><li>Expectations of clinicians </li></ul><ul><li>Legal Compliance – NHS Act etc. </li></ul>
  78. 82. Making It Fair <ul><li>Everyone has a voice </li></ul><ul><li>Not 'who shouts loudest' </li></ul><ul><li>Proactive work into marginalised groups </li></ul><ul><li>Continuous dialogues – not 'hit and run' </li></ul><ul><li>Sharing agenda setting </li></ul><ul><li>Influencing each stage of the commissioning cycle </li></ul><ul><li>Honesty – what can be influenced </li></ul>
  79. 83. Methodology <ul><li>Governance </li></ul><ul><li>Grass roots/ community approach </li></ul><ul><li>Communications </li></ul><ul><li>Online – breadth of involvement </li></ul><ul><li>Face to face – depth of involvement </li></ul><ul><li>Opportunities for direct access to decision makers </li></ul><ul><li>Emphasis on listening </li></ul>
  80. 84. Key Outcomes <ul><li>People feel listened to, and valued </li></ul><ul><li>Timely feedback received by customers </li></ul><ul><li>People see evidence of action </li></ul><ul><li>Quality of commissioning decision making improved </li></ul>
  81. 85. Going forward in Oldham <ul><li>Public commitment made </li></ul><ul><li>Early work: </li></ul><ul><ul><li>Mandate </li></ul></ul><ul><ul><li>Patient Communities </li></ul></ul><ul><ul><li>Musculoskeletal conditions </li></ul></ul><ul><ul><li>GP development </li></ul></ul><ul><li>Developing the architecture: </li></ul><ul><ul><li>Strategic (incl governance) </li></ul></ul><ul><ul><li>Thematic </li></ul></ul><ul><ul><li>Experience </li></ul></ul>
  82. 86. Conclusion <ul><li>GPCC Commitment </li></ul><ul><li>Co-production </li></ul><ul><li>Breadth of involvement </li></ul><ul><li>Depth of involvement </li></ul><ul><li>Everybody's opinion counts </li></ul><ul><li>Be proactive to be inclusive </li></ul><ul><li>Sustainability </li></ul>
  83. 87. What matters to patients? Oldham Health Commission April 2011 Mandy Wearne Director Service Experience
  84. 88. Putting the ‘S’ back in to the NHS!
  85. 90. More interest less action? <ul><li>90% of the time, the minuted board action point on patient experience is to note the report and take no action </li></ul><ul><li>Examples where patient experience data is used to spark debate and action were rare, as were examples of non-executive directors challenging performance Intelligent Board series (2010) </li></ul>
  86. 92. Begins with… <ul><li>What matters to patients? </li></ul><ul><li>Identifies key service areas through ‘recognition events’ or touch points i.e. what makes a difference to users </li></ul><ul><li>Measures it, benchmarks and builds on it </li></ul><ul><li>Recognises and celebrates it! </li></ul>
  87. 93. Generic themes <ul><li>feeling informed about condition & available services </li></ul><ul><li>patient involvement in their care & treatment decisions </li></ul><ul><li>staff who listen and take time </li></ul><ul><li>the value of support services </li></ul><ul><li>efficient processes </li></ul><ul><li>being treated as a person, ‘not a number’ </li></ul>
  88. 94. What matters most to patients <ul><li>‘ transactional’ aspects of care (in which the individual is cared ‘for’), e.g. meets the preferences of the patient as far as timings and locations of appointments are concerned </li></ul><ul><li>‘ relational’ models (where the individual is cared ‘about’), e.g. care that forms part of an ongoing relationship with the patient </li></ul>Iles V and Vaughan Smith J. (2009) Working in health care could be one of the most satisfying jobs in the world - why doesn’t it feel like that?
  89. 95. Patient experience is closely related to and influences clinical effectiveness and safety <ul><li>Patient-centred organisations have better clinical outcomes </li></ul><ul><li>Doctor-patient communication leads to greater compliance in taking medication and self-management for people with long-term chronic conditions </li></ul><ul><li>Patient anxiety and fear can delay healing </li></ul>Patient experience Clinical effectiveness Safety
  90. 96. Getting the basics right!
  91. 97. Get the basics right – don’t leave it to chance Ensure staff are competent, Don’t loose my notes, Keep the place clean Fit in to my life – not force me to fit in to yours Make the service easy to access, Give me convenient options, Don’t waste my time Treat me as a person – not a symptom Listen to me and take me seriously , Understand the wider context of my condition, Treat me with respect and dignity Work with me as a partner in my health – not just a recipient of care Encourage me to keep control of the process, Equip me to look after my own health Give me the support I need
  92. 99. The evidence suggest patients want to feel better <ul><li>Research shows this is as much about:- </li></ul><ul><li>How they feel about the service they received (emotional experience) as </li></ul><ul><li>The clinical outcome they were seeking (PROM) </li></ul>
  93. 100. Recognises .. <ul><li>Recognise two important dimensions: </li></ul><ul><ul><li>What happens to patients and </li></ul></ul><ul><ul><li>How they feel about the experience </li></ul></ul>
  94. 103. <ul><li>Making it personal </li></ul><ul><li>Interactive session </li></ul>
  95. 104. Vital Sign Care Card <ul><li>‘ Real time’ user led capture of emotional and preferred service experience </li></ul><ul><li>Enable tailored care to clearly signaled patient wishes and direction </li></ul><ul><li>Consistent evidence based statements for comparative benchmarking over time </li></ul>
  96. 106. Principles <ul><li>Foster meaningful conversation ‘in the moment’/real time about an individuals emotional and preferred service experience </li></ul><ul><li>Enable care providers to offer tailored responses to clearly signaled patient wishes and direction </li></ul><ul><li>User led : (user asked to place the cards in order of importance to them) </li></ul><ul><li>Allow a person to express as many or as few of the 8 statements that apply </li></ul><ul><li>Provide an ‘Open Card’  – to allow for free expression and interpretation </li></ul>
  97. 107. Q. What mattered most to you? <ul><li>Self Confidence </li></ul><ul><li>Respect </li></ul><ul><li>Reassurance </li></ul><ul><li>Effectiveness </li></ul><ul><li>5. Safety </li></ul><ul><li>6. Comfort </li></ul><ul><li>7. Understanding </li></ul><ul><li>8. Honesty </li></ul>
  98. 108. Voting via SMS messaging Please TEXT the word ‘CARE’ followed by the number (1-8) to 60095   e.g. If Self Confidence your choice Text: CARE1 to 60095
  99. 109. Q. What mattered most to you? <ul><li>Self Confidence </li></ul><ul><li>Respect </li></ul><ul><li>Reassurance </li></ul><ul><li>Effectiveness </li></ul><ul><li>5. Safety </li></ul><ul><li>6. Comfort </li></ul><ul><li>7. Understanding </li></ul><ul><li>8. Honesty </li></ul>Please TEXT the word ‘CARE’ followed by the number (1-8) to 60095
  100. 110. <ul><li>Experience and the new opportunity </li></ul><ul><li>The challenge is more than just money </li></ul><ul><li>Need to invest in a different offer </li></ul><ul><li>Reshaping the business processes to reflect a different offer for the public </li></ul><ul><ul><li>New relationship that builds on personal assets as well as service needs </li></ul></ul><ul><ul><li>Patient experience as a driver for NHS efficiency </li></ul></ul><ul><ul><li>GP consortia – a step closer to patient led commissioning </li></ul></ul>
  101. 111. <ul><li>Build local reputation and loyalty (by commissioning what matters locally. building reputation/loyalty – spread of the branding, service recovery paradox) </li></ul><ul><li>Improve quality (through personalised care outcomes: -clinical, patient reported and patient experience) </li></ul><ul><li>Improve efficiency (by identifying process improvements and wasted effort, increasing productivity by commissioning for patient experience and not the organisation) </li></ul><ul><li>Improve financial outcomes (e.g. Cost to serve savings, ROI, staff retention, reduction in staff sickness and complaints) </li></ul>Experience and efficiency
  102. 112. <ul><li>The ‘ value’ of experience </li></ul><ul><ul><li>Worth - price and cost, </li></ul></ul><ul><ul><li>Importance - usefulness, consequence </li></ul></ul><ul><ul><li>Appeal - attraction and pull </li></ul></ul><ul><ul><li>Measure – quantitative and qualitative </li></ul></ul><ul><li>The value of ‘good’ experience </li></ul><ul><ul><li>At every level, </li></ul></ul><ul><ul><li>Every bit of the journey </li></ul></ul><ul><ul><li>For both staff, patients and the public </li></ul></ul><ul><ul><li>Across care pathways and agencies </li></ul></ul>
  103. 113. <ul><li>The ultimate business question…. </li></ul><ul><li>‘ Did you get the care that mattered to you?’ </li></ul>