Dr Declan O'Neill: Implementing the decision: a story about prioritising
Implementing the decisionCase Study: NHS West Kent prevention strategy A Story about Prioritizing Dr. Declan O’Neill Director Public Health Improvement
Experience from a PCT’sStrategic 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
Key components of the PlanningProcess which developed ‘Prevention’as an integral part of the PCT’sStrategic Commissioning Plan1. A programme budget based SCP2. Adoption of a ‘fully engaged prevention scenario’3. An ‘economic approach’ to prevention using predictive model based on attributable fractions for major health risks4. To be funded in year two of SCP from development monies delivered by year one efficiencies
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
The financial environment Funding shortfallNHS funding 1995 2000 2005 2010 2015 2020 2025 Year
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 illnessesThereby restraining projected growth in the demand for treatment of illnessSo a “Fully Engaged Prevention Scenario”in West Kent meant modelling against real costs of care
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
Expenditure of NHS WK attributable topreventable ill health vsExpenditure on Prevention Spent on Prevention Preventabl <1% e 25% Non- Other PCT spend preventabl 99+% e 75%
To work all this out requires a fairly robust predictive model intowhich is fed year on year population age groups, prevalencepredictions morbidity costs and impacts of prevention.
Out of which comes a projected returns inmorbidity savings versus costs of programmes
Enabling you to go to the payer with aprediction of returns on investment from aprevention programme which makes goodeconomic 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
Short and Longer termSuch programmes are predicted to:• break even in about c. 5yrs• start returning investment around 7 years• Significantly multiply their returns after 10 years
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
What happened next? Other demands popped up andconsumed the supply at similar rates to before. Why?
In our environment the system appears to defaultto acute care. Is there mal-distribution of careprovision? 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
If we think there is mal-distibution of care is it demonstrably inefficient? Care Types Prevention Primary Community Acute SocialSuggested imbalance in distribution of care types which drives default to acute services
Addressing Maldistribution or moving care upstream:Bottom line assumption that major change needed at5 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
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
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
Imbalance will right itself!(Or possibly move in that general direction?) Care Types Prevention Primary Community Acute Social
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.
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.
• 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.
WHAT WAS DONE• A team of clinical auditors undertook a point prevalence (snap shot)study of admission appropriateness and subsequent appropriate use ofacute care on a specific day of care, through an audit of 344contemporary inpatients’ medical records using an updated version of avalidated and widely tested instrument AEP.• All of the notes completed on day of the admission were scanned bythe clinical reviewer against a set of ‘admission-day criteria’.• Similarly, all of the notes completed on a specific (subsequent) day ofstay were scanned by the clinical reviewer against a similar, (not thesame), set of ‘day of care criteria’.
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?
• 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.