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NHS East of England




       Long Term Conditions


    What’s wrong and what do we need?



    Dr Steven Laitner, Co-C...
A significant challenge

1. “ARCTIC”                    Real funding cuts (First 3 years: -2%, next 3 years, -1%)
2. “COLD...
• What’s the problem with LTC Care




                                     ©2009 . Private and Confidential
HCC National
Patient Survey
                 ©2009 . Private and Confidential
….and


• 82% of those with an LTC want to do more self care


• 75% would feel confident about self care if they had more...
….and some quotes from our Service User
Reference Group

         “recognise the “patient” as an expert in themselves
    ...
What’s the problem – care model?



• An overly medical and paternalistic model

• Insufficient personalisation, support f...
Musculoskeletal programme- variation in knee replacement costs



                                                        ...
What’s the problem – system?
• Inexorable demand with an forthcoming unprecedented
  reduction in resources
  (we need to ...
• So what can we do about it?




                                ©2009 . Private and Confidential
©2009 . Private and Confidential
OUR VISION FOR LTCs

• Personalisation
 –   Person not Long Term Condition Label
 –   Holistic Health - Physical, Emotiona...
so what “new” do we need to buy?



•   Demand Mx including Admission Avoidance
•   Specialist advice and support to 1’ ca...
Individual ’s story                              Professional ’s
                                                         ...
The clinic
                                Access &                             experience                          Named
...
The clinic
                                Access &                             experience                          Named
...
Decision Aids reduce rates of
                discretionary surgery
                                 0%       25%   50%   ...
Hysterectomy
          $0    $500         $1,000       $1,500   $2,000   $2,500




                        Standard
     ...
GIVE PEOPLE THE CARE THEY NEED AND NO
                 LESS,
    THE CARE THEY WANT AND NO MORE
A Whole Pathway Approach
Where do we buy it from?
The traditional
   commissioner approach
• The traditional providers and…
• The “add ons”
Traditional model – methods of controlling
Demand and delivering savings
My proposed
 transformational approach
• An integrating “pathway hub approach” with whole
  pathway (programme budget) cli...
Programmed budget model
Demand management
A Pathway Hub or
Whole Pathway Provider/ Prime Vendor and
           Subcontractor to:
• Provide, performance manage and s...
Summary - what do we need?

•   Support for Personal Health Planning
•   Support for Self Management/ Self Care
•   Naviga...
There are no short cuts to any
        place worth going



              Beverly Sills

steven.laitner@nhs.net
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
Long Term Conditions: Long Term Conditions  What’s wrong and what do we need?
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Long Term Conditions: Long Term Conditions What’s wrong and what do we need?

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Dr Steven Laitner (Co-Chair of the NHS East of England Long-Term Conditions Programme Board, GP and Associate Medical Director)
Steve will talk about the East of England Vision for improving the lives of people with Long Term Conditions like COPD, diabetes, CHF etc. He will then talk about the need for innovation to support patients in managing their own long term conditions and improving their health and the productivity of health services.

Published in: Health & Medicine
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Long Term Conditions: Long Term Conditions What’s wrong and what do we need?

  1. 1. NHS East of England Long Term Conditions What’s wrong and what do we need? Dr Steven Laitner, Co-Chair, LTC Programme Board ©2009 . Private and Confidential
  2. 2. A significant challenge 1. “ARCTIC” Real funding cuts (First 3 years: -2%, next 3 years, -1%) 2. “COLD” Zero real growth (0% every year) 3. “TEPID” Real increase (First 3 years: 2%, next 3 years, 3%) Tepid £ millions (2010/11 prices) Cold Arctic Source: “How cold will it be? Prospects for NHS funding 2001-17”, The Kings Fund, July 2009 ©2009 . Private and Confidential -2-
  3. 3. • What’s the problem with LTC Care ©2009 . Private and Confidential
  4. 4. HCC National Patient Survey ©2009 . Private and Confidential
  5. 5. ….and • 82% of those with an LTC want to do more self care • 75% would feel confident about self care if they had more guidance/ support • Half did not have a clear plan • More than half had not been encouraged to self care MORI ©2009 . Private and Confidential
  6. 6. ….and some quotes from our Service User Reference Group “recognise the “patient” as an expert in themselves “listen to us” “don’t only concentrate on the clinical” “be aware that management of the LTC is only a small part of my life” “I want to be seen as a whole person” “support us in seeing the same GP more than once!” “stop using language and knowledge as a barrier” “come down to our level” “speak to me with respect” “ don’t give too much information in one go” ©2009 . Private and Confidential
  7. 7. What’s the problem – care model? • An overly medical and paternalistic model • Insufficient personalisation, support for self care or Informed Decision Making • Variable service quality and customer experience • Lack of integration: – Generalist and specialist care – Physical and mental health – Medical and nursing, therapy – Medical and social • Unwarranted Variation in activity ©2009 . Private and Confidential
  8. 8. Musculoskeletal programme- variation in knee replacement costs Primary Knee Replacement - AgeSexNeeds standardised cost per 1000 population for PCTs 14,000 AgeSexNeeds standardised cost (£ 12,000 per 1000 population) 10,000 8,000 6,000 4,000 Top 30 PCTs (Lowest Rates) 2,000 Next 31 PCTs 0 1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 Next 30 PCTs PCT Next 31 PCTs Bottom 30 PCTs Primary knee replacements cost £5,808. (Highest Rates) There is a 4-fold variation in expenditure between PCTs (adjusting for age, sex and need). The coefficient of variation is 21.0%. (This takes into account all PCTs, not just the top and bottom PCTs.) The potential savings are £39M London (if PCTs with rates higher than the median reduced to this level). Total Inpatient Potential Saving using Potential Saving as % of Expenditure (£M) 50th percentile (£M) Total Inpatient Expenditure 392 39 10.0% 8
  9. 9. What’s the problem – system? • Inexorable demand with an forthcoming unprecedented reduction in resources (we need to do much better with much less) • Historical inability to manage demand using current levers • Poor alignment of incentives • “Micro-contracting” of an incredibly complex business process/ care pathway/ supply chain • Lack of clinical and financial management and accountability across the pathway
  10. 10. • So what can we do about it? ©2009 . Private and Confidential
  11. 11. ©2009 . Private and Confidential
  12. 12. OUR VISION FOR LTCs • Personalisation – Person not Long Term Condition Label – Holistic Health - Physical, Emotional and Social – Care according to needs and preferences – Patient outcomes as well as clinical outcomes and experience – Personal Health Planning • Self Care and “co-production” – Supported Self Care – Rehabilitation – Personal Health Planning • Commissioning of Long Term Conditions – Co-production at the strategic level – Whole pathway approach – User and carer engagement in re-commissioning ©2009 . Private and Confidential
  13. 13. so what “new” do we need to buy? • Demand Mx including Admission Avoidance • Specialist advice and support to 1’ care • Referral triage • Primary care clinical management (QOF++) • Shared Decision Making • Personal Health Planning • Supported Self Care • Holistic Biopsychosocial Approach • Integration • The “Holy Grail” of clinical and financial accountability ©2009 . Private and Confidential
  14. 14. Individual ’s story Professional ’s story Knowledge and health Emotional Behavioural Social Clinical beliefs Share and discuss information Goal Setting Action Action Action Action
  15. 15. The clinic Access & experience Named communication contact Registration, IT recall, review, templates Organisational and follow up processes Awareness of Awareness of process & options approach to self- partnership working HCP committed to Professional ’s Individual ’s story management informed patient story Structured education/ Knowledge Consultation Engaged, Emotional Behavioural Social Clinical Information and health beliefs skills / competencies Access to own Share and discuss information records Multi-disciplinary Goal Setting team working Pre-consultation results Knowledge of local options Emotional & Action Action Action Action psychological Clinical expertise support Commissioning - The foundation
  16. 16. The clinic Access & experience Named communication contact Registration, IT recall, review, templates Organisational and follow up processes Awareness of Awareness of process & options approach to self- partnership working HCP committed to Professional ’s Individual ’s story management informed patient story Structured education/ Knowledge Consultation Engaged, Emotional Behavioural Social Clinical Information and health beliefs skills / competencies Access to own Share and discuss information records Multi-disciplinary Goal Setting team working Pre-consultation results Knowledge of local options Emotional & Action Action Action Action psychological Clinical expertise support Commissioning - The foundation Measurement Commissioning Developing Linking micro- User Money / care planning the menu to macro- involvement contracts
  17. 17. Decision Aids reduce rates of discretionary surgery 0% 25% 50% 75% CA-Prostatectomy CAOrchiectomy* coronary bypass* coronary bypass hysterectomy . hysterectomy* mastectomy back surgery Standard Care mastectomy* D-Aid bphprostatectomy bphprostatectomy RR=0.76 (0.6, 0.9) O’Connor et al., Cochrane Library, 2009
  18. 18. Hysterectomy $0 $500 $1,000 $1,500 $2,000 $2,500 Standard care, $2,751 Video Decision Aid , $2,026 Video Decision Aid plus Coaching, $1,566 Kennedy et al. JAMA2002; 288: 2701-2708
  19. 19. GIVE PEOPLE THE CARE THEY NEED AND NO LESS, THE CARE THEY WANT AND NO MORE
  20. 20. A Whole Pathway Approach
  21. 21. Where do we buy it from?
  22. 22. The traditional commissioner approach • The traditional providers and… • The “add ons”
  23. 23. Traditional model – methods of controlling Demand and delivering savings
  24. 24. My proposed transformational approach • An integrating “pathway hub approach” with whole pathway (programme budget) clinical AND financial responsibility
  25. 25. Programmed budget model Demand management
  26. 26. A Pathway Hub or Whole Pathway Provider/ Prime Vendor and Subcontractor to: • Provide, performance manage and subcontract • Deliver Care Closer to Home (an alternative to hospital outpatients) • Identify and meet training needs of primary care • Ensure quality and VFM from 1’ Care • Manage the demand for secondary care services • Improve population and individual health (includes prevention responsibility) • Ensure provision of self care support, care planning, informed decision making • Manage the Programme Budget(s) on your behalf ALIGNING CLINICAL AND FINANCIAL INCENTIVES -CLEAR ACCOUNTABILITY ACROSS THE PATHWAY
  27. 27. Summary - what do we need? • Support for Personal Health Planning • Support for Self Management/ Self Care • Navigation support • Support for Informed Decision Making • Access to information • Access to support • Empowering services • Oh….and a integrating provider/ provider group to do this and more…..
  28. 28. There are no short cuts to any place worth going Beverly Sills steven.laitner@nhs.net

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