Early Implementers Workshop 23rd March 2016

www.england.nhs.uk
23rd March 2016
10.30am – 3.30pm
WELCOME!
LtC Year of Care
Commissioning
EIS and LTC Community of
Practice Workshop

www.england.nhs.uk
• National context
• Integrated intelligence – Kent
• Use of the linked data - Leeds
• Health 1000 – BHR
• LTC animations
Introductions and outline of today:

www.england.nhs.uk
• To understand national context and thinking around LTC
care for the future
• To hear and learn from LTC YoC Commissioning
Programme EIS around key achievements as at end
national programme
• To develop local thinking for 1617 and beyond
• To network and share knowledge
• To contribute to the development of the LTC framework
animations card game
Learning Outcomes:

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National Update
Julie Renfrew

www.england.nhs.uk
• 4 year national programme 2012 to 2016
• Lots of learning shared
• NOT the end of the work
• Close of the proof of concept stage - transition now to
mainstreaming.
• EIS plans / work in 15/16 to embed YOC
Commissioning outputs into operational processes
Long Term Conditions Year of Care
Commissioning Programme

www.england.nhs.uk
LTC Framework
Commitment
to Carers
Frailty
Health Ageing
Guide
Fire Service as
an asset
Care Homes
Quick Guides
Care & Support
Planning
Navigating Health
& Social Care
Self Care
Ambitions for
End of Life Care
Our Declaration
Delivery Models
Planning for Change:
• Capitated Budget
• Contracting
• Simulation Modelling
Patient and
Service
Selection
Planning for Change:
Workforce
Whole Population
Analysis;
Understanding your
population
LTC Dashboard LTC Toolkit

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Long term conditions resources
Simulation model
Unbundling recovery simulation model

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7
Using behavioural
change to open
minds
o Make a declaration at
www.engage.england.nhs.uk/survey/ltc
-declaration
o Tell your teams about our work
o Encourage them to make a declaration
o Ask them to feed back thoughts and
ideas
o Use our hashtag – #A4PCC – when
you see work that is relevant to
person-centred care for people with
LTCs
o Let us know of any events, activities or
social media opportunities that we can
join forces with you
#A4PCC – Action for Person-
Centred Care
Person
with long
term
condition

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National Context and
Perspective for 2016/17
Jacquie White
NHSE

www.england.nhs.uk
LTC care for
the future:
Person Centred
Co-ordinated
Care
Jacquie White
Deputy Director - Long Term
Conditions, Older People and End
of Life Care
Clinical Policy & Strategy Team
NHS England
23rd March 2016

www.england.nhs.uk
Opening thought
The good physician treats
the disease; the great
physician treats the patient
who has the disease.
William Osler - 1800s
11

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What’s the
diagnosis?

www.england.nhs.uk 13
1m
People with frailty
10m
People have two
or more LTCs
0.5m
At end of life
16m
People have one
LTC
Long term conditions: some facts

0.01%average no. hours
per year spent
with health
professional
33%70%health budget
spent on LTCs
3.2%
of people with LTCs
have a care plan
of GP consultations are
with people with multi
LTCs

50 50
96 4
50% of total emergency beds
days for over 75s
4% over 65s in care home
with 14% total emergency
admissions for over 65s
2570 25% of hospital beds
occupied by someone dying
Three-fold increase in cost
of health care with frailty

www.england.nhs.uk
16
1 in 9
1 in 5
received no practical support with
caring
Nearly 1 in 2
(46%) said they had fallen ill but just had to continue
caring
£1bn
in Carer’s Allowance goes unclaimed each year
said the person they cared for
had emergency admission or
social services while the carer
recovered from illness

www.england.nhs.uk
People living longer but not always well
The larger the number of co-morbidities a patient
has, the lower their quality of life
Increasing evidence on over-treatment and harm
Social isolation/loneliness a risk factor for mortality in
over 75s and should be supported as a co-morbidity
And…
24/03/2016

www.england.nhs.uk
Wellbeing is about more than just
medically managing a condition
It’s about thriving not just surviving
It’s an ethical, social and financial
issue
Shared decision-making is key
We need to take support people to
self-care, feel in control
No one knows more about their
condition than the patient
Navigating health and care: Living independently with long
term conditions, an ethnographic evaluation
• http://www.nhsiq.nhs.uk/improvement-programmes/long-
term-conditions-and-integrated-care/navigating-health-
and-care.aspx
18
Why does it matter to people with
LTCs?

www.england.nhs.uk
• More activated patients have 8% lower costs in the base year and 21% lower
costs in the following year than less activated patients
• Health coaching can yield a 63% cost saving from reduced clinical time, giving a
potential annual saving of £12,438 per FTE from a training cost of £400
• Coaching and care co-ordination has shown to reduce emergency admissions by
24%
• Social prescribing can reduce emergency admissions by 11%
• Timely physiotherapy for people with MSK conditions can save £1.50 for every
£1 invested
• Community-based neurological care models could save the NHS £369,286 per
patient over 10 years
• Improved medication adherence for instance in 6000 adults in the UK with Cystic
Fibrosis, could save more than £100 million over a 5-year timescale
• Proactive case finding, frailty assessment, care planning and targeted
intervention could prevent between 20% and 30% of hospital admissions in over
85’s
• Areas that have implemented EPaCCs* see an increase in home deaths and
annual savings of £35,910 per 200,000 population
*Electronic Palliative Care Co-ordination system
19
Benefits to all

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The
“treatment”

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Person centred
coordinated care
“My care is planned with people who
work together to understand me and my
carer(s), put me in control, co-ordinate
and deliver services to achieve my best
outcomes”
Goal:
Improve quality of life and experience of
end of life care for people with Long
Term Conditions and their carers
through:
21

www.england.nhs.uk
Framing delivery….
LTC Framework:
Empowered patient and carers
Professional collaboration
Best Practice (clinical and organisational)
Commissioning
Delivering Person Centred Co-ordinated
Care
Cf: ‘Roadmap for Strengthening people-centred health systems in the WHO
European Region: A Framework for Action towards Coordinated/Integrated
Health Services Delivery (CIHSD)’ (WHO 2013)

www.england.nhs.uk
The Framework
23
Organisational &
Clinical Processes
Informed and
engaged patients
and carers
Health & Care
Professionals
committed to
partnership
working
Commissioning
• Information and
technology
• Case finding & risk
stratification
• Guidelines,
evidence and
national audits
• Self Management
• Patient activation
• Health literacy
• Group and Peer
Support
• Care Planning
• Carer support
• 3rd sector support
• Community
mobilisation
• Integration of
services
• Multi Disciplinary
Teams
• Health coaching
• Clinical activation
• Workforce
development
• Care Co-ordination
• Place based
approach to needs
assessment and
planning
• Joint Commissioning
• Joint funding (BCF,
shared risk and
reward)
• Metrics and
Evaluation
• Service User and
Public Involvement
Key factors needed to deliver Person Centred Coordinated Care and that are
being supported nationally:

www.england.nhs.uk
The
“review”
24

www.england.nhs.uk
The LTC Year of Care journey
National
initiatives
(pre
2012)
Health &
Social
Care Act
(2012)
National
Collaboration
for integrated
care (2013)
Person
centred
co-
ordinated
care: LTC
framework
(2013)
Five year
forward
view
5YFV
(2014)
Post
election
(2015)
Integration
pilots,
Community
Matrons, Self
management,
Technology,
PHB,
LTC Year of
Care
Commissioning
Programme
“Duty”, New
organisations,
roles and
responsibilities
– Local,
National
National
support –
Narrative,
definition,
Better
care fund,
Integration
pioneers
Permissive
framework for
local
implementation –
House of Care
Clarity of vision,
priorities, new
national
programmes:
“new models of
care”,
“integrated
personal
commissioning”
LTCs
embedded
in all
programm
es, Self-
care
priority,
STPs
25
LTC Year of
Care:
Development
year and site
selection
LTC Year of Care:
1st year –
experimentation
to define scope
LTC Year of
Care:
2nd year –
technical
phase (data
and
analysis)
LTC Year of
Care:
2nd year –
technical
phase (data
and analysis
LTC Year of
Care:
3rd year –
development
of currencies
and new
delivery
models
LTC Year of
Care:
4th year –
implement
currencies,
testing
delivery
models and
capitated
budgets.

Celebrating success

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Sharing the LTC YoC learning
27
1. Handbook and case studies:
• Leadership and engagement
• Co-production
• Whole population diagnostic
• Patient & Service Selection
• Delivery Models
• Defining and managing a budget
• Contracting and performance monitoring

2. Communication and promotion:
• Nationally & Internationally
• Presentations, articles, social media
3. Supporting other programmes/initiatives:
• STPs, Vanguards, IPCs, Maternity review etc
4. EIS roles:
• Local sharing and input into wider plans
• 6 – 12 months f/u
• What else?

www.england.nhs.uk
Continuing to implement and push
the boundaries
29

www.england.nhs.uk
And finally - the world we operate
in…
30
I can't change the direction of the
wind, but I can adjust my sails to
always reach my destination.
Jimmy Dean

www.england.nhs.uk
@jaqwhite1
#A4PCC
jacquie.white@nhs.net
www.england.nhs.uk/resources/resources-for-ccgs/out-
frwrk/dom-2/
31
Thank you

www.england.nhs.uk
Working in partnership
across Kent developing
integrated intelligence
Kent LTC YOC Commissioning EIS

Year of Care Early Implementer
Workshop
23rd March 2016
Kent Long Term Conditions Year of Care
Commissioning Programme

Content
1. Public Health leading the informatics dimension using their
statutory powers – Abraham George
2. The Kent approach to linking data, and identifying YOC patients–
Pete Gough
3. The programme structure – for post Year of Care – Abraham
George
4. Data Quality Improvement – Tom Bourne
5. Using the linked dataset for Matched Cohort studies – e.g. Home
Safety Visits – Abraham George, James Finch (Kent Fire and
Rescue)

1. Using Public Health Powers
Abraham George, Consultant in Public Health

Context - Local Profile of Kent
• >1.5 million population www.kpho.org.uk
• Health and care service planning at multiple levels
• Public Health Intelligence works closely with local data
warehouse team that collates and link data from >100
health and care providers
• Kent LTC YOC programme – Year 4 out of 4
• 1 of 5 national early implementer sites
• Part of national Integration initiatives eg. Pioneer,
Vanguard, Integrated Personal Commissioning etc.
• Kent whole population dataset analyses examining
impact of multi-morbidity on health and care service
activity and costs.

Public Health Statutory Powers• Health and Social Care Act 2012 - Councils have a statutory responsibility for improving the health
of their citizens and for providing local public health services
• Includes a duty to take appropriate steps to improve the public health of people in our area -
include carrying out research, providing information, advice and facilities for the prevention and
treatment of illness and providing incentives to encourage the adoption of healthy lifestyles. We
also seek to minimise health risks to individuals arising from poor accommodation, environment or
other factors.
• Public Health has a statutory right to access and use your confidential information, but only does
so when absolutely necessary e.g.
– Organising the National Child Measurement Programme;
– Organising the NHS Health Check Programme;
– Organising and supporting the 0-5 health service and school nursing services;
• Statistics and intelligence are gathered about health and social care in order to meet our statutory
duties to produce:
– Director of Public Health’s Annual Report;
– Joint Strategic Needs Assessment; (Care Act 2014)
– Health and Wellbeing Strategy;
• We have a statutory responsibility to assess risks to public health arising from inequalities in
health care provision, poor quality or inappropriate housing, lifestyles, education and employment,
communicable diseases, chemicals, poisons, radiation and environmental health hazards.
• Public Health are also supporting CCG’s with regard to Section 3 NHS Act 2006 Under section
3(1), a CCG must arrange for the provision of certain specified health services to such extent as it
considers necessary to meet the reasonable requirements of the persons for whom it has
responsibility.

Why public health?
• Statutory powers
• Located in council
• Central position covering all CCG areas
• Informatics expertise
• Health intelligence expertise
• JSNA

Legal ways to link data
Four choices for sharing confidential data about
groups and populations:
• Consent (will generally need to be explicit rather
than implied)
• HSCIC power
• Support under s251 Regulations
• Anonymised/pseudonymised data
39

Pseudonymisation Options
Option 1: Pseudonymisation at Source (no re-
identification);
Option 2: Pseudonymisation at Source (variation using
Public and Private Key);
Option 3: Pseudonymisation on Landing;
Option 4: Full Consent;
Option 5: Section 251 application to the CAG;
Option 6: Department of Health issued directions to HSCIC
(and therefore DSCROs);
Option 7: A mix of the above (e.g. Southend-on-Sea).

Key Challenges
1. Information Governance
– Current approach to data sharing has been difficult –
different expert opinions on how to share / link data
2. Data quality and accessibility
– Good support from provider organisations
– Quality / completeness of data variables across
different organisations
3. Commissioner buy-in

Key Successes
1. Establishment of partnerships
2. Range of analytical projects to support commissioners
respond to national direction on payment systems
3. Enhanced data quality discussions with providers
(prompted by analysis of linked dataset)
4. Generation of research and development opportunities
with academia (PSSRU & Farr institute)
5. Raising awareness of informatics within local authority
6. Exploring new applications of linked datasets (e.g.
systems modelling)

2. The Kent approach to linking
data, and identifying YOC patients
Pete Gough, HISbi manager

Defining Methodology
Identify Year of Care Patient Cohort
Risk Strat Band 1 or 2 (top 5% of popn)
Rising Risk score –
Rapid – 3 consecutive rises (15 points overall)
Gradual – 4 rises in 6 months
Age 18 or over
2 or more of QOF LTCs (from GP data)
Remain in for minimum 6 months
Flagged as B,C,D,E depending on number of
LTCs

How to create main dataset
Key is to link data at a patient level
Need common identifier – NHS Number
Also need to keep data pseudonymous
THIS WAS A PROBLEM!!!!
A REAL PROBLEM
Took 6 months to solve

Solution:
Need method for organisations to flow
data into dataset pseudonymised but flag
as YoC
SQL Hashing Tool – via SQL Server
directly or via excel add in
Two numbers never exist in same place –
pseudonymisation happens in transit

Now have a way of linking all datasets
by patient without knowing who they
were or being able to link to any other
dataset
There was much rejoicing

3. Programme structure for
post–Year of Care
Abraham George, Consultant in Public Health

Implementing Integrated Payments
Linked
Dataset
HISbi
Providers
Change Management, Engagement, Governance
Programme Management
Data
Quality
PH
Informatics
Analysis
PH
Model of Care
Implement
Payment
Arrangements
Contracts
Design of
Payment System

Flow of data into the Kent Integrated Dataset
GP practice Mental
health
Out of
hours
Acute
hospital
HospiceAdult social
care
Ambulance
service
KENT INTEGRATED DATASET
Kent County Council Public Health and HISBI data
warehouse
Community
health
Public
health
KID minimum dataset: data on activity, cost, service/treatment received, staffing, commissioning and
providing organisation, patient diagnosis, demographics and location.
Datasets linked on a common patient identifier (NHS
number) and pseudonymised
Arrangements are in progress to link to data covering other services, including:
Health and social care services: Children’s social care, child and adolescent mental health, improving access to
psychological therapies, and non-SUS-reported acute care.
Non-health and social care services: District council, HM Prisons, Fire and Rescue, Probation, and Education.

C
KENT INTEGRATED DATASET
Ongoing data quality improvement efforts, to ensure data is of sufficient quality to
support new payment systems and decisions on service reconfiguration
1. CAPITATED BUDGETS 2. SYSTEM MODELLING 3. EVALUATION
1. Select Cohort/
population
2. Select services
3. Set the price
4. Financial risk mitigation
5. Payment cash flows
6. Gain/loss agreements
7. Quality/outcome
measures
1. Generating evidence-based
assumptions to support
systems modelling
2. Quality assuring and
refining existing models
Activity
Finance
Staffing Estates
Quality and safety
Contract model
1. Evaluation of
commissioned
services.
2. Attempts to identify
the economy,
efficiency and
effectiveness of
individual services.
3. Assessing the relative
benefit of services
compared to one
another.
Utility of the Kent Integrated Dataset

4. Data Quality Improvement
Tom Bourne, Senior Analyst

Why invest resource in data quality?
• The Kent Integrated Dataset (the KID) will serve at least 3 important purposes:
1. To generate budgets for integrated care services
2. To evaluate complex care models (and interventions)
3. To generate assumptions to support systems modelling
• Whether service providers, commissioners, and finance managers will accept
the KID’s evidence will depend on the assurances we can give on data quality.
• Or, put more positively, data quality can give service providers the confidence to
change services or payment systems for the benefit of patients
Context

Data quality efforts
Recording
and
prioritising
gaps
1. Formal data
reconciliation exercise
with East Kent
Federation of CCGs
2. Data quality clauses
in CCG commissioning
contracts (working with
CSU)
3. Informal data quality
discussions with
providers via Kent
Wide Finance and
Informatics Group
(supported by data
quality dashboard)
4. Working with
University of Kent to
establish whether the
cost and activity data
we hold is of sufficient
quality to support new
payment models
5. Compiling a
comprehensive data
dictionary
Data quality
improvement plan

Recording
and
prioritising
gaps
1. Formal data
with East Kent
Federation of CCGs
CSU)
discussions with
providers via Kent
Wide Finance and
Informatics Group
(supported by data
quality dashboard)
4. Working with
payment models
5. Compiling a
comprehensive data
dictionary
Data quality
improvement plan
Q, Do we have sufficient cost and activity data to support the
development of new payment systems?

Recording
and
prioritising
gaps
1. Formal data
with East Kent
Federation of CCGs
CSU)
discussions with
providers via Kent
Wide Finance and
Informatics Group
(supported by data
quality dashboard)
4. Working with
payment models
5. Compiling a
comprehensive data
dictionary
Data quality
improvement plan
Q, Is the quality of our data stable over time?

Data quality dashboard
1. This first version of the dashboard concentrates on the completeness and longitudinal stability of the key data
fields and aims to introduce an element of competition around compliance by providers and CCGs.
2. We are now discussing ‘fatal quality thresholds’. On stability, this could be set at 5%, meaning that if in one
month we received a dataset with only 94% of the number of records received from a data provider in the
previous month, then this would be flagged for further discussion.

Recording
and
prioritising
gaps
1. Formal data
with East Kent
Federation of CCGs
CSU)
discussions with
providers via Kent
Wide Finance and
Informatics Group
(supported by data
quality dashboard)
4. Working with
payment models
5. Compiling a
comprehensive data
dictionary
Data quality
improvement plan
Q, Do we have sufficient data to support new payment models?

PSSRU work- regression model to
identify drivers of average total cost
Multi-morbidity
Age
Sex
Risk score
(& previous use)
Controlling for
practice led
variation
Average Total Cost (ATC)
Predictors Explaining up to a third of the
variation in ATC
Q, Can we use these drivers to segment the population into cohorts
to build tariffs?
£1,014 across all
population
£1,708 across just
service users

PSSRU work - quantify likely
uncertainty/tolerance
£1,500- 1SD
- £200
+ 1SD
+ £200
Q, Will average costs produced from the dataset be sound
predictors of future prices to support risk sharing decisions?

Recording
and
prioritising
gaps
1. Formal data
with East Kent
Federation of CCGs
CSU)
discussions with
providers via Kent
Wide Finance and
Informatics Group
(supported by data
quality dashboard)
4. Working with
payment models
5. Compiling a
comprehensive data
dictionary
Data quality
improvement plan
Q, What have we learnt to date?

GP practices: need to focus efforts on West of the county (and
better understand any bias introduced by ‘patchy’ coverage)
14 of 19
flowing
15 of 17
flowing
18 of 21
flowing
19 of 29
flowing
34 of 34
flowing
20 of 61
flowing
8 of 14
flowing
Also need better assurance over the quality of GP read coding,
which we are using to define LTCs

High cost
drugs
GP
prescribing
data
Maternity
(non-
delivery)
IAPT
Pathology
Community
Wheelchairs
Sexual
health
Community
paediatric
services
For some we
have been able
to develop a
plan to bring in
Some we are unlikely
to ever get
For some datasets,
the impact is large,
and the ‘fix’
complicated, so we
will need to develop
temporary mitigation
strategies and
communicate
approximate nature
There are several healthcare activities, accounting for
significant chunks of expenditure, on which we are not yet
capturing data
However, we are reasonably confident we can ‘account’ for this expenditure
(known unknown) and must now prioritise sourcing this data and bringing it into
our dataset.

Data quality improvement plan
Quality dimension Research ready? (1-10)
Accuracy 5
Timeliness and punctuality 10
Accessibility and clarity 2
Comparability: geographic 6
Comparability: other units of healthcare 7
Comparability: over time 7
Coherence Yet to be scored
Relevance 6
Additional: External comparison Yet to be scored
Additional: Uniqueness 7
Additional: Engagement of data providers 9
Additional: Engagemenf of data users 5 (and rising)

5. Matched Cohort Studies
Gerrard Abi-Aad and James Finch

Matched cohort analysis of Kent Fire and
Rescue Home Safety Visit Data
Gerrard Abi-Aad, Head of Health Intelligence, Kent
County Council
Version: 01
Last updated: March 2016

Background
Increased interest in exploring the ‘hidden’
benefits of public services – fiscal constraints
coupled with a recognition of the need for
improved cross sectoral joint action.
Kent Integrated Dataset – enhanced
opportunity to evaluate ‘hidden impacts’
through data linkage techniques and
advanced analytics
71

Identification of the final ‘Intervention’ cohort
KFRS –
HSV data
72
Kent Patient
Master Index
(March 2015)
Individuals requesting and
receiving a HSV
(30,601, 01 April 2012 to 31
March 2015)
Initial NHS
number
matching
11,377 / 30,089
(37.8%)
2nd stage
matching to
identify
householders
Final intervention
cohort HSV (requesters
+ ‘presumed’ occupants)
27,021* (15,644 +
11,377)
*165 patients were removed
due to further data quality
issues resulting in a final
cohort of 26,856

Identification of the final ‘Control’ cohort
Presentation title, Month Year
73
Age
Index of Multiple Deprivation (LSOA)
Gender
A&E attendance date (01 April 2012 to 31 March 2015
SUS – A&E (Kent
residents only)
(>500,000 cases)

Findings_1
Of the 26,856 KFRS subjects identified, 7,478 (28%) were
found to have attended A&E during the period 01 April 2012
to 30 September 2015.
Of these, 4859 (65%) attended once only whereas 2,619
(35%) attended on two or more occasions.
In total the 7,478 KFRS subjects ‘generated’ a total of 12,178
A&E attendances.
The subject to attendance ratio for this group was 1.63
attendances per person on average.
74

Findings_2
The 7,478 subjects included in the analysis were case
matched to 9,588 (128.2%) ‘control’ subjects in the A&E
attendance dataset.
Of these, 8,874 (93%) attended once only whereas 714 (7.4%)
attended on two or more occasions.
In total the 9,588 control subjects ‘generated’ a total of
10,443 A&E attendances.
The subject to attendance ratio for this group was 1.1.
75

Findings_3
Non parametric tests were used to assess whether or
not the proportional distribution in A&E attendances
differed between the control and the intervention
groups.
A two-way analysis of variance by ranks revealed no
significant differences between both groups
(p=.180).
76

Conclusions
The apparent lack of association between HSV and reduction in A&E
utilisation is not necessarily indicative of absence of impact.
Requirement for a more nuanced case control matching framework
required but perhaps not possible? (A&E attendance for effects of
inhalation?)
Absence of a dynamic PMI may have introduced systematic bias
(difficult to determine the scope of any potential bias)
Perhaps most significantly, the high initial miss-match rate (62.2%)
may have introduced further unhelpful bias which impeded a more
accurate case control selection process. It has not been possible to
assess the underlying reasons for the high miss-match rate?
77

Kent Public Health Observatory
78

Thank you!
79
Gerrard.abi-aad@kent.gov.uk
Http://www.kpho.org.uk/

www.england.nhs.uk
Working in partnership across Kent
developing integrated intelligence
Questions and
discussion

www.england.nhs.uk
Developing integrated
data to support service
redsign
Leeds LTC YOC Commissioning EIS

Developing integrated data to
support service redesign
decision making
Alison Phiri - Business Intelligence Manager
Mohini Chauhan - YoC Commissioning Manager

• Developing the data set
What?
• Review of current Information Assets
• Gap analysis
• Developed Leeds Data Model
• Tailored Leeds Data Model for specific purposes.

What?
Leeds Integrated
Health & Social
Care Data Model
Datasets linked on a
common patient identifier
GP Practice
Data Notional costs assigned
Community
Dataset Notional costs assigned
Mental
Health Data Cost per unit assigned
Inpatient
Data
Adult Social
Care Data No costs assigned
Outpatient
Data
A&E Data
Year of Care Combined
Dataset
ACG Grouper
Linked data
processed through
the ACG Grouper to
create risk scores
Input Dataset
Used for
production of
capitated
budgets
Output
Dataset
Used for
cohort
identification
To be defined
Dataset for
shadow
monitoring
Key:

• How did we use the dataset?
So what?
• Cohort identification – pivot table hell!
• Created a tool that enabled us to get the best out of
the data

• Introduction to data packs
• Data packs were developed to create an impact and so they
could be easily distributed to stakeholders across the
system.
• Inspiration taken from commissioning for value data packs.
• A visual and engaging way of presenting data.
• The data packs do not provide the answers to which cohorts
should be selected. Their purpose is to generate discussion
and to support stakeholders to make a more informed
decision around which cohorts they would like to focus on.
Now What?

CASE
MANAGEMENT
DISEASE
MANAGEMENT
SUPPORTED SELF
CARE
POPULATION WIDE
PREVENTION
Which populations do we want to target?
Reducing unplanned
admissions?
Reducing
total costs?
Health outcomes/potential
years of life lost (PYLL)?
Multimorbidity?
Age?
Risk of high
healthcare
utilisation?
Focus on now
or the future?
Frailty?

Prevalence of CHD,
COPD and Diabetes
is higher than the
rest of the city
Around 40% of the NHS Leeds
South and East CCG population
has one or more LTC
The biggest cause of
years of life lost is due to
cardiovascular disease
cancer and respiratory
disease
More people
have mental
health
problems than
in the rest of
the city, above
the national
average
Health
related
quality of
life for
people with
LTC’s is
significantly
lower than
the national
average
25% of the CCG population have
an existing health problem, which
is above the England average
More people are
living with 2 or 3
LTC’s, compared
to the rest of the
city
By 18/19 PYLL to be
improved by 26.6%
Please note: the data on this slide was taken from a number of sources including; public health profiles, the LSE CCG 2 year plan, NHS England commissioning for value
packs and the NHS England long term condition dashboard.
NHS Leeds South and East CCG

Whole population dataset
Analysis of Leeds city wide data involved testing the following
methodologies to understand utilisation of healthcare services,
over a two year period:
a. Patients who had three or more A&E attendances
b. All patients aged 85 and over
c. All patients with a Frailty Index of seven or more
d. All patients with 4 or more long-term conditions
e. All patients in the top 2% by risk of unplanned hospitalisation in
the next 12 months (based on the Kings Fund’s Combined
Predictive Model algorithm).
The analysis demonstrated an increased use of healthcare services
over the subsequent two years when moving from (a) to (e) and
points towards a multimorbidity model.

0
2000
4000
6000
8000
10000
12000
14000
16000
18000
18-34 35-44 45-54 55-64 65-74 75-84 85+
Numberofpatients
Age category
Number of LTC’s, by age, for people with at
least one LTC*
13+
12
11
10
9
8
7
6
5
4
3
2
1
*NHS Leeds South and East CCG

£12,297,218
£11,947,166
£6,591,526
£12,381,539
£2,439,706
£43,220,633
£0 £5,000,000 £10,000,000 £15,000,000 £20,000,000 £25,000,000 £30,000,000 £35,000,000 £40,000,000 £45,000,000 £50,000,000
GP
Community
Mental Health
Outpatients
A&E
Inpatients
Total costs (£)
Servicearea
Total costs of services, for people with at
least one LTC*
14%
13%
7%
14%
3%
49%
% total costs of services
GP
Community
Mental Health
Outpatients
A&E
Inpatients
*NHS Leeds North CCG

-
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
1 2 3 4 5 6 7 8 9 10 11 12 13+
Totalcosts(£)
Number of LTC/s
Total costs of services, by number of
LTC’s, for people with at least one LTC*
Inpatient
A&E
Outpatient
Mental Health
Community
GP

-
2,000.00
4,000.00
6,000.00
8,000.00
10,000.00
12,000.00
14,000.00
1 2 3 4 5 6 7 8 9 10 11 12 13+
Averagecosts(£)
Number of LTC/s
Average costs of services, by number of
LTC’s, for people with at least one LTC*
Inpatient
A&E
Outpatient
Mental Health
Community
GP

Patterns of multimorbidity*
*NHS Leeds West CCG

Ischemic heart disease
COPD
Depression
(+any other conditions)
1028 people
affected of
which 47%
are male
Average costs
per person,
over a one
year period
£5,399
8.6 average
number of
LTC’s per
person
Total costs,
over a one
year period
£5,550,474
GP costs
£439,814
Inpatient
costs
£3,277,790
A&E costs
£199,067
Outpatient
costs
£438,993
Mental Health
costs
£155,436
Community
costs
£1,039,082

0
10
65
205
153 152
182
150
111
0
50
100
150
200
250
18-34 35-44 45-54 55-64 65-69 70-74 75-79 80-84 85+
Numberofpatients
Age category
Age split of patients who have IHD, COPD
and depression (+any other conditions)*

0 0 1
11
36
119
171
203
153
121
112
51
37
10
3
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Numberofpatients
Number of long term conditions
Numbers of multiple LTC’s for patients
with IHD, COPD and depression (+any other
conditions)*

12472
22856
14955
21171
14757
0
5000
10000
15000
20000
25000
Beeston Chapeltown Kippax Middleton Seacroft
Numberofpatients
Neighbourhood teams
Neighbourhood team breakdown, for
patients with at least one LTC*

0
1000
2000
3000
4000
5000
6000
7000
LeedsCityMedicalPractice
CityViewMedicalPractice
OakleyMedicalPractice
BeestonVillageSurgery
ShaftonLaneSurgery
CottingleyCommunityCentre
ShaftesburyMedicalCentre
Laybourn&PartnersTheMedicalPractice
BellbrookeSurgery
EastParkMedicalCentre
GardenSurgery
LincolnGreenMedicalPractice
ThePracticeatHarehillsCorner
RoundhayRoadSurgery
TheSurgery
YorkStreet
TheRichmondMedicalCentre
ShakespeareCommunityPractice
AshtonView
ConwayMedicalCentre
GarforthMedicalPractice
GibsonLanePractice
NovaScotia
KippaxHall
MoorfieldHouse
RadshanMedicalCentre
SwillingtonClinic
LingwellCroftSurgery
OultonSurgery
LofthouseSurgery
NewCrossSurgery
TheArthingtonMedicalCentre
WhitfieldPractice
MiddletonParkSurgery
HunsletHealthCentre
ColtonMillMedicalCentre
WindmillHealthCentre
ManstonSurgery
ParkEdgeSurgery
AshfieldMedicalCentre
TheFamilyDoctor
WhinmoorSurgery
Beeston Chapeltown Kippax Middleton Seacroft
Numberofpatients
Neighbourhood team
GP breakdown, by neighbourhood team, for
patients with at least one LTC

102
1632
533
279
520
329
591
138
1632
1001
789
1766
791
2702
326
533
1001
204
361
277
404
120
279
789
204
242
160
391
143
520
1766
361
242
236
746
86
329
791
277
160
236
510
64
591
2702
404
391
746
510
194
138
326
120
143
86
64
194
Coronary heart disease
(n= 1801)
Hypertension (n=8267)
Heart failure (n= 1122)
Stroke/ TIA (n= 1009)
Diabetes (n= 2314)
COPD (n= 1283)
Depression (n=8646)
Dementia (n= 399)
Coronary
heart disease
Hypertension
Heart failure
Stroke/ TIA
Diabetes
COPD
Depression
Dementia
Multimorbidity analysis at NT level

-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
COPD
Hypertention
Lipid Metabolism Disorders
Cardiac Arrhythmia
Ischemic Heart Disease
Heart Failure
Peripheral Vascular Disease
Renal Failure
Cerebrovascular Disease
Osteoporosis
Rheumatoid Arthritis
Epilepsy
Parkinsons
Multiple Sclerosis
Hypothroidism
Chronic Pancreatitis
Chronic Liver Disease
Cancer
Depression
Bipolar Disorder
Schizophrenia
Dementia and Delirium
Prevalence of other conditions for patients
who have Diabetes (n=10654)*
*NHS Leeds North CCG

I visited my GP 35 times,
in the past year
My name is Bob. I suffer
from COPD, IHD,
rheumatoid arthritis,
high blood pressure,
high cholesterol and
depression
The total cost for my
healthcare, over the year,
was around £9500
I was admitted to
hospital 8 times, which
cost £6000
I was seen by a number of
health professionals and
visited the outpatient clinic
19 times
I am between 45-54 years
old

Having a care plan will
help me feel more
supported to manage
my condition
I want to feel more
empowered to
manage my
condition
Where can I find out about self
help courses for people who
have long-term conditions?
I want to find out more about
my condition. Where are the
best places to do this?
Are there any lifestyle
changes I should make to
help my health?
What do our service users say?
How do I meet other people
who have the same
condition as me? Is there a
local or national support
group?I feel I cannot manage my
condition due to lack of
information and support
How can I make my condition
easier on my family and
friends?

Developing integrated data to support service
redesign decision making
Questions and
discussion

Health 1000:
A local complex care
organisation
BHR LTC YOC Commissioning EIS

My
services
selected
by Me
• Introduction
• Technology developed to
facilitate “YoC research and
Health 1000 provision”
• YoC Research & Cohorts
• Implementation of a Person
Centred Provider organisation
• Current Situation – Health 1000
Limited.
Establishing a Complex Care Organisation in East London
Presenter : Rob Meaker
Date : 23rd March 2016

Background on the pilot site area in East London
Introduction

East Of
England
LAS
Station
Central
London
Cluster 1
Cluster 2
Cluster 3
Cluster 4
Cluster5
Cluster4
Cluster6
Cluster2
Cluster 1
Cluster 1
Cluster 2
Cluster 3
Cluster 4
Cluster 6
Walk In
Centre
Cluster 5
Hospital
Geography of the boroughs and key health infrastructure
Borough
Population
770,000
Emerging GP
federations
Redbridge
federation
Havering
federation
Barking &
Dagenham
federation
Introduction

Alignment between YoC and the vision for health and social care in BHR
Introduction

2008 – Polysystems & Person Centred Care
2009 – Risk Stratification
2010 – Integrated data
2011 – LTC management, & The Year of Care
2012 – Integrated Case Management
2013 – Rapid Response & Community Treatment Teams
2014– Complex Primary Care Practice establishment
2015– became operational.
Timeline for person centred care & complex care organsiation
Introduction

Operational January 2015, Core Staff Recruited, Patients No increasing

Ben and Eileen have been married for 59 years. They have four children,
nine grandchildren and eighteen great-grandchildren and they also spent
fifteen years fostering teenagers. Now, their focus is on enjoying life and
their family.
Eileen was diagnosed with osteoporosis in 1986, and has had resulting
problems with her knees and joints. She overcame breast cancer and she
also had a heart attack in 2012. Her husband, Ben, was diagnosed with
prostate cancer last year and has a collapsed vertebrae in his back.
They had been registered at their previous GP practice for 40 years when
they received the call from Health 1000. Staff at the new practice explained
that there would be specialists on hand, that they would be able to get an
appointment whenever was convenient for them and that they could be
looked after in their own home if need be.
At first, they weren’t sure if they were doing the right thing by moving
practice, but the support they’ve received since joining Health 1000 has left
them confident that they’ve made the right decision.
For Eileen, the biggest difference is that someone is always on the other end
of the phone to help. When calling the practice, she can get straight through
to their key worker who is already aware of all their problems and the
medication they take.
She said: “They’re always informative and eager to help. It feels like they
know you personally and they’re interested in your welfare. It makes you feel
more confident. We haven’t been with Health 1000 very long, but we’ve
seen a big improvement.”
The emotional support that they receive from Health 1000 is as important as
the physical care. A while ago, Eileen was worried about her husband’s
health. She called the practice and spoke to their doctor, who offered to
come out to their home and give him a check-up that same day.
She said: “Just offering to get someone to come and see you makes you
feel so much better. You might not need it, but you know it’s there. They can
make you feel better in yourself just by being there, and you know that
they’re taking a real interest. That’s the most important thing.”
Patient case study - Health 1000
Ben and Eileen Eaton
Introduction

Before joining Health 1000, Maurice had been registered
with the same GP practice in Barking his entire life.
Maurice keeps busy and doesn’t like to take up too much
of his doctor’s time, but he has a number of health
problems and his GP suggested that he join Health 1000,
as doctors there would be able to treat him in a way that
would work better for him.
Asked for his views on how he’s been treated since
joining Health 1000, Maurice said: “I find I’m getting more
attention here than at my old practice. Before I was just a
number, but here I feel like they really listen to me. It gives
me confidence.”
Maurice finds it easier to get an appointment to see his
doctor: “At my old practice, I might have had to wait two
weeks to see my doctor. But pain doesn’t wait a fortnight!
You want to get treatment for it there and then. Now I
know I can call up in the morning, come down to Health
1000 and see someone.”
He also knows that if the doctor has any concerns or if he
needs an X-ray, they can send him on to the relevant
department straight away, and it’s quicker and easier for
him to collect his prescriptions.
For Maurice, one of the best things about Health 1000 is
the people that work there: “So far I’m impressed. They
listen. Without a doubt I would recommend the practice to
other people.”
Patient case study - Health 1000
Maurice Wilson
Introduction

The graphic below captures the experience of two patients using Health 1000

Play Video 540
Patient Story Part 1
https://youtu.be/x
5ThfJ3dvxU

The Year of Care Pilot
Data Analysis and Cohort selection
Data Analysis and cohort selection

Infrastructure for effective data analysis has been a challenge
Hospital
Data
GP
Data
Infrastructure is key
•Link data
•Commission a data platform
Platform should provide
•Risk stratification
•Case Management
•Activity level data
•Costed datasets
•Fast user defined analysis
•Not SQL
•Automated reporting
•Snova technology
•ITK standard interfaces
Community
data
Social Care
data

Cohort selection
Data Analysis
Case
Management
3949 individuals
Care Management
Supported self care
40,248 individuals
Self Care
Prevention and wellbeing promotion
162,163 individuals
RELATIVE RISK 2-20%
Emergency admits = 7129
A&E visits = 26,756
Total Cost= £47 million
RELATIVE RISK 0-1%
A&E visits = 7158
Total Cost = £16 million
RELATIVE RISK 21-100%
A&E visits = 23,586
Total Cost= £22 million
Case Management
Improving outcomes for
patients with complex health
and social care needs
Care Management
Increasing the ‘value of care’
provided to patients with long
term conditions
Self Care
Empowering patients, carers &
families to make informed
decisions about their care
treatment & providing choice in
primary care to meet these
needs

0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
Average cost of care for complex
patients 1 % risk
Average cost per
patient
Average
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Average cost of care for patients 10 %
Average cost per
patient
Average
0
5000
10000
15000
20000
25000
30000
BHR Total Kirklees
Total
Lambeth
Total
Leeds
Total
North
Staffs
Total
South
Essex Total
West
Hamps
Combined average for patient care
Average cost per patient
Average
Data Analysis

ICM increased community spend during YOC pilot
Data Analysis

Moved towards – comorbidities based on Scottish multimorbidity report 2008
Data Analysis

Diabetes
DementiaStroke
COPD
HypertensionCVD
Heart Failure Depression
Patient cohort for the service 5 or more long term conditions.
2000 patients eligible across BHRCCGs and aim to recruit 1000
Patient cohort
Row Labels Cohort Hypertension CHD Diabetes Stroke Depression COPD Heart Failure Dementia
LTC 5+ 100 99 96 80 70 80 69 75 36
Scottish modified LTC 4+ 1924 1816 1559 1421 863 793 783 679 303
Grand Total 2024 1915 1655 1501 933 873 852 754 339
The selected cohort criteria, excludes CHC patients

The number of patients in the complex care cohort by the annual number of
primary care contacts - 2013/14 data only, Barking & Dagenham CCG cohort only
This illustrates a relatively normal distribution of patients receiving primary care contacts around the mean of 51
contacts per year , but still there was one patient with 186 contacts in 2013/14 . The relatively normal distribution
of numbers around the mean is represented by a skewness value of close to 1

Activity Cost (£thousand)
2012/13 2013/14 2014/15 2012/13 2013/14 2014/15
Primary Care Contact
85,311 91,416 91,288 3,839 4,114 4,108
Pharmacy
272,793 271,471 274,340 4,804 4,781 4,831
Acute care A&E
2,341 2,342 1,936 277 291 244
Outpatient
11,523 11,077 11,320 1,219 1,502 1,546
Daycase
1,130 925 572 858 740 439
Elective
162 131 128 579 392 353
NEL short-stay
443 435 336 497 461 336
NEL long-stay
959 985 768 3,174 3,178 2,538
Community care Face-to-Face
12,052 20,654 24,936 2,210 3,814 4,396
Telephone
1,032 1,859 2,244 55 96 109
Total
17,511 19,368 18,899
Total annual number of events and total annual cost for all patients in the complex
care cohort - all CCGs
Activity and cost for the cohort

Variation in activity between patients
The averages in the previous slide hide a great deal of variation. Thus if we take
one example, patient's in the complex care cohorts on average visit A&E once a
year but over 50% of patients did not visit A&E at all during 2013/14, and one
patient visited 41 times .
Perhaps the most striking feature of the data is that large percentages of
patient in the complex care cohorts didn't require acute inpatient care at all in
2013/14.

The trend in adjusted cost for all patient in the complex care cohort by service type
• Costs have more than doubled in
7 years
• 0ver 50% of costs are primary care
• Acute care accounts for 29% of
cost and reducing
• £10k average cost per patient but
escalates dramatically in last year
of life
The costs have increased for these patients over the 7 years, presumably as more of the patients in the cohorts need services
and/or patients in the cohorts need greater volumes of services
The greatest cost increases over the period for patients in the cohorts were primary care and community care. In percentage
terms, the cost of acute care has decreased over the period.

The Implementation of a Complex Care
organisation
Implementation
Legal & governance issues , Clinical design, Financial
model, location and Patient recruitment

• Establishing the financial arrangements for the service as set up, then BAU and
capitated budget moving forward
• CQC registration
• Insurances wider provision of services
• GPs and the Provider list and having a non GP as the clinical lead
• CCG membership
• Receiving records from practices- system challenges
• Legal requirements for the Limited Company,
• The APMS contract
• Recruiting clinical teams for a time limited project and people leaving
• GPs and the Provider list and having a non GP as the clinical lead
Challenges setting up the organisation

• Early Implementer site for
YOC
• Advanced data sets from
primary care, acute
community and social care
• PMCF Bid to include testing
of capitated budget being
developed to one provider
in early 2014
in early 2014
• PMCF bid approved may
2014
May
2014
• Started work on
project
May
2014
June-September
2014
• academic development of the service
model and staffing requirements with UCLP
• Set up of the legal entity to operate the
service
• Source premises
• Source clinical leadership
October-January
2014
• Commence recruitment of
staff
• Training
• Premises set up
• Legal entity formed
• APMS discussions started
• Engagement with
practices
• January 16th APMS
contract signed
• January 19th first patient
registered
Complex Care organisation timeline

Governance
Community
Trust
Private
Provider
Voluntary
Sector
GP
Federation
Acute Trust

ROLE WTE at
start
up
Start up Cover provided WTE by
month 3
MD and Geriatrician
(50:50 role)
1.0 20 hours direct patient care plus 17.5 hours
management plus on call support as required
1.0
HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to
Sunday. This is a dual function role covering
reception and health care support and requires two
members of staff to be on duty during 08.00 to
18.30pm Monday to Friday
6.0
GPs 3.0 52 hours per week 08am to 18.30pm Monday to
Friday plus
On call for 5 hours per week Monday to Friday 6.30
to 8pm and 24 hours on Saturday and Sunday from
8am to 8pm
A total of 81 hours per week
3.0
Practice Manager 1.0 37.5 hours per week as required to cover 7 days per
week on rota
0.5
Nurse 1.0 37.5 hours per week during 8am to 6.30pm 0
OT 0.5 18.5 hours per week during 8am to 6.30pm 3.0
Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm 2.0
Pharmacist 0.5 18 hours per week Monday to Friday as required 1
Community Nurse 0.0 Not applicable 4.0
Mental health Nurse 0 Not applicable 0.5
Social Worker 1.0 Seconded from Local Authority
Complex Care organisation staffing model

Operation process for the clinical model

Key Features of the clinical model
• GP lead model of chronic disease management with proactive
case management of medical and social care
• Tele-monitoring
• Patient and carer education and enhanced self-management
• Promotion of independence and personal responsibility
• Shared care record with agreed care plan
• Quality improvement embedded in culture
• Key worker skills and competencies developed

Financial modelling
31/01/2015 28/02/2015 31/03/2015 30/04/2015
31/05/201
5
30/06/201
5 31/07/2015
31/08/201
5 30/09/2015
31/10/201
5
2 12 55 175 295 415 535 655 775 895
Costs
Clinical Staff B £53,131 £53,131 £53,131 £53,131 £54,417 £65,585 £65,585 £76,754 £83,495 £87,923
Operational £17,634 £17,684 £17,899 £18,499 £19,099 £19,699 £20,299 £20,899 £21,499 £22,099
Per Patient Per Month
Pharmacy £67 £133 £799 £3,663 £11,654 £19,645 £27,637 £35,628 £43,619 £51,610 £59,602
Acute £174 £349 £2,093 £9,592 £30,519 £51,446 £72,373 £93,300 £114,227 £135,154 £156,081
Community £175 £350 £2,098 £9,616 £30,596 £51,576 £72,556 £93,536 £114,516 £135,496 £156,476
Social Care £83 £167 £1,000 £4,583 £14,583 £24,583 £34,583 £44,583 £54,583 £64,583 £74,583
Out of Hours £34 £68 £405 £1,856 £5,906 £9,956 £14,006 £18,056 £22,106 £26,156 £30,206
£70,765 £70,815 £71,030 £71,630 £73,516 £85,284 £85,884 £97,653 £104,995 £110,022
Total Costs £71,831 £77,210 £100,340 £164,888 £230,722 £306,439 £370,987 £446,704 £517,994 £586,969
Revenue
Year of Care
Payment £707 £1,414 £8,486 £38,892 £123,747 £208,602 £293,457 £378,312 £463,167 £548,022 £632,877
APMS Revenue £80
Total Revenue £1,414 £8,486 £38,892 £123,747 £208,602 £293,457 £378,312 £463,167 £548,022 £632,877
Revenue > Cost???? YES YES YES YES
Total Spend Jan to Apr £433,846
Total Available £900,000
Total Remaining £466,154
Total Spend to Breakeven £230,430
IN BUDGET
Total Additional Funding
Requirement -£235,724
Point of transition where
operating costs are lower than
revenue and the organisation
breaks even

Financial modelling
Apr-15 May-15 Jun-15 Jul-15 Aug-15
Description Parameters
Staff Costs B Total Costs £164,888 £230,722 £306,439 £370,987 £446,704
Sensitivity Total Revenue Original £124,914 £210,569 £296,224 £381,879 £467,534
1 Flex Capitated Revenue Increase by 25% Total Increased Revenue £156,142 £263,211 £370,280 £477,349 £584,417
Decrease by -25% Total Decreased Revenue £93,685 £157,927 £222,168 £286,409 £350,650
Apr-15 May-15 Jun-15 Jul-15 Aug-15
Description
Sensitivity Total Costs (Staff Costs UCLP) £182,320 £250,007 £326,858 £416,858 £482,692
2 Choose Staff Costs Total Costs (Staff Costs Health 1000) £164,888 £230,722 £306,439 £370,987 £446,704
Total Revenue £124,914 £210,569 £296,224 £381,879 £467,534
£100,000
£300,000
£500,000
£700,000
£900,000
£1,100,000
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15
TotalMonthlyCosts/Revenues(£)
Total Costs Total Revenue Original Total Increased Revenue Total Decreased Revenue
Effect of changing Capitated Revenue Payment Only

Staff
NEW PATIENT (mins - once off) MD Geriatrician GP Nurse Therapist Social Worker Key Worker Source - see Health 1000 Staff email (hidden tab)
could either be any of five individuals doing this work so one fifth of
total time assigned to each.
Initial Visit 14 14 14 14 14 70
Assessment 24 28 24 24 24 72 various options of mix of staff undertaking work
Admin 60
Care Planning 10 40 10 10 10 10
TOTAL TIME A NEW PATIENT 48 82 48 48 48 212 minutes
EXISTING PATIENT (mins per month) MD Geriatrician GP Nurse Therapist Social Worker Key Worker
check 4 reviews
Reviews 5.83 5.83 5.83 5.83 0.00 23.33 quarterly review of 70 mins by one professional 560 560
Reactive 11.88 11.88 11.88 60 mins per day for 50 patients by 1 of 3 professionals
TOTAL TIME EXISTING PATIENT 5.83 17.71 17.71 17.71 0.00 23.33
WTE 40 hours per week for 48
weeks
1920
WTE NEW 0.0004 0.0007 0.0004 0.0004 0.0004 0.0018 WTE 160 hours per month 160
WTE EXISTING 0.001 0.002 0.002 0.002 0.000 0.002
minutes in hour 60
WITH UTILISATION MD Geriatrician GP Nurse Therapist Social Worker Key Worker Utilisation
WTE NEW 0.0005 0.0008 0.0005 0.0005 0.0005 0.0022 85%
WTE EXISTING 0.0007 0.0022 0.0022 0.0022 0.0000 0.0029
check for 1000 patients
1000 0.71 2.17 2.17 2.17 0.00 2.86
Financial modelling – Staffing model calculations option B
Patient number VS Staff Costs
0
200
400
600
800
1000
1200
£0
£20,000
£40,000
£60,000
£80,000
£100,000
£120,000
£140,000
£160,000
PatientNumbers
StaffCost
Staff UCLP Staff Health 1000 Patient Numbers

0
200
400
600
800
1000
1200
1-Jan-15 1-Feb-15 1-Mar-15 1-Apr-15 1-May-15 1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-15
Numberofregisteredpatients
1-Jan-15 1-Feb-15 1-Mar-15 1-Apr-15 1-May-15 1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-15
Actual cumulative 2 14 61 74 87
Planned 4 35 55 115 205 325 445 565 685 805 925 1045
Patient recruitment

Play Video 540
Patient Story Part 2

Outcomes per £ Spent
PROMS
Evaluation – Independent evaluation by the Nuffield Trust

May
2013
• Early Implementer site for
YOC
• Advanced data sets from
primary care, acute
community and social care
in early 2014
in early 2014
• PMCF bid approved may
2014
May
2014
• Started work on
ACO roll out
May
2014
June-September
2014
• academic development of the
service model and staffing
requirements with UCLP
• Set up of the legal entity to
operate the service
• Source premises
• Source clinical leadership
October-January
2014
• Commence recruitment of
staff
• Training
• Premises set up
• Legal entity formed
• APMS discussions started
• Engagement with
practices
• January 16th APMS
contract signed
• January 19th first patient
registered
Year of Care Timeline

Outline governance structure Direct reporting
lines
Information flow
Programme Management Board
Chair (independent)
NEDs (providers, CCGs, Programme Clinical
Lead)
Executive Lead (MD)
Other Executive (COO)
Complex Primary Care
Practice
NHS England
CCGs
Local Authorities
Contractual
Clinical Staffing
(via providers)
Support Services
HR
Finance
IT
Other
Owners
(‘members’)
Regulators etc
CQC
Monitor
NHSLA
TDA
2

Differences in hospital service use
between cases and controls (see
table 5, page 25)
-10
0
10
20
30
40
A&E attendance Outpatient
attendance
Elective inpatient
visits
Emergency
inpatient visits
Extra service use among the control group
n = 146 n = 126 n = 146n = 151

Estimated cost differences in acute
sector based on projected changes
in hospital activity.
-£100
-£50
£0
£50
£100
£150
£200
£250
Outpatients A&E Elective inpatient
visit
Emergency
inpatient visit
Costdifferenceperperson-
month
Low High Projected

The impact of the number of patients recruited to the service and plausible scenarios
for which costs balance.
£0
£25,000
£50,000
£75,000
£100,000
£125,000
£150,000
£175,000
£200,000
£225,000
£250,000
0 100 200 300 400 500 600 700
Health1000 Total running cost Lower bound Upper bound Projected Health1000 staff cost
Upper bound cost
differences
Lower bound cost
differences
Operational cost
Total running cost (including staff costs)
of delivering service at Health1000
practice
Projected cost
difference
estimates
Staff cost
+

Implications of relaxing eligibility
criteria
Lower service use =>
Recruitment of more
patients to achieve
acceptable statistical
power
e.g. with a 15%
reduction
Numbers needed to achieve
80% power
Recruited under
existing criteria
300
Existing criteria
600
Opening up to
three
conditions
800

-60%
-50%
-40%
-30%
-20%
-10%
0%
A&E attendances Outpatient visits Elective admissions
Emergency
admissions
Primary care
contacts
% difference in use over 2014
Health service use for people with
three conditions compared with those
currently eligible for Health 1000

The Next Steps
Implementing The Learning From
Health 1000 across the Wider
Health and Social Care Economy

Health 1000:
A local complex care organisation
Questions and
discussion

www.england.nhs.uk
LTC Framework
postcards game
Susie Peachey

www.england.nhs.uk
• Helping us to test and develop it
• Each group should have:
• Picture of the LTC Framework
• Set of 30 cards
• Aim is to match the illustrations to a
section of the Framework
• THERE IS NO DEFINITIVE CORRECT
ANSWER
• It is the discussions that are as important as the
final result
The LTC framework postcard game

www.england.nhs.uk
Summary of the day
and key messages
Bev Matthews

www.england.nhs.uk
23rd March 2016
CLOSE
LtC Year of Care Commissioning
EIS and LTC Community of
Practice Workshop

Early Implementers Workshop 23rd March 2016

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Early Implementers Workshop 23rd March 2016