Implementing the decision Case Study: NHS West Kent prevention

strategy

A Story about Prioritizing

Dr. Declan O’NeillDirector

Public Health Improvement

Experience from a PCT’s Strategic 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 Planning Process which developed ‘Prevention’ as an integral part of the PCT’s Strategic 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 risks

4. To be funded in year two of SCP from development monies delivered by year one efficiencies

1. A programme budget based SCPDeliver national, regional &

county commitmentsEliminate wasteEradicate the gap in life expectancy

Improve health, quality of life and patient experience

Deliver national, regional & county commitmentsEliminate wasteEradicate the gap in life

expectancyImprove health, quality of life

and patient experience

£37m

Dental

£32m

Maternity

£39m£45m£45m£46m£91m£17m£40m£ 35m£74m£63m

Priority Programmes Spend Profile 2014/15 (rounded)

Trauma & InjuriesRespiratoryNeurologyMusculo-

SkeletalMental Health

Infectious Diseases

Genito-UrinaryEndocrineCirculationCancers

Tumours

£37m

Dental

£32m

Maternity

£39m£45m£45m£46m£91m£17m£40m£ 35m£74m£63m

Priority Programmes Spend Profile 2014/15 (rounded)

Trauma & InjuriesRespiratoryNeurologyMusculo-

SkeletalMental Health

Infectious Diseases

Genito-UrinaryEndocrineCirculationCancers

Tumours

Programme Investment Strategy*

Programme Investment Strategy*

Prog

ram

me

Stra

tegy

Cancer Market Model

Circulatory Redesign

Diabetes Strategy

Sexual Health

Redesign

MMR Program

Mental Health

Efficiency

Older People

(inc. MSK/Falls)

COPD Redesign

Urgent Care

Model

Neurology Market Model

Asthma Redesign

Primary Prevention

Increasing Independence (self-care and carers)

Mental Health Market Model

End of Life Care

Transforming Community Services

Circulatory Market Model

Commissioning Innovation

Prio

rity

Initi

ativ

es

Op plan year 1

Cancer 2

Infectious Diseases

Dental 1 & 2

Circulation 1

Respiratory 1

Mental health 1

Cancer 2

Infectious Diseases

Dental 1 & 2

Circulation 1

Respiratory 1

Mental health 1

Op plan year 2

Circulation 2

Musculo-Skeletal

Endocrine

Maternity 1 & 2

Genito-Urinary

Neurology

Circulation 2

Musculo-Skeletal

Endocrine

Maternity 1 & 2

Genito-Urinary

Neurology

Op plan year 3

Respiratory 2

Cancer 1

Trauma & Injuries

Mental Health 2

Respiratory 2

Cancer 1

Trauma & Injuries

Mental Health 2

Op plan year 4

IncreasingIndependence

PrimaryPrevention

IncreasingIndependence

PrimaryPrevention

Op plan year 5

Subject to reviewSubject to review

Oper

atin

g Pl

an*

Goal

s

(1) (1) (1)

(2) (2) (2)

(1)

(2)

Maternity Redesign

MIMHS Review

(1)

(2)

ServiceImprovementCommissioningLeversHealth &Wellness

ServiceImprovementCommissioningLeversHealth &Wellness

Award & Monitor Dental

Contracts

Social Marketing

(1)

(2)

*Phasing refers to the year in which the major impact of an initiative is felt; work on Programmes is ongoing

*Neutral = +/- 5%

1995 2000 2005 2010 2015 2020 2025

Year

The financial environment

Funding shortfall

NH

S fu

ndin

g

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 illness

So a “Fully Engaged Prevention Scenario”in West Kent meant modelling against real

costs of care

An ‘economic approach’ to prevention

• Using attributable fraction methods estimate the specific burdens of preventable hospital morbidity (related to smoking, obesity, etc) in the locality

• Cost them• Identify local prevalence of

risks• Identify the cost and impacts

of effective programmes

• Extrapolate programme to prevalence modification target and cost.

• Estimate expected reductions in morbidity and benefits

• Demonstrate returns on investment

• Present rationale to payer• Expand budget in this area• Evaluate impact

% Prevalence trends over time

0

10

20

30

40

50

60

1970 1980 1990 2000 2005 2010 2015 2020

Smoking

Haz Alcohol

Falls

Obesity

Expenditure of NHS WK attributable to preventable ill health vsExpenditure on Prevention

Non-preventabl

e75%

Preventable

25%

Other PCT spend99+%

Spent on Prevention

<1%

To work all this out requires a fairly robust predictive model into which is fed year on year population age groups, prevalence predictions morbidity costs and impacts of prevention.

Out of which comes a projected returns in morbidity savings versus costs of programmes

Enabling you to go to the payer with a prediction of returns on investment from a prevention programme which makes good economic 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 £1.6mFalls £1mSexual Health £1.3mMental Health £1mAlcohol £0.9m Smoking £1.1m

£6.9m

Short and Longer term

Such 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 and consumed the supply at similar rates to

before.

Why?

In our environment the system appears to default to acute care. Is there mal-distribution of care

provision? 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?

Suggested imbalance in distribution of care types which drives default to acute services

Care TypesPrevention Primary Community Acute Social

Addressing Maldistribution or moving care upstream:Bottom line assumption that major change needed 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

Underpinning efficiency - QIPP plans and detailed indicators can demonstrate silos of improved

efficiency, but what about the overall outcomes?

• At the Kent & Medway (County) LevelK&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 KentNHS Eastern & Coastal Kent Medway NHS Foundation TrustDartford & Gravesham NHS Trust Maidstone & Tunbridge Wells NHS TrustEast Kent Hospitals University Foundation Trust Kent & Medway NHS & Social Care Partnership TrustMedway Community Services West Kent Community ServicesEast Kent Community Services Medway CouncilKent County Council South East Coast Ambulance ServiceQueen 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?)

Prevention Primary Community Acute Social

Care Types

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 of acute care on a specific day of care, through an audit of 344 contemporary inpatients’ medical records using an updated version of a validated and widely tested instrument AEP.

• All of the notes completed on day of the admission were scanned by the clinical reviewer against a set of ‘admission-day criteria’.

• Similarly, all of the notes completed on a specific (subsequent) day of stay were scanned by the clinical reviewer against a similar, (not the same), 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.

Questions?