reshaping the system part 1

Reshaping the System: Transforming Northern Irelands Health and Social Care Services

Appendix Part 1

CONFIDENTIAL

Sept 2010

This document is solely for the use of personnel in the Health and Social Care Board and Public Health Agency of Northern Ireland. No part of it may be circulated, quoted, or reproduced for distribution outside the HSCB or PHA without prior written approval. The document contains extensive material that is exempt from disclosure under the Freedom of Information Act 2000. It should not be released under the Act without prior consultation with the HSCB.

WORKING DRAFT

1About this document

This document comprises the analyses done in support of the accompanying memo, Reshaping the System

It is not a self-standing document and should be read in conjunction with that memo

2Contents of this appendix

1. Where we stand today2. The trends in health and social care needs and implications

for funding3. Opportunities to improve productivity and quality4. Implications for the system: what a new, higher quality and

more efficient service could look like5. What it will take to transform6. The pace of delivery7. Implementation plan: outlines our current (early-stage) plans

for implementation

3Quality of care in Northern Ireland has improved in recent years (1/2)CAGR (average annual % change)

Years (signs of good quality): a, b: 1991-93 to 2005-07; c: 2004 to 2008; d: 2008/09 to 2009/10; e: 2000 to 2009Years (signs of poor quality): (i), (ii) 1997-01 to 2004-08; (iii) 2001 to 2008; (iv) 2003 to 2009; (v) 2006 to 2009; (vi) 2004 to 2008* Average of Dip3, Tet3, Pert3, Pol (IPV)3, Hib3SOURCE: DHSSPS; PHA; Communicable Disease Surveillance Centre Northern Ireland

b. Life expectancy at birth, females 0.2%

a. Life expectancy at birth, males 0.3%

ii. Cancer mortality rate -1.4%

i. Infant mortality rate -1.3%

e. Immunisation uptake

3.0%d. Number of smokers setting a quit date 9.0%

c. % breastfeeding at discharge from hospital

0.3%

vi. Surgical site infection rate, orthopaedics -17.8%

v. C-Difficile reports,inpatients >65 years old -19.4%

iv. MRSA episodes -8.8%

Signs of good quality are increasing . . . . . . and signs of poor quality are reducing

Out-comes

Preven-tion

Safety in care

Iii. Rate of births to mothersunder

4Quality of care in Northern Ireland has improved in recent years (2/2)CAGR (average annual % change)

Years (signs of good quality): f, g, h: 2004/05 to 2008/09Years (signs of poor quality): (vi), (vii) 2007 (quarters 2-4) to 2010 (quarters 1-2); (viii) 2008 to 2010 (quarters 1-2); (ix), (x) 1997-01 to 2004-081 16 tests: Audiology - pure tone audiometry, barium studies; cardiology echocardiography; cardiology - perfusion studies; colonoscopy; computerised tomography;

cystoscopy; dexa scan; flexi sigmoidoscopy; gastroscopy; magnetic resonance imaging; neurophysiology - peripheral neurophysiology; non-obstetric ultrasound; radio-nuclide imaging; respiratory physiology - sleep studies; urodynamics - pressures and flows;

2 Standardised mortality rate for under 75 years old, deprived areas relative to NI as a whole

SOURCE: DHSSPS; PHA; QOF

Clinicaleffec-tiveness

Access

Inequal-ity

viii. % patients waiting >13 weeks for diagnostics1 16.0%

vii. % patients waiting >13 weeks for outpatient care 470.0%

vi. % patients waiting >13 weeks for inpatient care -9.0%

i. Patient and client survey TBC

h. Primary angioplasty

1.9%

g. Stroke scan 24h 1.6%

f. % thrombolysis

5.9%

x. Infant in deprived area more likely to die -2.1%

ix. Person in deprived area more likely to die2 -0.3%

User experi-ence

Signs of good quality are increasing . . . . . . and signs of poor quality are reducing

5Many aspects of Northern Irelands productivity have also increasedCAGR (average annual % change)

Years (signs of productivity): 1, 2. 2003/04 to 2008/09; 3. 2008/09 to 2010/11Years (signs of inefficiency): 4. 2003/04 to 2008/09; 5. 2004/05 to 2009/101 Relative to expected2 % of complex discharges delayed by more than 48 hoursSOURCE: DHSSPS; PHA; TOR

Inpatient

3. Day of surgeryadmissions % 11.0%

2. Throughput per bed 4.0%

1. % all admissions done as day case 1.0%

4. Average length of stay -4.5%

Primary care

5. Growth in primary careprescribing spend1 -3.0%

Signs of productivity are increasing . . . . . . and signs of inefficiency are reducing

6DHSSPS has delivered ~3% p.a. improvement; HSCNI 2%

SOURCE: HSCB Finance; DHSSPS

billion, nominal

-3 p.a.

+4 p.a.

0

1

2

3

4

5

2008/092007/08 2009/10 2010/11

DHSSPS Investment

CAGR 2007/08-2010/11, %

-2 p.a.

DHSSPS actual spendDHSSPS spend on existing services after efficiencysavingsHSCNI spend on existing services after efficiencysavings

7Northern Irelands life expectancy is lower than England, but comparable to Wales and North East England

Life expectancy at birth, Females2006-2008, years

Northern Ireland

Scotland

Wales

England

77.0

75.3

76.5

77.9

76.4

81.4

80.0

80.6

82.0

81.3

North East SHA

SOURCE: StatsWales; www.scotland.gov; Northern Ireland Neighbourhood Information Service, NCHOD

Life expectancy at birth, Males2006-2008, years

8NI mortality rates are higher than comparators, except for cancer

Scotland Unknown

Wales 614.7

North East SHA 660.0

England 581.9

Northern Ireland 837.6

Unknown

Unknown

201.8

183.7

265.5

206.8

190.9

203.9

173.9

179.2

SOURCE: Northern Ireland Neighbourhood Information Service, NASCIS 2008/09, Northern Ireland Cancer Registry, Information Service Division Scotland (ISD), StasWales, Welsh Cancer Intelligence and Surveillance Unit

Age standardised death rate 2003-07# per 100,000 population

All circulatory disease mortality age standardised, 2004-08# per 100,000 population

Cancer mortality European age standardised, 2004-08# per 100,000 population

9Smoking and poor diet could be among the causes of NIs lower life expectancy and higher mortality rates

Scotland 25

Wales 21

England 22

Northern Ireland 24

25.6

21.0

22.0

24.0

21

29

27

Unknown

SOURCE: Northern Ireland Neighbourhood Information Service, Information Service Division Scotland (ISD), StasWales ,Cancer Research UK, Public Health Observatory for Wales, International comparisons of Obesity 2008

1 Data for Scotland is 2004 (the latest), Obese is defined as BMI>30Kg/m2

Smoking prevalence(2008)%

Adult obesity, 16+, (2007)1%

Adults eating recommended 5 fruit or veg a day (2006)%

10

An increase in the prevalence of chronic diseases (reflecting the pattern in other parts of the UK) will increase care need . . .

0.5

4.5

0.5

5.6

0.8

1.1

1.6

4.1

0.4

5.1

9.9

0.4

5.9

0.8

1.3

1.5

3.5

Cancer

COPD

Hypertension 13.112.2

CHD

Learning Disabilities

Diabetes

Obesity 11.3Dementia

Asthma

Mental Health

EnglandNorthern Ireland

SOURCE: Quality Outcomes Framework, 2008/09; Northern Ireland Neighbourhood Information Service; NCHOD

Prevalence of disease by country%

11

NIs population is ageing

SOURCE: Northern Ireland Neighbourhood Information Service

2008 2009 2010 2011 2012 2013 2014 2015

125

120

115

110

105

1000

80+

60-79

40-59

20-390-19

Population growth by age group in Northern Ireland100 = 2008 population

12

Comparison of per capita spend across UK spend on services (including supplies), 2008/09

SOURCE: HSCNI; Information Service Division Scotland; Wales StatsWales; England Laing and Buisson 2008/09

264 246 227 157227

969905

835 1,0781,090

Wales

2,254

464

472

England

2,051

417

399

Northern Ireland (7% weighting)

2,066

Northern Ireland (16% weighting)

399

516

1,901

363

Northern Ireland

2,206

421

552 476

Spend per capita across types of care per capita

12%7% 10%

44% 51% 48%

Wales

6,759

21%

Northern Ireland

3,946

19%

25% 21%

England

95,311

20%

22%

100% =

Breakdown of Spend% of total spend (total spend, m)

Primary care

Social care

Community

Hospital

13

High-level benchmarking suggests the largest productivity opportunities lie in hospital spend and community prescribing . . .

Hospital spend by category

SOURCE: Laing & Buisson 2008/09, NHS Information Centre Prescribing Data, HES 2008/09, HSCNI data

% reduction opportunity from NI 16% weighting to England

%

42

15486

258

110

39

14279

238

101

30

10464

211

75 65

Non-elective inpatientElective inpatient A&EOutpatientDaycases

208

116

3675

-18%(30m)

-12%(61m)

-7%(6m)

-18%(53m)-26%

(54m)

per need-weighted population

Northern Ireland (16% weighting)Northern Ireland (7% weighting)

North East SHA

England

3385

3079 56

189

64

197

Mental health Learning disabilities

Mental health and learning disabilities spend

54

205

50

189

64125

145

Hospital Prescribing

N/A

CommunityPrescribing

-23%(91m)

Prescribing cost

35

116

32

10748

140

50

126

DentalGP

Primary care spend

14

SOURCE: Northern Ireland Neighborhood Information Service 2009; Department of Health; Social Services and Public Safety

Note: SARs information is based on the home address of the patient and will not give an accurate reflection of the over- or under-usage of hospital facilities within a Trust Area, as patients can attend hospitals outside their immediate home areas. The SAR is indirectly standardised and compares the ratio of observed admissions in an area to those that might have been expected had the area experienced the age specific admission rates of the NI population.

. . . and significant variations in performance across NI highlight potential for internal productivity improvements2009

1041049810095

WesternSouth-ern

South Eastern

North-ern

Belfast

Standardised Admissions Ratio All Admissions (including daycases)100 = NI

111108919995

WesternSouth-ern

South Eastern

North-ern

Belfast

Standardised Admissions Ratio Emergency Admissions100 = NI

Standardised Admissions Ratio Elective Admissions (excluding daycase)100 = NI

9910689114

88

WesternSouth-ern

South Eastern

North-ern

Belfast

Higher admissions in the Northern Trusts appear to be driven by higher elective admissions

In the Southern Trust the higher ratio is driven by emergency admissions

For the Western Trust higher ratios for both elective and emergency are seen

15

There are significant health and social disparities both within and external to the region, reflecting Appleby and others identification of a need gap

85

80

75

0Quintile 5 (most deprived)

Quintile 4Quintile 3Quintile 2Quintile 1 (least deprived)

82

80

78

Variation in life expectancy by deprivation quintile within NI2004/06, years

Female life expectancy

Male life expectancy

Disability living allowancesAllowances per 1,000 population (weighted and unweighted), as at November 2009

80

66

68

49

87

95

102

Wales

Scotland

North EastSHA

England

NI (at 16% weighting)

NI (at 7% weighting)

NI (unweighted)

Appleby and others have identified a need differential between England and NIThe judgement of this Review (to be confirmed or denied in the light of any subsequent results arising from a UK-wide allocation model) is that a reasonable need differential between England and Northern Ireland should be around 7%

Appleby: Identified potential disparity gap of up to 14-17%

Subsequent joint DFP / DHSSPSNIwork1:

1 Taken from internal unpublished report on need comparison compared to England, represents overall increased need for health and social care2 All analysis in this document considers both 7% and 16% overall need weightings (16% and 36% for social care specific analyses)SOURCE: NISRA; Independent Review of Health and Social Services Care in Northern Ireland, Kings Fund 2005; DHSSPS unpublished report

16

In 2009/10, Northern Irelands per capita spend on health care has dropped below that of other regions

SOURCE: HM Treasury Public Expenditure Statistical Analyses 2010

HealthcareSocial servicesNorthern Ireland

Wales

1.76Scotland

1.68Northern Ireland

1.66UK average

1.63

North East England 1.79

1.89

England

0.46

0.46

0.64

0.54

0.44

n/a

2007/08

1.78

1.86

1.86

1.97

1.75

1.95

0.48

0.47

0.64

0.58

0.46

n/a

2008/09

1.91

1.88

1.96

2.07

1.90

2.08

0.49

0.52

0.62

0.60

0.47

n/a

2008/09

per capita, not weighted for need

17

HSCNI spends less than England when need is taken into account

SOURCE: HM Treasury

NI 16%weighted

2,069

NI 7%weighted

2,293

NI un-weighted

2,400

England

2,361-12%

-3%

226m 606mFunding gap

per capita spend on health and social care, 2009/10

18

Contents of this appendix

1. Where we stand today2. The trends in health and social care needs and

implications for funding3. Opportunities to improve productivity and quality4. Implications for the system: what a new, higher quality and


for implementation

19

5.4

3

4

5

6

7

2014/152010/112006/07

SOURCE: SRF; DHSSPS; various Northern Ireland historical activity sources for residual growth (see appendix for details)

Historical/ forecast spend

Forecast do nothing spendDemographic change, residual demand growth and cost inflation, unmanaged, would increase spend by ~6% p.a.b per annum, nominal, total DHSSPS allocation

x Spend gap

2010/11 savings

NI-SPECIFIC ANALYSIS

20

Other regions have assumed residual activity demand growthabove demographic which has been similarly calculated for NI

0.8%

England SHA B2 0.9%0.3%

England SHA A2 1.9%

NorthernIreland 1.5%

Wales2 0.5%

Scotland 1.3%

Compound annual growth rate; 2010/11-2013/14 (England SHA A), 2007/08-2016/17 (England SHA B) or 2010/11-2014/15 (all other)

Demographic growth3

Unit price inflation

1.8%1.2%

N/A

2.5%

2.2%

1.9%

Total do-nothinggrowth in spend

N/A

6.2%3.5

6.0%

5.7%

3.9%2.6

1 Residual growth representing increasing expectations and demand for services, improving access to care, changes in care technology, changes to clinical practice, changes in disease profile and all other factors which increase demand for care, other than demographics. Details of calculation for Northern Ireland in appendix; calculated at 2.4% incorporating ageing factor and excluding prescribing (which were then deducted and added respectively to give figure shown above); 2.4% comprises ~4% for acute, ~1% for social care, ~0% for community and primary healthcare, based on 04/05 08/09 CAGRs; ~0.8% ageing factor and ~0.6% impact of prescribing volume increase are based on DHSSPS assumptions

2 Healthcare only, excludes social care3 Accounts for growth of whole population (0.7% CAGR for NI, source NISRA) and changes in age profile (0.8% CAGR for NI, source DHSSPS)NOTE: Total growth in spend CAGR for comparators is accurate; constituent CAGRs are approximate representations of the aggregation of CAGRs applied at service line and organisation

level and then compounded in each year. Differences in methodology mean that figures for different regions are approximately but not precisely comparableSOURCE: Expert interviews; DHSSPS; Welsh and English SHA QIPP plans

1 + 1 + 1 + -1

Residual growth1

1.8%

2.7%0.8%

1.8%

2.2%

1.3%0.9%

Low case

Base case

High case

21

On calculating the total size of the challenge

An estimate of likely future growth in required funding has beendeveloped in terms of three components: Demographic growth Residual growth Cost inflation

NISRA population growth projections (~0.7% p.a.) have been used for demographic growth with the calculated residual growth factor capturing all other phenomena (i.e., increasing expectations and demand for healthcare services, improving access to care, changes in healthcare technology, changes to clinical practice, changes in disease profile, ageing of the population)

The methodology for calculating residual growth factor is explained in detail on subsequent pages

Cost inflation has been developed using an approximate aggregation of the DHSSPS assumptions on pay and non-pay inflation (including GMS, pharmacist remuneration), grade drift and growth in prescribing volumes, using DHSSPS baseline 2009/10 spend assumptions, resulting in a 2.5% p.a. growth in required funding due to unit cost increases


22

SOURCE: TFR, Community Indicators, HIS, DHSSPS

603

258

233

784

222

392

292

4,160

4,210

3,749

219

296

Total outflow

Total spend

50Revenue generated

A&E 78

Daycase 145

Outpatient

Inpatient non-elective

Inpatient elective

Small bodies 169

DHSSPS, centrally-funded, depreciation/cost of capital

Total service spend

Primary care drugs

Other primary care (dental, ophthal., pharmacy remun.) 140General practice

Social care 969185

Community healthcare 415196

Other hospital (incl MHLD, physical/sensory disability)

Baseline spend figures used million, 2008/09

Improvement opportunitiesanalysed apply to this baseline

No specific improvementopportunities analysed apply

Community addiction teams, MHLDinpatient and hospital daycare, geriatric medicine inpatient, physical disability inpatient

Inpatient (community hospitals)

Non-inpatient (district nursing, health visiting, etc)

Nursing care, residential care, statutory day care, social work, domiciliary care, meals

Multiple data sources had to be used to reach this level of granularity. As a result, not all of these figures will match those in any given data source but these variances should be small

1 RQIA, HPA, NIPEC, NISCC, NIGALA, NIMDTA, NIFRS, CSA


23

Population growth is forecast to continue at a similar rate to recent past

1.721.70 1.71

2003 04 05 06

1.76

07

1.74

0.7% p.a.0.8% p.a.

20141308

1.79

09

1.80

10

1.78 1.851.84

12

1.83

11

1.82

Million persons in Northern Ireland

SOURCE: NISRA


24

Most English health economies have estimated future residual growth based on historical plus judgement

SOURCE: Team Analysis

HighBaseline

Scenario

LowRegion/project

N/A As per Healthcare for London review 2009 with some local adjustments

N/ASHA 2

N/A As per Healthcare for London review 2009 with some services adjusted to reflect local historical rates (A&E, Medicine, Regular Attender, Primary Care)

N/ASHA 4

N/A Scenarios (varying by PCT) some per Healthcare for London original 2007 with some modification (e.g., plus 0.5% for Obstetrics to reflect greater fertility of increasing immigrant population); others per historical local PCT rates

N/ASHA 3

Baseline plus 1% for Medicine (reflecting greater pace of future development in technology, drugs and clinical practice) and plus 1% for Primary Care and 2% for Outpatients (reflecting continuing improvements in access through Polyclinic model and increased patient expectations)

Historical 00/01 to 05/06, adjusting for known one-off phenomena (e.g., A&E historical residual growth rate of 8% p.a. halved because impact of 4-hour wait and improved access not expected to continue)

Used national historical rate for inpatients and primary care, local for other

Estimate: 1% for areas with higher historical growth (Medicine, A&E, Primary Care), 0% for others

Healthcare for London original 2007

Historical growth 00/01 to 07/08 Used national historical rate for inpatients

and primary care, local for other

N/A Estimate: 0.5% Medicine 1% Primary Care 0% all other

Healthcare for London review 2009

Similar approach adopted by HSCNI

CASE STUDIES

25

English residual assumptions varied across regions and services

SOURCE: Healthcare for London, expert interviews

Healthcare for London Affordability 2009

Healthcare for London, modified obstetrics for immigrant pop

HistoricalHistorical plus judgement

Healthcare for London 2007 SHA 4 2009 SHA 2 2009 SHA 3 2010Scenario

4.3

2.2

Other N/A

Specialised commissioning N/A

Mental health N/A

Primary care 5.31.0

Communitycare

4.2

A&E 4.0

0

Outpatients 2.1

0

Regularattenders 0

Paediatrics 1.0

Obstetrics 1.5

Surgery 0.5

Medicine 2.70.5

Percent

1.7

2.0

3.0

3.3

0.1

3.2

1.01.0 5.3

N/A

4.21.0

4.01.0 0

0

2.1

0

0

0

1.5

0.5

3.71.0 1.0

N/A

N/A

4.3

3.2

4.0

0.1

0

0

2.0

0.5

2.7

NA

NA

NA 0

4.3

1.3

2.3

2.3

1.3

1.3

1.3

1.3

1.3

1.3

1.3

0

1

3

3

0

10

3

1

3

3

Per serviceline

Per serviceline

Source

Low estimate

High historical 00/01 to 07/08

Low - below historical

High - above historical

Historical 00/01 to 05/06except A&E (lower)

CASE STUDIES

26

In aggregate, residual growth will likely increase required funding by ~2.4% p.a.

22150

ECRsGeneral practice 217

85308

1,319

2.4% p.a.

2,628

1,044

25878

22224

219

784

A&E

Social careCommunity healthcare

Outpatients

Inpatients

2014/15

3,032

831

2008/09

4

31.5-0.3

Residual growth CAGR, 2008/092014/15

Spend, m; growth due to residual only (excludes growth due to demographic change)

0.213

1

SOURCE: Trust Financial Returns; HIS

Considered baseline spend excludes ~1,587m of other spend (see previous baseline spend page)


27

Inpatient/ daycase acute activity residual growth is ~4% p.a.

Residual growth relative to previous yearAdmissions, %

Note: Regular Attenders and independent sector activity Included

SOURCE: KH03a

Historical residual CAGR2004/05 008/09, %

Residual CAGR used for forecasting 2009/10-2014/15, %

2008/09 admissions

574,813

4%Overall CAGR for forecasting (aggregated using baseline activity)

x Variance to historical rate

Surgery downsized to reflect on-going trend of interventions moving from surgical to medical. Elective waiting time targets not adjusted for, on the basis that there has been a steady growth year on year (3-4%) in elective IPDC activity

Mental health adjusted to 0% on the basis that there is no reason to believe demand for mental health services is truly declining; rather, these figures may reflect some shifting of activity out of acute into the community

-20

-15

-10

-5

0

5

10

15

2008/092007/082006/072005/06

4.2 3.2 203,955

5.3 5.3 279,405

-6.4 0 10,670

1.6 1.6 40,034

1.2 1.2 40,749

Surgery

Medicine

Mental Health

Obstetrics

Paediatrics


28

Outpatient acute activity residual growth is ~3% p.a.

Note: Independent sector activity Included. T&O ICATS figures excluded for 07/08 and 08/09. During 0809 a number of Mental Health OP services were reclassified to non consultant led, therefore 0809 is excluded from the Mental Health Residual Growth figures

SOURCE: KH09 & QOAR

3%Total CAGR for Forecasting (using baseline activity)

1,606,360

-3-2-10123456789

10

2007/082006/072005/06 2008/09

Residual growth relative to previous yearOutpatients, %

Historical residual CAGR2004/052008/09, %


2008/09 OP attendances

1.6 1.6 74,560Paediatrics

1.0 1.0 111,644Obstetrics

5.5 5.5 56,976Mental Health

3.5 3.5 621,359Medicine

2.9 2.9 41,821Surgery


29

A&E activity residual growth is ~1.5% p.a.

SOURCE: KH09 Part 2

0

0.5

1.0

1.5

2.0

2.5

2008/092007/082006/072005/06


Residual CAGR used for fore-casting 2009/10-2014/15, %

2008/09 A&E attendances

1.5 1.5 732,022

Residual growth relative to previous yearA&E attendances, %


30

General practice activity residual growth is ~0% p.a.

SOURCE: Continuous Household Survey

-2.0

-1.5

-1.0

-0.5

0

0.5

1.0

1.5

2.0

2007/082006/072005/06 2008/09

Residual growth relative to previous yearGP and nurse consultations in general practice, %



2008/09 consulta-tions

-0.3 -0.3 10,323,830

Negative growth rate in general practice activity over and above population growth may be due to registration being over 100% of population


31

ECR spend has been growing ~13% above population

SOURCE: ECR Regional Report

All programmes of care

Note: 08/09 is based on an estimate figure

0

5

10

15

20

2008/092007/082006/07

Residual growth relative to previous yearExtra contractual referrals spend, %



2008/09 spendm

13 13 23.9

This analysis is based on annual growth in costs rather than activity as comparable historical activity figures are not readily available


32

Community healthcare activity residual growth has fluctuated

Note: Total number of contacts in the above chart include District Nurses, Community Dental/Midwives/Psychiatric Nursing, AHPs, Health Visitors, LD Nurses, Family Planning and Clinical Psychology

-4

-3

-2

-1

0

1

2

3

4

2008/092007/08



2008/09 contacts

0.2 0.2 4,064,382

Residual growth relative to previous yearCommunity health care contacts, %

SOURCE: Trust Financial Returns Community Indicators

Year to year change (above population growth) in the number of contacts has been highly variable over the 3 years for which data is available. This data has been used nevertheless because longer-term comparable historical data was not readily available


33

Social care activity residual growth has varied across services but is estimated at ~1% p.a. overall

SOURCE: Trust Financial Returns Community Indicators

Residual growth relative to previous yearActivity, %



2008/09 activity

4 4

2 2

-3 -3

1 1

-2 -2

4 4

1,417,936

411,457

246,093

94,808

1,088,986

13,820,318

-15

-10

-5

0

5

10

15

20

25

30

2008/092007/08

Social Work (caseload)

Residential Care (occupied resident weeks)

Nursing Care (occupied resident weeks)

Meals delivered to client homes

Domiciliary care (hrs worked)

Meals delivered to client homes growth rate is erratic, however impact limited as total spend is only 7m

1%Total CAGR for forecasting (using baseline spend)

When calculating costs for domiciliary care, direct payments are included

Discussions with experts have suggested there may be an apparent decline in some social care activity due to the increase in direct payments

Statutory Day Care (attendances)


34

Unit cost inflation assumptions aggregate to ~2.5% p.a. increase in required funding

2.8%2.8%2.1%2.5%Aggregate effect

0.0%0.0%0.0%0.9%Superannuation

5.2%5.2%5.2%5.2%Demand Increase Prescribing1

1.0%1.0%1.0%1.0%Grade Drift HSC

2.7%2.6%2.3%1.9% Non Pay inflation

1.0%3.5%

1.0%3.5%

0.0%3.5%

0.0% 3.5%

Pay inflation HSC(Pharmacists)

14/1513/1412/1311/12

1 DHSSPS figure of 6.5% minus DHSSPS forecast population growth factor of 1.3%SOURCE: DHSSPS, Aug 2010; NISRA

Elements of cost inflation, growth relative to preceding year


35

Residual activity demand growth Data-to-analysis explanation

Approach: Calculate historical residual growth and apply judgement to modify as a proxy for anticipated future residual growth Historical data was used to measure activity growth for as long a historical period as was available and provide a trendline For each 1-year period (e.g., 2004/05 to 2005/06), historical population growth as a % was deducted from historical activity growth as a %

to give historical residual growth as a % The compound effect of this historical residual growth in any given service (e.g., medicine inpatient/ daycase) over the full historical period

examined was calculated as a CAGR (compound annual growth rate) These service-specific CAGRs were aggregated (by summing 2008/09 activity and 2014/15 activity implied by the CAGR, then calculating

the CAGR between these totals) to give the CAGR for a given setting of care (e.g., inpatient/ daycase). (For social care, where the various services were too different to meaningfully sum activity, spend was used instead)

The total impact of all of these setting of care specific growth rates on required funding was calculated by applying each to its associated 2008/09 spend to estimate the 2014/15 spend required for each setting of care, then summing the 2008/09 and 2014/15 spend and calculating the CAGR between these totals

Approach and assumptions

Estimation of future residual activity demand growth

IPDC & OP Activity A&E Attendances GP & Nurse Consultations ECR spend Mid year population estimates Spend Community activity and spend IS activity

Data Sources

Hospital Statistics Publication by POC (KH03a, KH09, QOAR)

KH09 part 2 Continuous Household Survey Extra Contractual Referrals NI HSC Recent

Trends and Issues NISRA Trust Financial Returns Community indicators IS quarterly activity returns

During 2008/09 a number of Mental Health OP services were reclassified to non consultant led and therefore 2008/09is excluded from the Mental Health Residual Growth figures

Inpatients, Daycases and Outpatients treated in the Independent Sector are included in activity Regular Attenders are included in the Inpatient activity ICATS activity for T&O during 0708 and 0809 are excluded from outpatient activity

Comments

Laura Smyth (DHSSPS), Christine Kennedy (DHSSPS), Christine Frazer (HSCB Finance), Dermot McAteer (HSCB), Caroline Earney(HSCB Information), Penny Murray (Primary Care)

Internal Contacts/Data owners

1NI-SPECIFIC ANALYSIS

36

Contents of this appendix

1. Where we stand today2. The trends in health and social care needs and implications

for funding3. Opportunities to improve productivity and quality4. Implications for the system: what a new, higher quality and


for implementation

37

At country level, extra spend does not seem to drive better health status

Healthcarespend/headUS $

Japan 2,690

Italy 2,845

UK 3,361

Germany 3,669

Canada 3,912

France 4,056

USA 6,714

Life ExpectancyYears

83

81

79

80

81

81

78

3

3

5

4

5

4

7

InfantMortalityPer 1000 live births

9

3

4

WHO healthsystem rankout of 192

24

41

35

72

SOURCE: WHO SIS (2006)

CASE STUDY

38

and, for example, at hospital-level, increased cost is not associated with lower mortality

-5

-4

-3

-2

-1

0

1

2

3

4

5

6

-4 -2 0 2 4 6

Risk-adjusted mortality (Z-value), 2001

S

e

v

e

r

i

t

y

a

d

j

u

s

t

e

d

c

o

s

t

(

Z

-

v

a

l

u

e

)

,

2

0

0

1

Note: Data are based on 10 HCUP states. Mortality is a weighted composite of 10 risk-adjusted inpatient mortality rates. Cost adjusted for wage index,case mix, and severity of illness

SOURCE: Joanna Jiang, Ph.D.; Center for Delivery, Organization and Markets, AHRQ

Variation in hospital mortality and cost per patient (sample of US acute care hospitals)

CASE STUDY

39

It is therefore possible to both increase quality and decrease cost; some actions achieve both, others benefit one without affecting the other

Main focus ofthis assessment

Quality improvements

Productivity improvements

E.g. Improved procurement

E.g. New technology or drugs that are more effective

E.g. Protocols that minimise the chance of errors

40

We have assessed the potential impact of the main quality and productivity improvement opportunities

Applies butnot analysed2

Y Quantified

1 Social care content across all levers has been grouped into a single chapter (6) of this document2 Because either expected size of opportunity is very small, or because sufficiently meaningful data is not available3 Excluding the implications of other improvement opportunities

Reduce the unit cost of required care (technical efficiency)

Optimisethe care delivered (allocativeefficiency)

Main improvement leversCategory HospitalPrimary/ FHS

6Social care1

Community healthcare

14 Reduce management costs and other administrative overheads Y YYY

13 Renegotiate unit price or reprocure externally-provided services Y

12 Patient flows to/ from other regions (RoI, England) ~

11 Estates better use of space3 ~

10 Procurement of other supplies ~ ~~

9 Prescribing and pharmacy procurement Y Y

8 Productivity (staff productivity, inpatient ALOS) Y YYY

7 Shift to lower cost settings Y YYY

4 Referral management, variation in assessment (OP, NEIP shortstay, social care, diagnostics) Y Y

3 Prevention, re-enablement Y ~

2 Decommissioning Y ~

1 LTC management, early intervention Y YY

5 YYYOptimise urgent care


41

Methodology has drawn upon experiences from within the NI system, other UK regions, and internationally

1 Case studies have been chosen to be as comparable as possible to NI, but differences in system and/or context making should be taken into account in further work

Outside-in analysis

Most analyses are based on centrally-available data from NI, England or external sources it is not intended to provide specific or local granularity

using benchmarking

Opportunities identified through benchmarking against, for example: England (highest/ lowest quartile) Wales and Scotland Between NI HSC Trusts

and good practice

Opportunities identified, ratified and enhanced using selected international academic research and case studies of good practice1

augmented by local insight

Interviews with approximately 20 Director-level leaders and senior professionals (from HSCB, PHA and DHSSPS)

System leaders workshop (~70 participants from HSCB, PHA, DHSSPS, HSC Trusts and LCGs) Data analysis and collection supported by HSCB, PHA, DHSSPS and HSC Trust information

and finance specialists

to size potential

Top-down identification of opportunities Approx size of opportunity shown as a range, assuming full costs can be made variable (e.g.,

wards or sites can be closed where relevant) Next step: further investigation as part of local implementation planning

for various scenarios on need

Considering 3 both 7% and 16% weighting for overall need relative to England (16% and 36% for social care specific need)


42

Improvement opportunities can be prioritised according to quality and financial impact and ease of implementation

INDICATIVE

SOURCE: Workshop 16 August 2010 (70 participants), NI interviews, experience of similar initiatives in England

High PriorityMedium PriorityLower Priority

LTC management, early intervention1

Decommissioning2

Prevention3

Referral management, variation in assessment4

Optimise urgent care5

Productivity (staff productivity, inpatient ALOS)8 Prescribing and Procurement of Pharmacy9

Shift to lower cost settings7

Procurement of other supplies10

Estates better use of space11

Patient flows to/ from other regions12

Renegotiate unit price or reprocure services13

Reduce management costs and other administrative overheads

14

Quality impact Financial impact Ease of implementationLow High Low High Low High

Social care6


43

About the pages that follow

In the pages that follow you will find A covering page for each major improvement opportunity, laying out the estimated size

of the opportunity Based either on

Attainment of highest/lowest quartile benchmark; or, where unavailable Review of case studies and clinical literature

Displaying potential financial benefit for each of The year from which data was used (usually 2008/09) 2014/15

Showing (by means of a range) the impact of whether Northern Irelands population weighting to reflect deprivation relative to England is 7% or 16%1

NB. The opportunities are shown here on a standalone basis and are not additive. In the summary sector they have been aggregated so that double-counting has been removed

Supporting pages behind that covering page show greater detail behind the figures

1 7% using Kings Fund Independent Review of Health and Social Services Care in Northern Ireland assessment; 16% using internal HSCNI unpublished report on need comparison compared to England, which identified 1417% variance

44

Smaller opportunities are detailed in the appendix, and some further opportunities (beyond the 16) have not yet been assessed

3 Prevention

10 Procurement of supplies other than drugs

Estates use of space11

Patient flows12

Renegotiation of externally-procured services (GP)

13

Reduce administrative overheads14

Service overlaps: for example, multiple A&Es in close proximity

Reconfiguration: Much of the financial impact of

reconfiguration has been taken into account (e.g., through using the full cost of activity to estimate savings from reduced LOS or fewer LTC admissions)

However, other aspects have not yet been quantified (e.g., rent and maintenance costs avoided, capital impact of selling property, where viable)

Mental health, learning disabilities and non-acute care reconfiguration: reducing ALOS, centralising

Opportunities assessed in the appendix Potential opportunities not yet assessed


45

Details behind opportunity sizing

Social care6

Copayment by the service user15Reduce administrative overheads14Renegotiate unit price or reprocure services13Patient flows to/from other regions12Estates - use of space11Procurement of other supplies10Prescribing and drug procurement9Productivity (staff productivity, inpatient ALOS)8Shift to lower cost settings7

Optimise urgent care5Referral management, variation in assessment4Prevention3Decommissioning2LTC management, early intervention1

46

1 Assumes that Northern Ireland need is 7-16% higher than EnglandSOURCE: Reference Costs Returns 2008/09, team analysis of HRG 4.0 to 3.5 map, 2008/09 Activity Based Funding Model, Continuous Household Survey, Mid-Year Estimate, HES 2008/09,

DH weighted populations, Healthcare for London; Coye (HealthTech) Transformation In Chronic Disease Management Through Technology

Benchmark to highest/ lowest quartile

Results, 2008/09

Methodology used

Results, 2014/15

Total 12-1610-12

Elderly 0

Physical Health 12-1610-12

Compared LTC acute admissions per weighted population with English PCTs lowest quartile

Assumed ~8 community/GP contacts to prevent 1 inpatient spell (double what used in similar analyses in England, to reflect NIsstrong starting performance)

Opportunity net ofRe-provision cost

Re-provision Cost

Estimate of potential benefits, m

1

Total 13-15

Improving management of long term conditions would improve quality and could release ~13m1


47

LTC-related HRGs were allocated to sub-LTC groupings for benchmarking (1/5)

LTCGroupingHRG

COPDPneumonia/Empyema (D12D14, D4143)D42COPDPneumonia/Empyema (D12D14, D4143)D41COPDCOPD (D3940)D40COPDCOPD (D3940)D39AsthmaAsthma (D2122)D22AsthmaAsthma (D2122)D21COPDPneumonia/Empyema (D12-D14, D41-43)D14COPDPneumonia/Empyema (D12-D14, D41-43)D13COPDPneumonia/Empyema (D12-D14, D41-43)D12DiabetesDiabetes - eye surgery (B30)B30Hypertension Stroke + TIA (A19-23, A99)A99Mental healthOld Age PsychiatryA38

Hypertension Stroke + TIA (A19-23) A23Hypertension Stroke + TIA (A19-23) A22Hypertension Stroke + TIA (A19-23) A21Hypertension Stroke + TIA (A19-23) A20Hypertension Stroke + TIA (A19-23) A19

SOURCE: Healthcare for London; interviews with English HES experts


48


LTCGroupingHRG

Hypertension Hypertension (E2425) E25Hypertension Hypertension (E2425) E24CHDCABG + AMI + IHD (E4,1115,22-23) E23CHDCABG + AMI + IHD (E4,1115,2223) E22Heart failureHeart Failure (E18E19)E19Heart failureHeart Failure (E18E19)E18CHDCABG + AMI + IHD (E4,1115,2223) E15CHDCABG + AMI + IHD (E4,1115,2223) E14CHDCABG + AMI + IHD (E4,1115,2223) E13CHDCABG + AMI + IHD (E4,1115,2223) E12CHDCABG + AMI + IHD (E4,1115,2223) E11CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E09CHDPacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)E07CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E02CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E01COPDCOPD Elderly respiratory (D99)D99COPDPneumonia/Empyema (D12D14, D4143)D43

1



49


LTCGroupingHRG

DiabetesDiabetes Other (J41, L09)J41Frail/elderlyFrail/Elderly Falls (H39, 86-87)H87Frail/elderlyFrail/Elderly Falls (H39, 86-87)H86Frail/elderlyFrail/Elderly Falls (H39, 86-87)H39Frail/elderlyFrail/Elderly Catch all (F99, L99, S99)F99Other non-specificOther IBD (F55)F55CHDPacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)E99CHDCABG + AMI + IHD (E4,1115,2223) E04CHDPacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)E39CHDPacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)E38CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E36CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E35CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E32CHDSyncopsy, Chest Pain (E0102,09,3132, 3536) E31CHDCardiac Arrhythmias (E29E30)E30CHDCardiac Arrhythmias (E29E30)E29CHDPacemakers, HF, PCI (E07, 1819, 2830, 3839. 99)E28

1



50


LTCGroupingHRG

DiabetesDiabetes (K11K17, K29)P29Frail/elderlyFrail/Elderly Catch all (F99, L99, S99)L99DiabetesRenal failure (L4951) L51DiabetesRenal failure (L4951) L50DiabetesRenal failure (L4951) L49DiabetesRenal replacement (L01, L4648)L48DiabetesRenal replacement (L01, L4648)L47DiabetesRenal replacement (L01, L4648)L46DiabetesDiabetes Other (J41, L09)L09DiabetesRenal replacement (L01, L4648)L01DiabetesDiabetes (K11K17, K29)K17DiabetesDiabetes (K11K17, K29)K16DiabetesDiabetes (K11K17, K29)K15DiabetesDiabetes (K11K17, K29)K14DiabetesDiabetes (K11K17, K29)K13DiabetesDiabetes (K11K17, K29)K12DiabetesDiabetes (K11K17, K29)K11

1



51


LTCGroupingHRG

DiabetesDiabetes foot and vascular procedures (Q1619)Q19DiabetesDiabetes foot and vascular procedures (Q1619)Q18DiabetesDiabetes foot and vascular procedures (Q1619)Q17DiabetesDiabetes foot and vascular procedures (Q1619)Q16DiabetesEndovascular procedures (Q12 & Q15) Q15DiabetesEndovascular procedures (Q12 & Q15) Q12

1



52

Opportunities have been identified by analysing a range of HRGsby condition (1/2)

000

00

0

0

Hypertension 29-34Heart Failure 31-36Syncopsy, Chest Pain 23-29Frail/Elderly - FallsFrail/Elderly - Catch allEndovascular proceduresDiabetes 12-18Diabetes - OtherDiabetes - foot and vascular proceduresDiabetes - eye surgery 26-32COPD 26-31COPD - Elderly respiratory 0-1Chest painCardiac Arrhythmias 28-33CABG + AMI + IHD 8-15Asthma

SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; team analysis; HES 2008/09; DH weighted populations; Healthcare for London

Potential reduction of admissions, in %, 2008/09 compared to English PCTs

HRG Group

1

Lowest Quartile


53

Opportunities have been identified by analysing a range of HRGsby condition (2/2)

0

0

0-1

Renal failure 15-21

Pneumonia / Empyema 23-29

Pacemakers, HF, PCI

Other - IBD 0-5

Stroke + TIA

Renal replacement

SOURCE: 2008/09 activity based funding model; continuous household survey; Mid-Year Estimate; HES 2008/09; DH weighted populations; Healthcare for London

Potential reduction of admissions, in %, 2008/09 compared to English PCTs


HRG Group Lowest Quartile

54

Minimal correlation between age and long term condition admissions in benchmark dataset

SOURCE: HES 2008/09

Tower Hamlets City and Hackney Teaching Newham Hammersmith and Fulham Kensington and Chelsea Coventry Teaching Isle of Wight NHS Greenwich Teaching North East Essex Medway Luton Barking and Dagenham Brighton and Hove City Nottingham City Brent Teaching

0

2

4

6

8

10

12

14

0 20 40 60 80 100 120 140 160

Population aged 75 and abovein percent

Rank by number of LTCadmissions per 1,000 Weighted Population

R2=0.114

Herefordshire Plymouth Teaching Kirklees North Lincolnshire Warwickshire Waltham Forest Telford and Wrekin County Durham Newcastle Bradford and Airedale Leeds Peterborough Westminster Wakefield District Shropshire County

30 PCTs with lowest LTC admissions per 1,000 weighted population

1

Note: R2 is the coefficient of determination, a measure of the interdependence of the two metrics, 0 indicating low interdependence, 1 indicating high interdependence

In discussions on the foregoing analysis with stakeholders in NI, the question was raised to what extent the PCTs being used as lowest-quartile comparator were those with the youngest populations (which would invalidate the comparison). This analysis shows that this is not the case


55

Long-Term Condition Management Data-to-analysis explanation (1/2)

Compare acute admissions per weighted population in LTC-related HRGs For each LTC, a group of HRGs typically associated was identified Number of admissions per 1,000 weighted population was compared to English PCTs lowest quartile, for the

above-mentioned group of HRGs The cost per admission was estimated based on a map of hospital cases coded under both HRG 3.5 and HRG

4.0, since the admissions for English PCTs were only available in HRG 3.5 while the NI unit costs were only available in HRG 4.0

It was assumed that to prevent each LTC-related admission, it would require two GP consultations and six district nurse contacts, at a total cost of ~360 shown on the charts as re-provision cost


Comments

Benchmarking Admissions for specified HRGs Northern Ireland England

NI unit cost of HRG admissions England weighted populations

Data Sources

2008/09 Activity Based Funding model HES 2008/09 2008/09 Reference Costs (HRG 4.0) DH exposition book

PCTs with lowest quartile admissions are not outliers with regard to their age profile

Given the relative under-investment in mental health in Northern Ireland, although this analysis could have been applied to mental health related HRGs, it was not

Comments

Christine KennedyContacts/ data owners


56

With good disease management at primary care level, hospital activity for long term conditions can be significantly reduced

Condition Core references

Reduction in acute unscheduled activity

Increase in PC con-sultations required to deliver LTC in London case example

x 2.5

Asthma Cochrane,2003(1) (36 trials); BTS

Asthma Guideline, 2004 (25 trials) DH Compendium of CDM citing

BMJ,2004,328,144;Thorax,2001,56,687-90;Pub Health Med,2002;25;258-60

x 1.7

Diabetes DH CDM Compendium citing Cochrane

(41 RCTs) & 3 RCTs Diabetes Med, 2003(1),32-8 (1 study)

x 2.4

COPD

Congestive heart failure

Intervention Heart,2005,91,899-906 (74 trials);

JGenInternMed,1999,14 (2), 130-4 (7 trials); Chest, 2005,127;2042-8 (4yr study)

BMJ,2001;323;715-8 (1 RCT) JAMA,2004,291,11 (18 RCTs) CHD NSF Chapter 6 Euro Heart Journal, Guidelines for the

diagnosis and treatment of CHF, 2005

Multi-disciplinary managed care2

Specialist nurse interventions

Discharge planning and post discharge support

Active case management4

Specialist asthma nurses

Active disease management

Specialist primary care (GPwSIs)

Early discharge planning and hospital-at-home

Multi-disciplinary pulmonary rehab for 6-12 weeks

Thorax(NICE),2004,59,39-130 (2 RCTs; 1 for each intervention)

NHS Institute Directory of Ambulatory Emergency Care for Adults (citing NICE guidance)

LOS

54%

40%

50%

50%

Adm123-85%3

58%

25%

36%

10-38%

25%

10-30%

10-30%

x 1.8

1 Hospital readmission (inpatient); 2 Best evidence for programmes of 3m including education, lifestyle advice, exercise, home visits, nurse case managers and regular monitoring; 3 Weighted average = 27%; 4 Including written care plan, supported self-monitoring and regular practitioner reviews

SOURCE: Disease prevalence numbers from QOF data for 2005/6 (applied to GP registered populations for percentage prevalence), NHS Information Centre; Decision Resources Patient Base for CHF prevalence and severity breakdowns between conditions; Department of Health (for GP registered populations)

CASE STUDY

1

57

Using a registry to target secondary prevention, Kaiser reduced hospitalisation rates and reduced mortality by 76%

Quality improvements All cause mortality down

76% over 8 years Patients at target LDL up

from 22% to 77% 266 less major cardiac

events each year in 12,000 population

Cost improvements Annualised savings of

$3m/year ($242 per patient) due to less hospital activity

Background/Context Cardiovascular disease is the leading cause of

death in the US There is robust evidence that cholesterol and blood

pressure control reduces mortalityProgramme details All patients with an acute coronary event are

offered enrolment in the KP Colorado programme 12,000 patients enrolled, average age 70

Patients are seen by a nurse within 24 hours and agree a prevention plan Education, therapy, medication and monitoring

Nurses, pharmacists and clinicians share an electronic medical chart and online registry

Highly proactive case management by nurses and pharmacists to monitor adherence and efficacy

Collaborative approach across clinicians, nurses and pharmacists, enabled by good IT systems and integrated care

Resources Kaiser is currently evaluating total costs

Impact

22

77

+250%

% patients at target LDL

100

24

-76%

All-cause mortality over 8 years

CASE STUDY

1

SOURCE: Permanente Journal, Summer 2008, Volume 12 No. 3

58

Disease registries: Key success factors and replicability

Key success factors

Identify appropriate personnel Nurses skilled in education Pharmacy medication experts

Build appropriate systems Identify and track patients Communicate plans and

problems Track outcomes and

performance

Collaborate with clinicians

Lessons for adoption in the NHS

Kaiser invested 2 to 3 years in developing the evidence base on protocols

Significant investment in high-quality IT system is necessary

Protocols, once agreed, were made compulsory for all clinical staff

Productivity dropped in the first year as need was discovered and the new system was implemented

CASE STUDY

1

SOURCE: Permanente Journal, Summer 2008, Volume 12 No. 3,

59

1,5251,521

661610 520665

DMP

Prescription drugs

Inpatient care

4,177OtherOutpatient care

1,471

Non-DMP

4,800

2,004

620

0

1.0

2.0

3.0

2 3 4 5 6Duration of DMP

Half-years

-63%

German national disease management programme (DMP) improved outcomes and reduced costs of LTCs

Costs of care for patients with diabetes EUR per year, 2006

Patients in DMP with new cases of diabetic feetPercent per quarter, adjusted to patients at risk

DMPs achieved improved medical

outcomes

Higher cost effectiveness by

Improved treatment and coordination

SOURCE: Interviews with DMP experts

CASE STUDY

1

60

Number of emergency admissions for 106 patients over 12 weeks

Recent English PCT frail/elderly pilot has yielded a 58% reduction in admissions compared with a control group

SOURCE: Pilot PCT; PARR++ estimates

17

41

Pilot patientsControl group

-58%

Registered with the 6 pilot practices

Identified by PARR++ based on inpatient records from 2007-2009

PARR++ score of more than 30

Admissions is measured as total emergency admissions over 12 weeks for the top 106 patients

Current patients under the pilot at the 6 practices

Selected through a combination of PARR++ analysis and local intelligence

Patients selected through PARR++ have median score of 36. A large percentage of the original PARR list have been filtered out through local intelligence

Admissions is measured as number of emergency admissions in first 7 weeks and projected across 12 weeks

Control Group Pilot patients

CASE STUDY

1

61

Case study of multidisciplinary staff project: Croydon virtual wardsImpact to date

Since May 2006 Has saved 1 million Has resulted in the closing of 100

Acute beds

Enablers and prerequisites for this change

Description and context

Context ~2,600 patients in Croydon with >2 emergency admissions per year due to worsening LTC Croydon decided that these patients need to be managed better to reduce admissions

This caused the introduction of a Virtual Ward, each with 100 beds Each ward is a team with a community matron, ward clerk, GP attached Beds are offered to patients with high risk of admission Ward staff and processes are similar to acute, but patient remains at home If patients exceed risk factor they are admitted to a real hospital Local hospitals, GPs and NHS Direct aware of who is in these wards to be available 24/7

Patient selection Predictive algorithm (PARR) identifies 100 patients most at risk of emergency admission

Usually patients with worsening LTCs Adjustable boundaries mean wards do not need to be co-terminous with boroughs/PCTs

Effective leadership by local authorities

Pooled funding The risk management tool which

contained a predictive algorithm (PARR) created by the Kings Fund

Organisational structure

Community matron (ward clerk) Coordination of ward

staff and specialist care

Ward staff Nurse Health visitor Pharmacist Social worker Physiotherapist

Occupational therapist Mental health link Voluntary sector helper GP

Specialist services Specialist nurses Palliative care team

Alcohol service Dietician

SOURCE: Kings Fund; NHS Institute for Innovation and Improvement

CASE STUDY

1

62

Veterans Health Administration trialled remote patient management and realised significant savings in admissions and bed days

Quality improvements 86% mean satisfaction

score rating Cost improvements

25% reduction in bed days of care

20% reduction in numbers of admissions

Background/Context The VAs Care Coordination Home Telehealth (CCHT)

program began in 2001 A total of 43,430 patients have been enrolled since VHA

implemented CCHT in 2003. VHA will increase these services 100% above 2008 levels to reach 110,000 patients by 2011 (only 50% of projected need).

Programme details (what was done & how) Use of health informatics, disease management and home

telehealth technologies to provide routine non-institutional care (NIC) and chronic care management services to patients with diabetes, congestive heart failure, hypertension, posttraumatic stress disorder, chronic obstructive pulmonary disease and depression

In 85% of cases the technology utilised was messaging/monitoring services; video-telemonitors 11%; videophones 3%

VHA attributes the rapidity and robustness of its implementation to the systems approach taken to integrate the elements of the program.

2520

Reduction in bed days

Reduction in admissions

Impact% reduction

SOURCE: Coye (HealthTech) Transformation In Chronic Disease Management Through Technology

CASE STUDY

1

63

Condition Number of Patients % Decrease UtilizationDiabetes 8,954 20

Hypertension 7,447 30

CHF 4,089 26

COPD 1,963 21

PTSD 129 45

Depression 337 56

Other Mental Health1

653 41

Single Condition 10,885 25

Multiple Conditions 6,140 26

resulting in dramatic reduction of LTC acute care utilisation at the Veterans Health Administration

SOURCE: VA Care Coordination/Home Telehealth Studies 2004-007, in Darkins et al. Telemedicine and e-Health, Dec 2008 Ratan (MKR-A) | 5/12/2009 | 2009 Robert Bosch LLC and affiliates. All rights reserved.

1 Since this applies to acute care settings only, not directly for entirety of Mental Health provision.

CASE STUDY

1

64

Healthways Diabetes management programme reduced healthcare cost per patient by 20%

SummaryComprehensive disease management for diabetes Reduces overall

healthcare costs Primarily through

hospitalisation reduction

InterventionHealthways Comprehensive Diabetes Disease Management Program

Sample size20,539 patients with diabetes enrolled in the Medicare+ program across the USA.

Follow-up Patients followed-up for

12 months Results stratified between

those staying on the programme continuously vs intermittently

Coordinated series of interventions managing all aspects of the diabetic patients care Patients stratified on 20 parameters to determine the appropriate

intensity of support required Patient care manager assigned to each patient Pro-active outreach and patient engagement programme Self-care counselling and support Regular testing and monitoring Active management of acute episodes Planned preventative interventions

All healthcare costs reduced by 17.1% (21.2% for patients staying continuously on the programme for 1 year)

Hospitalization costs reduced by 15.9% (23.7% 1 year) Hospital admissions reduced by 15.6% (20.5% 1 year) Bed days reduced by 21.7% (26.6% 1 year)) Rate of HbA1c testing increased by 21%, from 61% to 74% HbA1c levels reduced from mean 7.75 to 7.48 Increased rates of

Retinal eye exam Foot exam Serum creatinine testing Cholesterol screening

Approach

Impact

SOURCE: American Healthways, American Healthways Comprehensive Diabetes Disease Management Program Improves Health Status for Medicare Recipients and Reduces Health Care Costs by 17.1 Percent, http://www.americanhealthways.com/articles/outcomes/CDCHandoutFINAL.pdf

CASE STUDY

1

65

Ownhealth in Birmingham proactively manage patient care, delivering improved outcomes

Example outcomes, %Overview

Telephone-based case management service run by nurse care managers

Covers diabetes, COPD, heart failure and CVD

Currently operating across 3 PCTs and serving around 1300 patients (July 2007)

Operates in several languages Focus on:

Proactivity: outbound calls to patients at agreed time

Patient responsibility: patients set own goals

Motivation, coaching and support of patients

6

4136 38

7065

Stop smokingDietPhysical activity

% in action or maintenance stage at baseline% in action or maintenance stage at follow-up

91220

28

671614

Hyper-glycaemicsymptoms

Hypo-glycaemicsymptoms

Angina pectorisHeart failure symptoms

BaselineFollow-up

Overall patient satisfaction 96% September 2006good adviceyou are not on your own when you have a care managercan always ring up and ask a question if you are worriedreally educational I am in safe hands with the care managerreassuring to share my feelings what I was doing right and what I knew I was doing wrong

SOURCE: OwnHealth presentation materials; National Commissioning Conference

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Tower Hamlets has negotiated an innovative contract that will incentivise the right behaviours in procuring care packages

Tower Hamlets derived an innovative contract for commissioning diabetes care from GPs, which included both requirements for minimum standards of activity and pay for performance to incentivise behaviour. Over time percentage of payment made for outcomes will increase.

% of payment Definition When paid70% Undertaking all activity required by the care packages Quarterly

% of payment Definition When paid10% Accurate and timely data coding Year end5% Patient satisfaction Year end5% Improvement in HbA1c, BP, Chol. Year end5% All patients have individual care plans Year end

Payment for activity ensures adequate care is provided:

Payment for performance aligns incentives to improved outcomes:

SOURCE: Tower Hamlets PCT, 2008 (contact Andrew Ridley)

1

Background

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67

Background/Context Crisis resolution teams are intended to reduce

psychiatric bed use and provide rapid access to services. Their roles are to assess everyone for whom acute admission is considered and, whenever feasible, to provide intensive home treatment instead of admission.

No randomised evaluation of this service model had previously been carried

260 residents of the Inner London borough of Islington who were experiencing crisis severe enough for hospital admissions to be considered

Programme details (what was done & how) Compare admission rates and satisfaction of the

group of 135 who received care from crisis resolution team (experimental group) vs. the group of 125 who receive the standard inpatients services and community mental health teams support (control group)

Crisis resolution teams can reduce the need for mental health inpatient admissions by 4050%

Quality improvement Care delivered closer to home and reduced

need for hospital admissionsProductivity improvement Patients in the experimental group were less

likely than those in the control group to be admitted during the eight weeks after the crisis

Overall36

69

Crisis House 19

13

Psychiatric ward 22

59

4775

2418

2967

8 weeks after the crisis:

6 months after the crisis:

-48% -37%

Control groupGroup supported by CRT

SOURCE: NHS

Impact

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Mental health example: Early intervention in Northumberland reduced bed days due to psychosis by 54%

1.3

1.9

0.4

0.9

Number of re-admissions

Number of admissions

1 Early intervention in psychosis service and psychiatric admissions - Guy Dodgson, Kathleen C Rebbin, Caroline Pickering, Emma Mitford, Alison Brabban and Roger Paxton - Psychiatric bulletin (2008), 32, 413-416. doi: 10.1192/pb.bp.107.0174 42

SOURCE: Psychiatric bulletin (2008)

Study details: Early intervention in psychosis team was

established in Northumberland (2002) aimed to take on all individuals with first-episode psychosis in the county

Participants were service users under 36 years of age who presented between October 1998 and September 2005 The first group (n=114) were individuals

who presented between October 1998 and September 2002 (i.e. before the service had been established), but who would have met the acceptance criteria for the service.

The other group (n=75) were all individuals who received treatment from the service between September 2002 and October 2005

The groups were biased in prognostic indicators such that the treatment group was expected to have a worst prognosis

Number of admissions in the first 3 years of treatment

Early intervention (n=75)No early intervention (n=114)

Bed days

44.9

99.7

Mean number of bed days in first 3 years of treatment

Reduction: 52% 69% 54%

1CASE STUDY

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Other studies also demonstrate the potential impact of early intervention/ long-term condition management in preventing the need for mental health inpatient spells

SWL and St George's COPD pilot

Cochrane, Community mental health teams for people with severe mental illnesses and disordered personality (Review), 2007, 3

Dupont S Breathlessness Clinic at Hillingdon Hospital

Moore RK, Groves DG, Bridson JD, Grayson AD, Wong H, Leach A, Lewin RJ, Chester MR. A Brief Cognitive-BehavioralIntervention Reduces Hospital Admissions in Refractory Angina Patients. J Pain Symptom Manage. 2007 Mar;33(3):310-316.

Lewin B, Cay E, Todd I, Soryal I, Goodfield N, Bloomfield P, Elton R The angina management programme: a rehabilitation treatment. British Journal of Cardiology 1995; 2(8): 221-226

Liverpool and Leeds psychiatric liaison services

SOURCE: Various, cited above

Study Study conclusions 83% reduction in admissions (sample size ~40) and 84%

reduction in LOS for those admitted, through use of integrated physical and mental health community teams

13% reduction in inpatient admissions through use of community teams

COPD: CBT based interventions significantly reduced health care utilisation, including accident and emergency attendance, bed usage, and pharmacy costs, with improvements in depression and anxiety

Psychological intervention and psycho-education angina stability improved by 30%, 40% reduction in emergency admissions for refractory angina

Leeds Partnership for Older People Project reduced hospital admission of people with dementia, leading to over 1000 bed days saved per annum and cashable savings. An analysis in Liverpool of 320 cases managed by the liaison team social worker showed a lowered six month re-admission rate, with 87% of re-admissions for medical, not mental health or social, reasons

ILLUSTRATIVESAMPLE1

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Social care6



71

Benchmark to highest/ lowest quartile

Results, 2008/09

Methodology used

Results, 2014/15

Decommissioning procedures of limited value could reduce spend by ~12m

SOURCE: Reference Costs Returns 2008/09, team analysis of HRG 4.0 to 3.5 map, 2008/09 Activity Based Funding Model, continuous household survey, mid-year population estimate, London Health Observatory Save to Invest: Developing criteria-based commissioning for planned health care in London; Hospital Episode Statistics 2008/09 2009, Re-used with the permission of The Health and Social Care Information Centre, DH weighted populations; JAMA 4 Dec 2002 (vol 288) no. 12

Estimate of potential benefits, m

1 30% re-provision cost deducted for spend on alternatives

2Re-provision cost

Opportunity net of re-provision cost

12-15Total

Comparison of interventions per weighted population with England Reference cost returns (HRG 4.0) mapped to HRG 3.5 for unit prices Overcounting for both England and Northern Ireland possible, as analysis was

not conducted at procedure level; results should be seen as indicative

3.1-4.2Effective, closerisk-benefit ratio

9.6-12.0Total

Effective interventions,cost-effective alternatives1 0.4-0.9

Potentially cosmetic interventions 1.6-1.9

Relatively ineffectiveinterventions 4.5-5.0

A

B

D

C


72

Decommissioning procedures Data-to-analysis explanation (1/2)

Benchmarking Admissions for specified HRGs Northern Ireland England

Unit costs of admissions English PCT weighted populations

Data Sources London Health Observatory Save to

Invest: Developing criteria-based commissioning for planned health care in London

2008/09 Activity Based Funding model Hospital Episode Statistics 2008/09 NI 2008/09 Reference Costs DH exposition book

Comments PCTs with lowest quartile admissions are not outliers with

regard to their age profile Overcounting for both England and Northern Ireland

comparators is possible, as analysis was conducted at HRG but not procedure level; results should be seen as indicative

Comments

Christine Kennedy

Contacts/ data owners

2

Compare admissions per weighted population for interventions of limited clinical value Based on Save to Invest report, HRGs representing treatments of limited clinical value were identified Number of admissions per 1,000 weighted population was compared to English PCTs lowest quartile, for the

above-mentioned group of HRGs The cost per admission was estimated based on a map of hospital cases coded under both HRG 3.5 and HRG

4.0, since the admissions for English PCTs were only available in HRG 3.5 while the NI unit costs were only available in HRG 4.0

For interventions with more cost efficient alternatives, 30% re-provision cost was assumed



73

We used these HRGs to represent the majority of treatments with potential for decommissioning

SOURCE: LHO Save to invest: Developing criteria-based commissioning for planned health care in London

Tonsillectomy Spinal Cord Stimulation Back Pain : Injections and Procedures Grommets Knee Washouts Trigger Finger Dilation and Curettage Jaw Replacement Minor Skin Lesions Inguinal, Umbilical and Femoral Hernias Incisional and Ventral Hernias Aesthetic Surgery - Breast Varicose Veins Aesthetic Surgery - ENT Other Hernia Procedures Aesthetic Surgery - Plastics Aesthetic Surgery - Opthalmology Orthodontics Knees Primary Hip Hip and Knee Revisions Cataract Surgery Female Genital Prolapse/Stress Incontinence (Surgical) Wisdom Teeth Extraction Dupuytrens Contracture Cochlear Implants Other Joint Prosthetics Female Genital Prolapse/Stress Incontinence (Non-Surgical) Hysterectomy for Menorrhagia Carpal Tunnel Anal Procedures Bilateral Hips Elective Cardiac Ablation

C58 A03 R03,R04,R07,R09 C55 H10 H14,H20,H16, H17 M05 C25, C35, C45 J33,J34,J35,J36,J37 F73, F74 F71, F72 J01,J04,J05,J06,J07,J50 Q11 C21,C32,C56 F76, F77 J29,J32 B17,B18 C04 H03, H04 H80,H81 H05,H06,H07,H71,H72 B13 M03 C58 H13,H16, H17,H14 C60 H08 M13 M07,M08 H13 F92,F93,F94,F95 H01 E38,E39

HRG Description HRG version 3.5 Part of service line

Medicine

Effective inter-ventions with a close benefit/risk balance in mild cases

Effective inter-ventions where cost effective alternatives should be tried first

Effective inter-ventions with a close benefit/risk balance in mild cases

Effective inter-ventions where cost effective alternatives should be tried first

Surgery


74

By benchmarking activity per weighted population to England, thepotential reduction in NI activity was identified (1/2)

000000

0

0000

0

Varicose Veins 30-36Other Hernia Procedures 16-22OrthodonticsMinor Skin LesionsInguinal, Umbilical and Femoral HerniasIncisional and Ventral HerniasAesthetic Surgery - PlasticsAesthetic Surgery - OpthalmologyAesthetic Surgery - ENT 23-29Aesthetic Surgery - Breast

Trigger FingerTonsillectomySpinal Cord StimulationKnee WashoutsJaw Replacement 22-28Grommets 23-29Dilation and Curettage 45-49Back Pain : Injections and Procedures

SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; HES 2008/09; DH weighted populations

Potentially cosmetic interventions

Relatively ineffective interventions

HRG Group

2

% potential reduction in number spells if NI moves to English lowest-quartile PCT rate, 2008/09

A

B


75

By benchmarking activity per weighted population to England, thepotential reduction in NI activity was identified (2/2)

0

0

0

0

0

Primary Hip1 8-15

Other Joint Prosthetics 55-58

Knees

Hip and Knee Revisions

Femal Genital Prolapse/Stress Incontinence (Surgical) 35-40

Female Genital Prolapse/Stress Incontinence (Non-Surgical) 0-4Cochlear Implants 27-32

Cataract Surgery

Hysterectomy for Menorrhagia 4-11

Elective Cardiac Ablation 19-26Carpal Tunnel

Bilateral Hips

Anal Procedures 0-7

Effective interventions with close benefit-risk-balance in mild cases

Effective interventions where cost-effective alternatives should be tried first1

C

D

SOURCE: 2008/09 activity based funding model; continuous household survey; mid-year population estimate; HES 2008/09; DH weighted populations1 For these treatments we assume a 30% re-provision cost, e.g., for drug-based treatment


% potential reduction in number spells if NI moves to English lowest-quartile PCT rate, 2008/09HRG Group

For some of these treatments, Northern Ireland activity levels are already below English comparators

76

PCTs with lowest levels of this kind of activity tend to have slightly younger populations but not to extent of discrediting this analysis

These PCTs have the lowest level of interventions with potential for decommissioning per weighted population

with a slight bias towards younger populations, but not sufficiently so to discredit the analysis

0

5

10

15

20

0 20 40 60 80 100 120 140 160

% of 2008 population over 75

Spells per 1000 wt pop,interventions with potential to decommission

1. Tower Hamlets PCT2. Kensington and Chelsea PCT3. Westminster PCT4. City and Hackney Teaching PCT5. Newham PCT6. Leicester City PCT7. Camden PCT8. Heart of Birmingham Teaching PCT9. North East Lincolnshire CT10. Hammersmith and Fulham PCT11. Nottingham City PCT12. Islington PCT13. Wandsworth PCT14. Manchester PCT15. Liverpool PCT

SOURCE: LHO Save to invest: Developing criteria-based commissioning for planned health care in London; applied to PCTs using HES 2008/09

16. Luton Teaching PCT17. Brent Teaching PCT18. North Lincolnshire PCT19. Stoke on Trent PCT20. Leeds PCT21. Bolton PCT22. Brighton and Hove City PCT23. Knowsley PCT24. Barking and Dagenham PCT25. Middlesbrough PCT26. Walsall Teaching PCT27. Darlington PCT28. Wolverhampton City PCT29. Salford PCT30. Ealing PCT

R2 = 0.35

Note: R2 is the coefficient of determination, a measure of the interdependence of the two metrics, 0 indicating low interdependence, 1 indicating high interdependence

2

In discussions on the foregoing analysis with stakeholders in NI, the question was raised to what extent the PCTs being used as lowest-quartile comparator were those with the youngest populations (which would invalidate the comparison). This analysis shows that this is not generally the case


77

Decision aids in the UK have reduced hysterectomy rates by 20% and total costs by 43% per case

SOURCE: JAMA Dec 4 2002 vol 288 no 12

1 Costs reduced more than the hysterectomy rates because after the interview costs decreased both in women who had hysterectomies and in women who did not

When compared to standard care, the interview Reduced hysterectomy

rates by 20% Reduced costs by 43%

or 780/case1 Increased long-term

satisfaction Neither information nor

interview had a negative effect on health status

Background/Context The NHS aims to increase patient participation

in treatment Decision aids can help, because they

Inform patients better about the tradeoffs in care choices (probabilities of benefit and harm)

Clarify individuals values on how the patient perceives benefit and harm

Offer support through the decision making process using guidance and prompts

Study details An information pack and interview were

developed to help women with menorrhagia 894 women in South West England were

randomised to decision aid or usual care Two year total cost to the payor was recorded

CASE STUDY

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Decision aids increase patient engagement

Decision aids reduce the use of discretionary surgery withoutapparent adverse effects on health outcomes or satisfaction

Conclusions of Cochrane review

Perspectives

Challenges for adoption in the NHS Many procedures are unnecessary Commissioners can avoid

unnecessary procedures by Decommissioning certain services Developing service access criteria Implementing decision aids

Careful value judgements need to be made in discussion with clinicians about thresholds for intervention

Patients with decision aids 15% higher knowledge scores 40% less passive in decisions 70% more realistic expectations

Examples in the NHS Croydon PCT has developed common

services access criteria Decision aids for menorrhagia in

hospitals in South West SHA reduced hysterectomy rates and costs (see next page)

SOURCE: OConnor et al., Cochrane Library, 2009

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Systematic review finds that decision aids could reduce electivesurgical procedures by 2025%

Prostatectomy (for BPH)8%

14%

Back surgery26%

33%

Mastectomy23%

40%

Coronary Bypass surgery41%

58%

Orchidectomy56%

83%

Prostatectomy (for cancer)63%

83%

With decision aid

Standard Care

International surgical review South West SHA example

Background/Context Decision aids can help increase patient

participation in treatment, because they Inform patients better about the tradeoffs in

care choices (probabilities of benefit and harm) Clarify individuals values on how the patient

perceives benefit and harm Offer support through the decision making

process using guidance and promptsStudy details An information pack and interview were developed

to help women with menorrhagia 894 women in South West England were

randomised to decision aid or usual care Two year total cost to the payor was recorded Impact When compared to standard care, the interview

Reduced hysterectomy rates by 20% Reduced costs by 43% or 780/case1 Increased long-term satisfaction

Neither information nor interview had a negative effect on health status

Percentage of patients deciding to have a procedure with or without use of Decision Aids

1 Costs reduced more than the hysterectomy rates because after the interview costs decreased both in women who had hysterectomies and in women who did not

SOURCE: OConnor et al., Cochrane Library, 2007 & updated 2009; JAMA Dec 4 2002 vol 288 no 12

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81

Prevention will be an important driver of long-term quality and productivity, short-medium term effect will be more limited

3

SOURCE: NIAO Obesity and Type 2 Diabetes in NI report, January 2009, Postnatal care: routine post-natal care of women and their babies: Cost Report: Implementing NICE guidance in England, July 2006; Reference Costs Returns 2008/09; Continuous household survey, mid-year population estimate; London Health Observatory Save to Invest: Developing criteria-based commissioning for planned health care in London; Hospital Episode Statistics 2008/09 2009, Re-used with the permission of The Health and Social Care Information Centre

Case studies/ research

Results, 2008/09

Results, 2014/15 4.6

Savings are estimated using some indicative case study programmes as examples

Although many studies exist to prove the clinical impact of prevention programs, exact costs, financial benefits and implementation timelines remain unclear

Given the short-medium term timeline to 2014/15, assumptions have been conservatively based on: Alcohol: based on results from English Total Places pilots scaled to NI3 Diabetes: Successful delivery of obesity reduction programme to 2-3% of

diabetics1; with savings per person pro-rated from US Why WAIT case study Infants breastfed: 10% increase in initiation from post-natal care programme

leading to reduction in otitis media, gastroenteritis, asthma cases and teat usage (from NICE costing report) (scaled to NI)2

Further savings could be possible from other programme areas for example, smoking and sexual behaviour

Estimation of benefits, m

3.6

Scale of savings triangulates to expected prevention benefits in other health regions

1 Assuming 65k diabetics in NI (NIAO Obesity and Type 2 Diabetes in NI report, January 2009) with Why WAIT savings pro-rated down by variance in healthcare spend/head

2 Based on cost-benefit analysis outlined in Postnatal care: routine post-natal care of women and their babies: Cost Report: Implementing NICE guidance in England, July 2006

3 Based on Total Place pilots in Leicester, Birmingham, South Tyneside, Sunderland and Gateshead; with results scaled to NI

SOCIAL CARE ASPECTSIN CHAPTER 6


82

Preventing health and well-being issues has significant knock-on impact to broader health issues reducing serious harm in the mid term

1 of adults, 15 and above, 2008/092 of adults, 15 and above, 2005/063 2005SOURCE: Northern Ireland Continuous Household survey; Northern Ireland Health and Social Wellbeing survey; ERPHO, 200305; NIAO Obesity and

Type 2 Diabetes in NI report, January 2009; Mid-Year Estimate of Population

NI Prevalence

Smoking

Obesity

Estimated health impact CHD Cancer 2,400 smoking

deaths per year

Diabetes Hypertension Dyslipidemia Breathlessness Sleep apnoea Gall bladder

disease

Patient action Stop smoking

5 fruits/vegetables a day 27%2 compliance

5

reshaping the system part 1

Documents

years signs of poor

higher quality

implementation3quality

recent years

years old

inpatient care

outpatient care

social care board