January 2014 Introduction 2 How do we use this Any town health system guide This guide has thus far outlined the challenge facing health systems in the form of a potential quality and funding ID: 934680
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Slide1
Any town health system
A guide to finding further information on the interventions
January 2014
Slide2Introduction
2
How do we use this Any town health system guide?
This guide has thus far outlined the challenge facing
health systems in
the form of a
potential quality and funding
gap by
FY 2018/19.
The
following section highlights
interventions
that the evidence suggests can help health economies to achieve cost savings while delivering better quality
care and further interventions that we have not included in the modelling and report but may be of interest to health systems. These include interventions provided by other partner organisations such as Public Health England and we are very grateful for their contribution.
However, we recognise that not all health economies are the same:
Their demographic make-up and the prevalence of conditions among the population will vary considerably
Some health economies may already have begun implementing some of the initiatives we have discussed
Furthermore, we recognise that implementing each of these interventions could pose a significant challenge to health economies. Which should be prioritised and how should a health economy approach the challenge?
With this in mind, this section presents
interventions,
a list of leads to follow up on, and a series of guides to getting started with each of the interventions.
These guides are intended to provide a high-level ‘starter for ten’ to assist with initial planning, including:
Initial selection of priority interventions (based on health economy characteristics and target population groups
) and further interventions not included in the main report;
Enablers and implementation
steps;
Potential
barriers; and
Suggested phasing of the
interventions.
We recognise that health economy decision-makers are likely to require a greater level of detail in the course of the planning and execution of each intervention. For this reason we provide a list of further reading, which includes case studies, academic studies and, where relevant, contacts for organisations that have experience implementing the
intervention
Slide3High Impact Interventions (HII)
Slide4The evidence base
4
We have performed a non-exhaustive literature review to collate the evidence base behind our selected
High Impact
I
nterventions
. This review was composed of three inter-connected phases
:
Incorporating interventions from existing academic
r
eviews
2
Assessing NHS case
s
tudies
1
This process resulted in a ‘long-list’ of potential interventions, which were then screened to determine their suitability for inclusion in Any town health system
These internal case studies were supplemented through the use of academic reviews of specific interventions (e.g., primary care referral management and patient self-help).
These provided context on the state of the evidence base for each intervention, as well as providing some fully impact-assessed controlled studies of specific interventions.
Furthermore, NICE assessments were consulted
where available (
e.g., for the cost-effectiveness of early diagnosis interventions).
Adding specific
c
ase
studies from Third Sector organisations
3
Finally, specific examples of innovative interventions were drawn from publications produced by third sector organisations, such as the King’s Fund or the British Heart Foundation.While many of these case studies did not fully meet our impact assessment criteria, those that did were shortlisted for further study.Where these suggested the existence of impact assessment for interesting interventions we followed this up in the academic literature.
We began with 270 self-reported case studies of healthcare interventions currently being implemented by health economies around the country, which provided an overview of the breadth of interventions already being trialled across the NHS.While many of these did not meet our inclusion criteria (see next slide), those that did were short-listed for further consideration.
Slide5The short-listing exercise
5
We have used four criteria to short-list from a long list of interventions. The process for selecting
high
i
mpact
i
nterventions
included input from
subject
m
atter
e
xperts
and
national
clinical leads to further refine the list
1
2
3
The interventions are fully impact assessed
from both
a quality and finance perspective. Outcomes are clearly articulated, realised and easily measurable for modelling purposes.
The outcomes derived from the interventions would contribute to the quality and financial challenge indicated previously in this report – interventions where one benefits to the detriment of the other were excluded.The narrative around the intervention is clearly articulated, so that an Any town health system could easily implement the interventions.The intervention is easily scalable to a broad population group (i.e. no interventions targeting ‘niche’ population groups that are unlikely to exist in large numbers across many health economies) – this ensures the intervention produces a high impact.
4
Slide6The high
i
mpact
i
nterventions (HIIs)
6
In this section, for each
high i
mpact intervention
we provide
:
1
2
3
A high-level summary of the HII case study used to model the effects of the intervention and the quality and finance benefits demonstrated in the source literature.
Further information on additional interesting case studies where the intervention has been implemented (where available).
A deep-dive into the impact of the intervention on each quality ambition.
A brief primer on getting started with implementation – patient groups affected, potential enablers, barriers and likely timeframes for realisation of the intervention’s benefits.
4
Slide7The high
i
mpact
i
nterventions (HIIs)
7
We have collected a range of
case
studies and
produced
a short-list as the
high
i
mpact
i
nterventions
1. Early
diagnosis:Early detection and diagnosis to improve survival rates and lower overall treatment costsExample case study:
Lovibond et al , 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011), The Lancet 378: 1219-1230
2. Reducing variability within primary care by optimising medicines use and referringReducing unwanted variation in primary care referring and prescribing to improve clinical outcomes and patient experience, whilst delivering financial savings
Example case study:‘Reducing Unwarranted Variation to Deliver Efficiencies in Primary Care’ (NHS Erewash Clinical Commissioning Group)3. Self-management:
patient-carer communities:Self-management programme for those suffering with a long-term condition,
who educate and support each otherExample case study:The Expert Patient Programme: Richardson et al, 'Cost Effectiveness of the Expert Patients Programme (EPP) for patients with chronic conditions' (2008), J Epidemiol Community Health, 62, 361-3674. Telehealth/telecare:Using telecare/telehealth to transform health care through giving patients the confidence
to manage their own condition more effectively in conjunction with their cliniciansExample case study:Telemedicine for frail/elderly nursing home patients in Airedale - 'Airedale shares telemedicine success at global event' (Airedale NHS FT, 3 July 2013)Telemonitoring of high-risk heart failure patients in Hull - Cruickshank & Paxman, "Yorkshire & the Humber Telehealth Hub: Project Evaluation" (2020health, 2013)5. Case management and coordinated care:Multi-disciplinary case management for the frail elderly and those suffering with a long-term conditionExample case study:‘National Evaluation of the Department of Health’s Integrated Care Pilots’ (RAND Europe, 2012)6. Mental Health – Rapid Assessment Interface and Discharge (RAID):Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general hospitalsExample case study:George Tadros, 'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience' (Birmingham and Solihull NHS Trust)7. Dementia Pathway:Improve health outcomes and achieve efficiencies in dementia care, by developing a fully integrated network modelExample case studies:‘Service redevelopment: Integrated whole system services for people with dementia’ (Mersey Care NHS Trust, 2012)8. Palliative care:Community based, consultant-led palliative care serviceExample case study:Midhurst MacMillan, ‘Community Specialist Palliative Care Service, Delivering end-of-life care in the community’ (The King’s Fund, 2013)
Slide8The High
I
mpact
I
nterventions
8
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3. Self-management:
patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide9Case study: early diagnosis
9
Early diagnosis of high blood pressure improves quality of life, increases life expectancy, and reduces the overall cost of
healthcare
Name and source of literature
Ambulatory screening for hypertension, assessed
in
Lovibond
et al
, 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011)
The Lancet
378: 1219-1230
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61184-7/abstract
Description of intervention
The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. This study aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension
using a Markov model-based probabilistic analysis
Clinical outcomes
The model weighs the increase in quality-adjusted life-years (QALYs) associated with early detection of hypertension via ambulatory, home or clinic-based diagnostics
For patients
aged over 50, ambulatory screening is predicted to produce an average per patient increase in QALYs
Financial outcomes
Ambulatory screening is predicted to be cost-effective compared
to other screening techniques, for all patients aged over 40Modeled estimates of per patient lifetime savings ranged from £56 for men aged 75 to £323 for women aged over 40Relevance to Any town health systemEarly screening for a range of long-term conditions to prevent or delay onset of the disease has positive public health and economic impacts. Through prevention and early treatment of an LTC, the time spent in the more severe and costly treatment settings can be markedly reduced. Specifically, the use of ambulatory diagnostics of hypertension has been recommended by NICE
Other UK
examples
Cost-effectiveness of population-based screening for colorectal cancer, ‘
British Journal of Cancer 2012’; ‘NICE cost impact and commissioning assessment: quality standard for stroke’ (NICE cost impact and commissioning assessment, 2010)Other international examples
‘Cost effectiveness of early detection of breast cancer in Spain’,
BMC Cancer, 2011; ‘Cost-effectiveness Analysis of a Prospective Breast Cancer Screening Program In Turkey’ (Middle East Technical University, 2011); ‘Cost effectiveness of an integrated vascular risk assessment and management intervention’ (Australian Centre for Economic Research on Health, Australian National University, 2011)
Slide10Impact of interventions
on
quality
:
early diagnosis
10
Early
diagnosis –
Ambulatory screening for
hypertension
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect
on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
This intervention produces a net QALY gain for hypertensive patients over 50, and is expected to reduce PYLL in the long term. However,
based on available data it is not possible to map this benefit directly onto Ambition 1
1
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people 1.12. Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
This intervention produces a net QALY gain for hypertensive patients over 50, and is expected to improve HRQoL. However,
based on available data it is not possible to map this benefit directly onto Ambition 21
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
This intervention produces a net cost saving for hypertensive patients over 40, and is expected to reduce unplanned admissions for chronic ambulatory care sensitive
conditions
. However,
based on available data it is not possible to map this benefit directly onto Ambition 3
1
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy]
Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
This intervention does not
target a change in Ambition 4
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
This intervention does not target patient
experience of hospital care, and so is not expected to produce a change in Ambition 5
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
This intervention does not
target a change in Ambition 7
Source:
(
1) 'Lovibond
et
al
,
'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011)
The Lancet
378: 1219-1230
−
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide11Getting
started: early diagnosis
11
Population groups affected:
Adults with LTCs
Frail elderly and dementia sufferers
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
One of the key success factors for this intervention is
patient education and awareness-raising
, in order to achieve the maximum impact through high uptake. This can be achieved through advertising, literature, and GPs, among other methods
Alongside this, a sustained effort is required to
identify and target those patients who are most at risk
and who are therefore most likely to benefit from the intervention
Investment in new devices
as well as the support teams and other infrastructure is an important aspect of the intervention
Have you considered whether the following may be barriers?
Paying for the benefits:
in some cases ‘investigational’ costs (i.e. for monitoring for early signs of disease) are distinct from the budget for medications, meaning that savings in the drug budget do not necessarily translate into resources for early detection. Tackling this requires greater ‘joining up’ across the system
Encouraging uptake
: patient awareness may be a barrier, as many at-risk patients may not realise they are eligible for the screening programme or wish to take advantage of it
Have you considered how you will phase the intervention?
It is to be expected that the benefits for this intervention take some time to reach their full scale, given that the emphasis is on preventing future conditions or the worsening of current conditions
There is likely to be some initial benefit as patients are diverted from A&E, but the majority of the benefit will emerge in subsequent yearsThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
0.5
0.4
0.3
0.2
0.1
0.0
0.6
0.7
0.8
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched
Initial benefits commence
Further benefits develop
Forecast savings per year Urban CCG (£m)
Slide12Key leads and further reading:
early diagnosis
12
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? There are a range of examples available through NHS England
resources for CCGs (
http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-1
/
), including:
NHS Erewash CCG
– Atrial
Fibrillation Detection
Programme
South London – screening programme
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful;
'
Lovibond
et
al, 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011) The Lancet 378: 1219-1230
‘NICE cost impact and commissioning assessment: quality standard for stroke’ (NICE cost impact and commissioning assessment, 2010)
Slide13The High Impact Interventions
13
1. Early diagnosis
2. Reducing
variability
within
primary care by optimising medicines use
3. Self-management:
patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide14Overview of medicines optimisation
14
The four principles of medicines optimisation
Medicines optimisation is a patient-focused approach to getting the best from investment in and use of medicines that requires a holistic approach, an enhanced level of patient centred professionalism, and partnership between clinical professionals and a patient
.
The Royal Pharmaceutical Society, working with patient representatives, medical and nursing royal colleges, and the pharmaceutical industry, endorsed by NHS England, has
identified four key principles of medicines optimisation:
1
Aim to understand the patient’s experience:
through an open, ongoing dialogue about the patient’s experience of using medicines, and recognising that the patient’s experience may change over time
Evidence based choice of medicines:
the most clinically appropriate and cost-effective medicines are used to meet the needs of the patient, informed by the best available evidence base
Ensure medicines use is a safe as
possible:
healthcare practitioners take responsibility for safe
use of medicines
and discuss this with patients and carers. This includes
unwanted effects, interactions, safe processes and systems, and effective communication between professionalsMake medicines optimisation part of routine practice:
healthcare professionals routinely discuss with one another and with patients how to achieve the best outcomes from medicines
Royal Pharmaceutical Society, ‘Medicines optimisation: helping patients to make the most of medicines’ (May 2013) (http://
www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf)
Slide15Case study: reducing variability within primary care
15
This primary care intervention focuses on reducing variability in cost and patient outcomes through addressing prescribing and secondary care referrals
Name and source of literature
Reducing Unwarranted Variation to Deliver Efficiencies in Primary Care – NHS Erewash Clinical Commissioning Group
http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/d2-cs/#ere
Description of intervention
During 2011-12, the CCG was expected to deliver savings of £4.1m as part of the QIPP
agenda. This programme tackled the productivity challenge by engaging with patients and concentrating on quality standards within Primary Care, impacting on all groups accessing primary care. The work was based on the Primary Care Foundation Report 2009, focusing on three
aspects of
activity – referrals to secondary care, emergency admissions and prescribing. Specific changes in respect of these three areas include the circulation of comparison data packs, practices were visited by Fellow GPs, secondary care consultant master classes were held, introduction of prescribing advisors, a “buddying” system, and quality payments for the development of care plans.
Clinical outcomes
Building solid foundations to a patient-centred approach to optimising medicines use through engaging with patients, improving safety, collaboration across professions and sector, more appropriate prescribing and better monitoring of outcomes
High levels of patient feedback
Secondary care clinicians reporting less duplication of tests from improved systems and processes and improved quality of referral letters
More appropriate prescribing, driving better patient safety and experience
Financial outcomes
Inappropriate hospital admissions prevented, down by 4% annually – (mainly long-term conditions and frail elderly) driving better outcomes and experience for these patients
Secondary care referrals from practices were down 14%
Referral rate variance across 13 practices dropped from 202-378 per 1000 in 2010-11 to 174-257 - a reduction of over 50% in variation
These improvements led to £1.04m saving on referrals and admissions – 14-fold return on the investment in 2011-12
In addition, the CCG’s prescribing overspend was cut by 75%, saving £600,000 Relevance to Any town health systemOptimising
medicines use can help reduce variation in the care provided to patients. This not only improves quality of care and patient experience; financial savings on hospital care and prescribing can also be realised.
The success of this case study can be widely applied to Primary Care across the NHS.
Slide16Impact of interventions on quality: primary care
16
Primary
care
–
Reducing
unwarranted
v
ariation
in NHS Erewash Clinical Commissioning
Group
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect
on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
T
he literature review has not
revealed that this intervention would produce a significant effect upon PYLLPotential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people 1.12. Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
It is expected that the aspect of this intervention relating to
safe and appropriate use of medicines would have a significant impact upon patient quality of life as a secondary benefit of a reduction in drug-related adverse effects
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
This intervention has
produced an overall 14% reduction in elective referrals to secondary care. The literature does not suggest a reduction in unplanned admissions
1
However, techniques regarding
safe and appropriate use of medicines
might be expected to also reduce emergency admissions as a secondary benefit of a reduction in drug-related adverse effects
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
None yet
quantified – however, it may be expected that some of the reduction in referrals produced by this intervention will produce a positive impact on Ambition 4
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4b
This intervention does not target patient
experience of hospital care, and so is not expected to produce a change in Ambition 5
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5c
This intervention does not target
hospital care, and so is not expected to produce a change in Ambition 7
Source:
(
1)
‘0404
Case Study - QIPP CQUIN - Reducing
Unwarranted
Variation to Deliver
Efficiencies
in Primary
Care’
(
NHS Erewash CCG, 2013)
−
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide17Getting
started:
reducing variability within primary care
17
Population groups affected:
All patient groups
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
This intervention focuses on tackling unwarranted variations between practices and practitioners. A key element is therefore to
focus on changing behaviour
Engaging patients
in their medicines use to achieve optimal outcomes is key
The intervention
is more likely to be successful if it
involves all practitioners
across and within sectors
Shared
experience
, e.g. via personal experience data packs circulated monthly, enables clinicians to identify and tackle variations in their practices
Other effective tools include
master classes and practice based clinical pharmacists
to increase levels of awareness and education
Peer support, encouragement and challenge and a process of regular peer review are also key elements of the interventionPractice quality payments can provide a financial incentiveHave you considered whether the following may be barriers?
Ensuring that standards of care remain high is a central concern, as well as reassuring patients that their health and well-being is not compromised in any wayGaining practitioner buy-in is fundamental to the success of this intervention and is a key challenge. It is more likely where there is an effective communication effort and practitioners feel they are involved in the development of the interventionEffectively monitoring and gaining compliance from practitioners is necessary to ensure the maximum impact from this intervention – previous experience suggests that maintaining an ongoing dialogue with practitioners is the most effective way to achieve thisHave you considered how you will phase the intervention?Some initial impact is likely to be experienced in the first year of implementationHowever, the full impact is likely to take at least an additional year to materialise, and is dependent on altered prescribing practices and the embedding of new prescribing normsThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
2.0
1.0
0.0
0.5
1.5
2.5
5.0
4.0
3.0
3.5
4.5
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched and initial benefits commence
Main benefits commence
Further incremental benefits
Forecast savings per year Urban CCG (£m)
Slide18Key leads and further reading: reducing variability within primary care
18
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
NHS Erewash CCG
PrescQIPP
is designed to support quality, optimised prescribing through providing guidance, resources and tools to health economies. There are currently over 60 CCGs enrolled – visit
http
://
www.prescqipp.info/user/registration-notes/register
for further info
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful.
0404 Case Study - QIPP CQUIN - Reducing u
nwarranted
v
ariation
to
deliver
e
fficiencies in Primary Care (NHS Erewash CCG, 2013)
Slide19The High Impact Interventions
19
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide20Case study:
Self-management -
patient-carer communities
20
This
self-management
intervention empowers patients through education and support, improving health related quality of life and reducing their reliance on secondary
care
Name and source of literature
The Expert Patient Programme, analysed
in, Richardson
et al
, 'Cost Effectiveness of the Expert Patients Programme (EPP) for patients with chronic conditions' (2008)
J
Epidemiol
Community Health
, 62, 361-367
http://jech.bmj.com/content/62/4/361.short
Description of intervention
Originally based
on the US Chronic Disease Self-Management Program, the Expert Patient Programme (EPP) is a patient-led system of group support for sufferers of a range of chronic diseases. The programme typically consists of 6 weekly 2.5 hour lay-led meetings of ~10 patients, who educate and support each other on topics such as dealing with pain / other symptoms, coping with depression / anxiety and healthy lifestyle choices.
In 2008, Richardson
et al assessed the cost-effectiveness and quality outcomes of the EPP in a RCT of ~700 chronic disease sufferers from around England.
Clinical outcomesOver the 6 month trial, improvement across all five dimensions of the EQ5D system was observed for intervention patients. Healthcare service usage was lower for EPP patients versus controls, with a 49% reduction in average number of inpatient days, a 6% reduction in outpatient appointments and a 73% reduction in occupational therapy home visits for EPP patients.Financial outcomesOn the basis of these data a 0.02 QALY gain per patient for the intervention group was estimated. Once EPP provision costs are accounted for, this produced a £27 per patient saving.Relevance to Any town health systemSchemes such as this provide strong non-financial benefits in the form of improved patient outcomes (e.g., community integration, sense of wellbeing / empowerment). Their broad applicability and low barriers to access mean that, while the per patient cost saving is low, across a health economy the potential aggregate savings are larger.
Other UK
examples
‘People
powered health co-production catalogue’ (NESTA, 2012); ‘Delivering better services for people with long-term conditions: building the house of care’ (The King’s Fund, 2013)Other international examples
The CDSMP programme for chronic conditions: Lorig
et al, 'Effect of a Self-Management Program on Patients with Chronic Disease' (2001) Effective Clinical Practice, 4:256-62
Slide21Case study:
Self-management -
patient-carer communities
21
For the purposes of modelling we have used UK-based impact assessed evidence.
Whilst
not based in the UK, we present a case study from Kaiser Permanente that may be further explored by health
economies
Case study: Self-Management Program on Patients with Chronic Disease
For patients with chronic disease, there is growing interest in “
self-management” programs
that
emphasise
the patients’ central role in managing their
illness. The
Chronic Disease Self-Management Program is a 7-week,
small group
intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and
emphasises problem solving, decision making, and
confidence building. The following metrics were monitored: health behaviour, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilisation. These were assessed at baseline and at 12 months by self-administered
questionnaires. At 1 year, participants in the program experienced statistically significant improvements in health
behaviours (exercise, cognitive symptom management, and communication with physicians), self-efficacy, health
status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, comparedwith 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomised, controlled trial.
Programme costs were estimated to be about $200 per participant. The study replicated the results of our previous clinical trial of a chronic disease self-management program in a “real-world” setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.Source: Lorig et al, 'Effect of a Self-Management Program on Patients with Chronic Disease' (2001) Effective Clinical Practice, 4:256-62Innovators
Slide22Impact of interventions on quality:
self-management
22
Patient-Carer
communities
–
The e
xpert patient programme
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect
on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
None yet quantified – however, by helping patients better manage their conditions, it may be expected
that the intervention will reduce PYLL in the long term
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people
1.1
2. Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
The intervention has produced
a 7.7% increase in health-related quality of life for patients with long-term conditions1
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
None has yet been quantified – however, this intervention aims to reduce admissions for patients with long-term conditions. Therefore,
it can be expected to produce an improvement in Indicator 2.6. Indeed, it has produced a quantified reduction in A&E attendances and inpatient bed-days
2
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
None yet quantified – however, this intervention
can be expected to increase the proportion of older patients still at home 91 days post-discharge
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
This intervention does not target patient
experience of hospital care and so is not expected to produce a change in Ambition 5
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
This intervention does not target
hospital care and so is not expected to produce a change in Ambition 7
Source:
(
1) Kennedy
et al
, 'The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised control trial' (2007)
J Epidemiol
Community
Health
,
61:254-261; (2
) Richardson
et al
, 'Cost Effectiveness of the Expert Patient Programme (EPP) for patients with chronic
conditions‘ (2008
)
J Epidemiol Community Health
, 62:361-367
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide23Getting
started:
self-management
23
Population groups affected:
Adults with
LTCs
Children with LTCs
Carers
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Provide
training for clinicians
in the core competencies of self care
Develop a
more personalised self-management pathway
for patients, responding to the feedback from patients that they can feel they are treated ‘like robots’
Learn from the experience of patients and clinicians to
continually inform service design
, leading to a dynamic process of
f
eedback and improvement
Identify and target patients with the conditions that are most likely to benefit from self-managementEnsure that self-management goals become an integral part of the care process and form part of a personalised care planCo-ordinated action at both local and national level is a powerful enabler of this initiative and offers a route to overcoming many of the challenges involvedConsider how self management programmes fit in with the wider strategy for self care
and self management supportUse of third sector organisationsHave you considered whether the following may be barriers?Overcoming negative attitudes among staff to new approaches to patient care with an emphasis on self-management. In many cases this can be mitigated through improved provision of training and informationLack of awareness, both among patients and staff, can also be a significant barrier to the success of this intervention as this can lead to lower rates of participationPatients may not be ready or confident for self management and need to address any concerns they haveTechnical issues, such as the inability of current IT systems to register information such as patients’ issues and goalsMulti-morbidity (for example, where the patient suffers from both mental and physical conditions) poses an additional challenge, given that most clinical guidelines and IT systems are geared towards single conditionsHave you considered how you will phase the intervention?Done well, self-help interventions can be a relatively quick win, with training courses and other forms of support for patients and clinicians feeding through into rapid outcomes (as quickly as four to six months in some studies)It is to be expected that benefits will continue to build over future years as awareness grows and service design is improved in response to the experiences of patient and cliniciansThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRural
Urban
Other
0.0
0.2
1.0
0.4
0.6
0.8
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched and benefits commence
Further incremental benefits
Forecast savings per year Urban CCG (£m)
Slide24Key leads and further reading:
self-management
24
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
The Expert
Patients Programme:
get.info@eppcic.co.uk
Patient Participation team, NHS
England:
england.patientsincontrol@nhs.net
)
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
http://
www.expertpatients.co.uk/sites/default/files/files/Evidence%20for%20the%20Health.pdf
Richardson
et al
,
'Cost Effectiveness of the Expert Patient Programme (EPP) for patients with chronic conditions' (2008)
J Epidemiol Community Health,
62:361-367Kennedy et al
, 'The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised control trial' (2007) J Epidemiol community Health, 61:254-261‘Delivering better services for people with long-term conditions: building the house of care’ (The King’s Fund, 2013)Patient Participation Guidance by NHS England ‘Transforming participation in health and care’ (2013) http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf
NESTA People Powered Health http://www.nesta.org.uk/publications/health-people-people-and-people Patient-centred care resource centre by the Health Foundation http://personcentredcare.health.org.uk/
Slide25The High Impact Interventions
25
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide26Case study: telehealth and telecare
26
A broad range of
telehealth
/
telecare
interventions keep patients healthy and within their own home by allowing remote consultation with physicians, monitoring of vital signs or phone-based coaching in self-care
methods
Name and source of literature
Telehealth
for older patients and those with long-term conditions at Airedale NHS Foundation Trust, from
'Airedale shares telemedicine success at global event'
(Airedale NHS FT, 3 July 2013)
http://www.airedale-trust.nhs.uk/Media/NewsItems/2013/News03July13.html
Description of intervention
Airedale Hospital has a Telehealth Hub on site, which connects to over 1,000 patients across Airedale Hospital’s catchment area.
These
include
those with chronic heart failure, chronic obstructive pulmonary disease (COPD), diabetes
and the frail elderly living at home and in 33 residential and nursing homes via secure video links. The service allows them to have face-to-face consultations with nurses and doctors 24 hours a day, seven days a week. Patients can view consultants on either their own TV with a set top box or a mobile video system. The system also covers several GP surgeries, 20 prisons and
Manorlands Hospice.Clinical outcomesCompared to the year before intervention, telehealth delivered, in the 12 months post-intervention, for nursing home patients, a:69% reduction in A&E visits;45% reduction in admissions from nursing homes; and a30% reduction in length of inpatient stay from nursing homesFinancial outcomesWhile net financial benefits of the scheme have yet to be formally calculated, during its first 11 months of operation, the system has saved £330,000 gross by avoiding 124 admissions and 94 face-to-face clinic appointments.Relevance to Any town health system
This
case study indicates the power of technology to deliver interventions which both improve the quality of care and clinical outcomes while potentially driving significant cost savings. Technology is likely to be a key enabler of delivering ‘better for less’ in the Any town health system of the future
Other UK
examples
John Cruickshank, Jon Paxman, ‘Yorkshire & the Humber Telehealth Hub: Project Evaluation January 2013’ (2020health, 2013); 3 million lives’ case studies
Other international examples
Veterans’ Health Administration (VHA) telecare/telehealth (United States); Natasha Curry & Chris Ham, 'Clinical and Service Integration' (The King's Fund,
2010)
Slide27Case study: telehealth and telecare
27
There are a number of other innovative case studies that could be further explored by local health economies – below we detail an international example from the Veterans’ Association Health Administration
Case study: Applying the evidence of impact of the Veterans’ Health Administration to the NHS in England
The VHA is a large, publicly-funded system delivering comprehensive services to a veteran population of 23 million, with an annual budget of over £30 billion. Using
telehealth
, VHA aims to support patients with long-term conditions through care ‘at a distance’ and self-management skills, leading to significant reductions in acute care. According to various studies, VHA consistently provides a more cost-effective and better quality of care than other health systems in the USA, with around 50,000 VHA patients receiving telehealth services in 2011.
The programme relies on health informatics, disease management and home telehealth technologies to enhance access and improve healthcare services. With the use of telehealth, the VHA was able to integrate both vertically and virtually; in other words, the patient was treated in an integrated fashion by the appropriate VHA case organisation or non-VHA provider through the use of a care agreement and providers being able to integrate and share information via the patients Electronic Health Record, irrespective of location.
Drawing parallels for England, based on the evidence from the VHA experience, reports suggest approximate decreases in bed utilisation for four key disease areas: diabetes (-20.4%), hypertension (-30.3%), heart failure (-25.9%), COPD (-20.7%), and depression (-56.4%).
Sources:
‘What can the NHS learn from the experience of the US Veterans Health Administration?’ (2020health, 2012); ‘Telecare and Telehealth –a game changer for health and social care’ (Deloitte Centre for Health Solutions, 2012)
Innovators
Slide28Impact of interventions
on
quality
: telehealth and telecare
28
Telehealth
and
Telecare
–
Airedale NHS Foundation
Trust
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
None yet defined for Airedale – however, other telecare
schemes have demonstrated a 45% decrease in mortality (and hence PYLL) among target patient groups
1Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people 1.12. Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
None yet quantified – however, in Airedale patients using the scheme qualitatively report improved HRQoL
2
3. Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
This intervention
has produced a 45% reduction in non-elective admissions for patients with chronic ambulatory care sensitive conditions
3
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
While no benefit has yet ben quantified,
it can be expected that this intervention will increase the proportion of older patients still at home 91 days post-discharge
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
This intervention does not target
an improved experience of hospital care and so is not expected to produce a change in Ambition 5
6. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
This intervention does not target
hospital care and so is not expected to produce a change in Ambition 7
Sources:
(1
) Steventon
et al
, 'Effect of teleheath on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomized trial' (2012)
BMJ
344; (2
) Jennifer Truland, "It's time for your screen
test“,
HSJ Telehealth
(
March 14 2013
); (3
)
'Airedale shares telemedicine success at global event
' (Airedale NHS FT, 3 July 2013)
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide29Getting started: telehealth and telecare
29
Population groups affected:
Adults with LTCs
Frail elderly and dementia sufferers
Children with LTCs
Note: intervention may target one or all of these groups
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Keeping
safe
, digital
records
in secondary
care
to allow
integration
with primary
and other care
settings is a precursor to giving patients and carers access to their own
records. Telecare equipment and health apps that allow people, in conjunction with their
physicians,
to manage their own LTCs can then be introduced to empower patients, while at the same time ensuring that their actions remain embedded in the care they receive from the NHS. See ‘interoperable health records’ in ‘Further Ideas’ for more detail.The key to cost-effective implementation is
achieving scale, as relatively high fixed costs are offset by low marginal costs for each additional user. This means a single telehealth intervention is like to serve an area larger than a single health economy. It is worth considering:Whether there is existing telehealth infrastructure with spare capacity that could be utilised, or if combining with other health economies is possible;If developing bespoke provision, what is the potential market in terms of other users in the region and nationally?Ensure that telehealth is integrated into mainstream healthcare provision, meaning it is considered as part of any initial assessment, and is built into staff appraisalHave you considered whether the following may be barriers?Funding: implementing telehealth requires an initial investment, and providers may be concerned that it will drive up their costs. Early identification of funding sources and development of a clear provider reimbursement model is therefore importantScale: a telehealth intervention which fails to achieve adequate scale may not be cost-effectiveStaff engagement: without strong leadership and getting staff buy-in, there is a risk that staff will resist adoption of new technology and ways of delivering services to patientsPublic understanding and cultural/psychological barriers: public awareness of the telehealth technology is low, especially among older population segments who are more likely to benefit from the technologyWorking with industry: this is the best way to prevent excess costs and solutions that are not adapted to the needs of patientsInformation governance: protection of confidential patient information is a priority, especially where third party providers are involved, and ensuring this is a key considerationHave you considered how you will phase the intervention?Initial impacts on cost and quality should begin to materialise after a year. However, the full impact will take longer to develop as ways of working adapt and more patients begin to use the equipment as part of their care packagesThe impact is likely to grow over many years, through reducing the growth in demand for healthcare services to a manageable levelThe graph below indicates the likely phasing of this intervention. As noted above, benefits are likely to continue to mount beyond the five-year period due to deflected future demand for servicesLTCs
Frail elderly
Depri-ved
Rural
UrbanOther
1.0
0.0
1.4
0.6
0.8
0.4
1.2
0.2
2014/15
2015/16
2018/19
2016/17
2017/18
2013/14
Planning begins
Intervention launched
Initial benefits commence
Further incremental benefits
Forecast savings per year Urban CCG (£m)
Slide30Key leads and further reading: telehealth and telecare
30
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? We have identified three examples of ‘best practice’ in this area. For practical guidance and experience on implementing this intervention, these are the people to speak to.
Kent and Medway
Commissioning Support (
http://www.kmcsu.nhs.uk
/#
)
Airedale (see
http://www.airedale-trust.nhs.uk/blog/3rd-july-2013-airedale-shares-telemedicine-success-at-global-event
/
)
Wakefield City Council (see reference below)
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
John Cruickshank, Jon
Paxman
, ‘Yorkshire & the Humber Telehealth Hub: Project Evaluation January 2013’ (
2020health
, 2013
)
Leeds City Council, ‘Embedding telecare into reablement, intermediate care and delayed transfers of care services’‘Transforming integrated care – using Telecare as a catalyst for change’ (Wakefield City Council, 2012)‘Implementing Telecare to achieve efficiencies: Care Services Efficiency Delivery’ (Department
of Health, 2009)Steventon et al, 'Effect of teleheath on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomized trial' (2012) BMJ 344Jennifer Truland, ‘It's time for your screen test’, HSJ Telehealth (2013)3 million lives project – includes resources on how much each CCG can save by adopting this approach (https://3millionlives.co.uk)
Slide31The High Impact Interventions
31
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide32Case study: case management and coordinated care
32
Case management and coordinated care
works towards an integrated
health and social care
system. Full
integration
can require > 5
years, case management
can still
produce significant benefits within that time
frame
Other UK
examples
Continuity of care for older patients’ (The King’s Fund, 2012);
‘Enablers and Barriers to Integrate
d Care (Frontier Economics, 2012);
'The development and impact of the British Heart Foundation and Big Lottery Fund heart failure specialist nurse services in England: Final Report
' (University of York, 2008)
Other international examples
PACE, VHA,
‘Clinical and Service Integration’ (The King’s Fund, 2010); David Meates, ‘Making integrated care work in Canterbury, New Zealand’ (The King’s Fund, 2013)
Name and source of literatureIntegrated Care Pilots of case management for patients with LTCs and older people, analysed in ‘‘National Evaluation of the Department of Health’s Integrated Care Pilots’ (RAND Europe, 2012)”https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215103/dh_133127.pdfDescription of interventionThe programme of Integrated Care Pilots (ICPs) was a two-year DH initiative that aimed to explore different ways ofproviding integrated care to help drive improvements in care and well-being. Organisations across England were invited to put forward approaches and interventions that reflected local needs and priorities - six of these specified case management as the focus of their integration efforts. While each ICP targeted distinct patient groups, the two most common were patients with LTCs and elderly patients at risk of inpatient admission. Here, we focus on the pilot site where case management solutions, such as increased sharing of patient information and colocation of staff and services, aimed to reduce unplanned hospital admissions and fragmentation of care pathways.Clinical outcomes
Over the course of the 2 years, these pilots demonstrated a:
21% reduction in elective admissions;22% reduction in outpatient appointments;3% reduction in A&E attendances; and a
9% increase in non-elective admissions
Financial outcomes
Across the pilot site an average cost saving of £446 per patient was observed (net of running costs)
Relevance to Any town health system
This kind of co-ordinated care management is generally applicable across a range of patient groups and geographies.
It h
as the potential not only to reduce the cost associated with unnecessary admissions, but also (if
applied correctly) to
improve patient experience of treatment and clinical outcomes.
Slide33Case study:
case
management and coordinated care
33
There are a number of other innovative case studies that could be further explored by local health economies – we present a case study from Medicaid and Medicare
below
Case study: Programme for All-inclusive Care for the Elderly
The US PACE (Programme for All-inclusive Care for the Elderly) is an
integrated provider model for
individuals with Medicaid and Medicare coverage
. It aims
at
maintaining independent community living for
frail older
people
for as long
as possible
. The key feature of PACE is that services are co-ordinated by, and organised around, adult health day-centres which are run by its own directly employed staff. The day centre is
the primary setting for the delivery of most care services and operates similarly to a
geriatric outpatients clinic where primary medical care is provided along with ongoing clinical oversight. There is a multidisciplinary team, comprising nurses, physicians, therapists
, social workers and nutritionists. The team is responsible for managing patients, dispensing services, promoting co-ordination and continuity of care and collectively holds clinical responsibility for each individual in their
charge. Patient care is also facilitated
by a data system that collects information on all aspects of a patient’s health status and forms the basis of the patient’s care plan. Resources are pooled and – through capitation payments from Medicare and Medicaid – the programme has total control over all long-term care expenditure, assuming financial risk for its populationWhen compared with a control group, PACE-enrolled older people showed a 50% decrease in hospital
use, 20% decrease in nursing home admissions, and when they were admitted, used 16 fewer bed days. However, PACE patients used more ambulatory care services (93 per cent compared with 74 per cent in the control group). The overall cost-effectiveness of PACE is unclear, although State Medicaid agencies estimates cost savings of 5 to 15 per cent over standard fee-for-service care.In terms of patient experience, patients and their carers were 15% more likely to be satisfied with their care than those not in PACE. Health status and quality-of-life outcomes have been found to be generally positive, with 43 per cent (vs. 37 per cent in the control group) reporting good health and 72 per cent (vs. 55 per cent in the control group) reporting a ‘more satisfying life’. Sources: Natasha Curry and Chris Ham, ‘Clinical and service integration, the route to improved outcomes’ (The King’s Fund, 2010); Kodner and Kay Kyriacou, ‘Fully Integrated Care for Frail Elderly: Two American Models’ (International Journal of Integrated Care, 2000)Innovators
Slide34Impact of interventions on quality: case management
34
Case
management
&
coordinated
c
are
–
Integrated
care
p
ilots
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
None yet
quantified – however, it may be expected that this intervention will reduce PYLL for the target patient group through a reduction in mortality ratesPotential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people 1.12. Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
Significant
qualitative evidence of improved HRQoL exists. In other settings, interventions of this kind have produced c.7% improvements in HRQoL scores using standard measurement instruments1,2
3. Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
In the National Evaluation of the
DoH’s
Integrated Care Pilots (ICPs) this intervention
produced a 12.0% increase in non-elective admissions for patients with a chronic ambulatory care sensitive condition, despite targeting a reduction.
3
Further statistical tests by the authors showed that this increase is non-significant, and once confounding factors (such as poor matching of control site patients) is accounted for, all that can be determined is that the intervention failed to reduce ACS admissions. However, other case studies of this intervention have demonstrated a reduction in unplanned ACS admissions: for example, the BHF Specialist Heart Failure Nurse programme has produced a 35% reduction in ACS readmissions
2
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
In
another setting, t
his intervention has produced a 23.2%
decrease the proportion of older patients still at home 91 days after discharge
4
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
In the
ICPs this intervention produced a moderate increase in poor patient feedback, based on feelings of reduced choice
3
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
None yet quantified – however,
it is expected that this intervention will produce significant improvement in Ambition 7
Sources:
(
1
) 'Evaluation of the BHF Arrhythmia Care Co-ordinator Awards'
(University of York, 2010
); (2
)
'The development and impact of the British Heart Foundation and Big Lottery Fund heart failure specialist nurse services in England: Final Report'
(University of York, 2008); (3) Case management ICPs in:
‘National
Evaluation of the DoH Integrated Care
Pilots’
(
RAND Europe, 2012
); (4
) Rich
et
al,
'A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure' (
1995)
N
Engl J Med
333:1190-1195
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide35Getting
started: case management and coordinated care
35
Population groups affected:
Adults with LTCs
Frail elderly and dementia sufferers
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Strong leadership
is crucial, with senior sponsorship of the programme underpinning its importance
Invest in
building key relationships
and strengthening existing ones, especially across organisations and disciplines
Shared values and vision
are key facilitating factors. This can be achieved through a
strong and consistent communication effort
to gain staff buy-in. In particular, clear communication of the benefits and involvement of staff in the development of new services have been shown to be of great importance in gaining the engagement and commitment of staff in the process
Assign resources to developing
appropriate education and training,
especially where roles are required to change. Staff will need support to adapt to and perform well in changed roles
Development of
personalised care plans
that clearly articulate patients’ goalsHave you considered whether the following may be barriers?
Absence of strong leadership has been identified as a significant barrier to progress in this intervention, especially where there is a lack of sponsorship and ownership among senior staffFailure to engage a key group of staff, e.g. GPs, means that the cross-organisational and multidisciplinary nature of the intervention will be difficult to initiate and sustainChanges to individual staff roles can generate resistance – one way to tackle this is to ensure that staff feel informed about and involved in any changesInadequate IT resources and infrastructure can impede the effective implementation of the initiative. This can include both systems and also policies and practicesInadequate project management can undermine the scale and complexity needed to deliver the interventionLittle evidence of improved patient experience or reduced secondary care costs in the short termHave you considered how you will phase the intervention?Given the cross-organisational nature of this intervention, an initial period of investment and bedding in is likely to be required before impacts begin to emergeBased on previous examples, we anticipate that the impacts will begin to materialise in the year following the commencement of the interventionThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
3.0
2.0
1.0
0.0
0.5
2.5
3.5
1.5
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched
B
enefits commence
Further incremental benefits
Forecast savings per year Urban CCG (£m)
Slide36Key leads and further reading: case management and
coordinated
care
36
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
Six sites were identified in the RAND analysis (see reference below) of the Integrated
C
are
P
ilots as adopting a case management approach. These provide strong examples of best practice. The sites are:
Church View, Sunderland (Church View Medical Practice and City Hospitals Sunderland Foundation Trust)
Cumbria (
Cockermouth
,
Maryport
and South Lakeland)
Northamptonshire Integrated Care Partnership
Norfolk Integrated Care Network
NorthumbriaPrincipia Partners in Health, Nottinghamshire
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful.
National Evaluation of the DoH Integrated Care Pilots (RAND Europe, 2012)Frontier Economics, ‘Enablers and barriers to integrated care and implication for Monitor’ (2012)'The development and impact of the British Heart Foundation and Big Lottery Fund heart failure specialist nurse services in England: Final Report' (University of York, 2008)Rich et al, 'A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure' (1995)
N Engl J Med 333:1190-1195 Bardsley et al, ‘Evaluating integrated and community-based care’ (Nuffield Trust, 2013)Patient-centred care resource centre by the Health Foundation http://personcentredcare.health.org.uk/
Slide37The High Impact Interventions
37
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide38Case study: mental health
38
An effective liaison psychiatry service offers the prospect of improving health and wellbeing for patients with a mental illness and promotes early supported discharge from an acute
setting
Name and source of literature
Rapid Assessment Interface and Discharge (RAID) at City Hospital, Birmingham. Impact
assessed in: “Parsonage &
Fossey
, Economic evaluation of a liaison psychiatry service( LSE, 2011)”
http://www.centreformentalhealth.org.uk/pdfs/economic_evaluation.pdf
Description of intervention
Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general hospitals. The co-occurrence of mental and physical health problems is very common among these patients, often leading to poorer health outcomes and increased health care costs.
RAID offers comprehensive mental health support, available 24/7, to all people aged over 16 within the hospital. At the time of assessment, the RAID service was provided by Birmingham and Solihull Mental Health NHS Foundation Trust and commissioned jointly by Heart of Birmingham and Sandwell PCTs.
The service offers a comprehensive range of mental health specialities within one multi-disciplinary team, so that all patients over the age of 16 (including those who self-harm, have substance misuse issues or have mental health difficulties commonly associated with old age, including dementia) can be assessed, treated, signposted or referred appropriately regardless of age, address, presenting complaint, time of presentation or severity. The service operates 24 hours a day, 7 days week, emphasising rapid response. The service also provides formal teaching and informal training on mental health to acute staff throughout the hospital - a key feature to widen its impact beyond patients seen directly by RAID staff.
Clinical outcomes
Very strong patient and staff satisfaction ratings
14% increase in the proportion of older people at home 91 days after discharge
97% increase in discharge rate of older patients into their own homes rather than institutional care
Financial outcomes
74% lower readmissions rate for mental health patients using RAID compared to those not using it
8.7% reduction in inpatient bed-days
Total per annum savings of £3.4m (highly conservative estimate)
Relevance to Any town health system
The success of this case study can be widely applied to mental health care across the NHS,
reducing care costs while also improving patient experience and clinical outcomes
Slide39Impact of interventions on quality: mental
h
ealth
39
Mental Health
–
Rapid Assessment Interface and Discharge (RAID) at City Hospital,
Birmingham
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
None yet quantified
– however, it may be expected that this intervention will produce a mild reduction in PYLL due to better patient management
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people
1.1
2.
Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
There is strong qualitative evidence for
improved patient QoL as a result of this intervention1
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
This intervention produces reductions in inpatient admissions and length
of stay. However, it does not target the specific medical conditions covered by the indicators we are considering under Ambition 3
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
This intervention has produced a 14.0%
decrease the proportion of older patients still at home 91 days after discharge
1
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
While no
quantified change has been documented, the majority of patients treated are very satisfied with this intervention
1
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
The literature review does not suggest that this intervention will produce a change
in
Ambition 7
Source:
(
1) 'George Tadros,
'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience
' (Birmingham and Solihull NHS Trust)
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide40Getting
started: mental health
40
Population groups affected:
Frail elderly and dementia
sufferers
Adults with complex needs
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Based on previous experience of implementing this intervention,
training has been identified as a key to success
For staff directly involved in the intervention
For acute staff throughout the hospital – for example, regular one-hour weekly teaching sessions and periodic 2-day courses certified by a higher education institution
Strong and focused leadership with real commitment to driving the intervention through is likely to greatly enhance the chances of success
The intervention is likely to be most effective if it
provides
24/7
coverage
and
involves a
multi-disciplinary team
offering a comprehensive range of mental health specialitiesTo deliver its full potential, the intervention should focus on rapid response – for example, a target time of 1 hour to assess referred patients who present to A&E, and 24 hours for seeing referred patients on wardsProvide follow-up clinics for discharged patients, focusing on specific mental health needs such as self harm, substance misuse, and old age psychiatry
Have you considered whether the following may be barriers?Funding: while this intervention should provide good value for money, it requires some up front investment (e.g. in training, additional staff and clinics), the sources of this funding need to be identified at an early stage and maintained for the duration of the intervention to achieve the full effectStaff buy-in can be a barrier, especially where education and communication are inadequate and acute staff do not understand the intervention. This could lead to resistance to the intervention if not pre-emptedAdequate staffing across the multi-disciplinary team is required in order to meet rapid response and coverage targets – without this it will be difficult to meet the targets for the intervention, meaning that clinical and financial impacts could fall short of their potentialHave you considered how you will phase the intervention?A small part of the impact is likely to be experienced during the first year of the interventionHowever, based on previous experience, the majority of the impact will materialise during the second year of the intervention and subsequentlyThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
1.0
0.5
1.5
2.0
0.0
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched
Initial benefits commence
Further benefits develop
Forecast savings per year Urban CCG (£m)
Slide41Key leads and further reading:
mental health
41
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? The following sites have been identified by the Centre for Medical Health as examples of established liaison psychiatry services (see the reference below for further details):
St Helier Hospital Liaison Psychiatry Service, Carshalton, Surrey
Exeter
Liaison Service, Royal Devon and Exeter Hospital, Exeter, Devon
Department
of Liaison Psychiatry,
Arrowe
Park Hospital, The Wirral, Cheshire
Department
of Psychological Medicine, Hull Royal Infirmary, Hull, East Yorkshire
Leeds
Liaison Psychiatry Service, St James University Hospital & Leeds General
Infirmary, Leeds
, West
Yorkshire
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful. 'George
Tadros, 'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience' (Birmingham and Solihull NHS Trust)
Michael Parsonage, Matt Fossey & Carly Tutty, ‘Liaison psychiatry in the modern NHS’ (Centre for Medical Health, 2012)
Slide42The High Impact Interventions
42
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide43Case study: dementia pathway
43
Dementia pathways shifts care from acute care settings to locally-based and home-based
services
Name and source of literature
‘Service redevelopment: Integrated whole system services for people with dementia’ (
Mersey
Care NHS Trust, 2012)
http://www.evidence.nhs.uk/search?q=integrated%20whole%20services%20dementia
Description of intervention
The intervention is intended to improve health outcomes
and achieve efficiencies in dementia care across the North Mersey area by developing a fully integrated network model. This is to be achieved by redistributing resources from acute care settings to locally-based and home-based services. The overall aim is to keep people with dementia independent for longer and where they require hospital treatments to get them back into the community as swiftly and as well prepared for independent life as possible. The pathway comprises four main components: general hospitals, home support, care homes and reduction in antipsychotic drug prescribing.
As this initiative is in the early stages of implementation, the benefits described here are expected rather than demonstrated. However, the initiative is underpinned by guidance from NICE and DH with extensive financial modelling of benefits.
Clinical outcomes
Anticipated quality outcomes include:
Reducing barriers to accessing care, including safer and more appropriate use of medicines
Reduction in unnecessary prescribing of antipsychotics, improving patient safety
Improved patient and carer experience
Financial outcomes
Estimated
net savings are £2.1m, or £246,000 per 100,000 population. These savings break down as follows:
Reduction in dementia bed days: £1.28m
Reduction in length of stay: £0.508m
Reduction in older adult beds: £1.89mSavings in prescribing: £1.05mLess recurring costs of £2.617mRelevance to Any town health systemThe rising number of people with dementia will be a significant source of demand for services over the coming decade, owing to longer life expectancy and the increase in the number of people aged over 85. This is therefore a key area where health economies will seek to improve quality and achieve efficiency savings.
Other UK
examples
Other examples of whole systems approaches to dementia include Leeds, Mary Godfrey, ‘Leeds Partnership for Older People Pilot: Whole system change in later life, Final Report’ (University of Leeds, 2009),
Oxleas, ‘Oxleas Advanced Dementia Service’ (The King’s Fund, 2013) and Lincolnshire, ‘Improving services and support for people with dementia’ (NAO, 2007)
Slide44Case study:
dementia pathway
44
There are a number of other innovative case studies that could be further explored by local health economies – below
is the
Oxleas
advanced dementia
s
ervice
Case study:
Oxleas
advanced dementia service
The
Oxleas
Advanced
dementia s
ervice was formed in November 2012. It brought together two services – Greenwich Advanced Dementia Service (GADS) and Bexley Advanced Dementia Care At Home project.
Since 2005, GADS has provided
care co-ordination, palliative care and support to patients with advanced dementia living at home and their carers. The model was implemented in Bexley in 2011 and they now operate jointly as Oxleas Advanced Dementia Service. The current service consists of a consultant in old-age psychiatry, several specialist nurses and a dementia social worker.
This model aims to help patients with advanced dementia to live at home for as long as possible in the last year of life with support from family
and/or carers. The core team works with GPs, secondary care and social services to support carers in providing ongoing
and palliative care. Where possible, staff respond to crises at home to prevent unnecessary hospital admissions and reduce the likelihood that patients are placed in residential careIn Greenwich, care co-ordination is led by a consultant old-age psychiatrist based in the local mental health trust, working alongside specialist nurses called community matrons. In Bexley, the same psychiatrist works
with a community psychiatric nurse (CPN), an advanced practice nurse (APN) and a social worker specialising in dementia. Staff in the service liaise with community mental health services and general practitioners (GPs) to provide care in patients’ own homes, focusing on supporting the carer and/or family to provide palliative care for the patient.An internal audit of the service has shown that 70 per cent of patients die at home, compared to 2010 figures for England and Wales of 6 per cent for dementia patients. Analysis of the first year of the Bexley project observed improvements for the majority of patients on the quality of life in late stage dementia (QUALID) scale and reduced stress levels for carers using the Relative Stress Scale.Source: ‘Oxleas Advanced Dementia Service’ (The King’s Fund, 2013)Innovators
Slide45Impact of interventions on quality: dementia pathway
45
Integrated Dementia Care
-
Mersey Care NHS
Trust
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect on
Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
The literature review has not
revealed that this intervention would produce a significant change in PYLL
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people
1.1
2.
Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
In
another case study, t
his intervention has produced
a 8.0% increase in health-related quality of life for dementia patients, based on mapping of improvement in the QUALID HRQoL indicator onto EQ5D1
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
This intervention produces reductions in inpatient admissions and length of stay. However, it does not target the specific medical conditions covered by the indicators we are considering under Ambition 3
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
None yet quantified
– however, it is expected that the intervention will increase the proportion of older patients still at home 91 days post-discharge
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4.b
The
literature suggests a
strong improvement in
patient experience of hospital care is expected from this intervention
2
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5.c
None yet
quantified – however,
t
he literature review has not
revealed that this intervention would produce a significant effect upon Ambition 7
Sources:
(
1)
‘
Oxleas
Advanced Dementia Service
’, (
The King’s
Fund,
2013); (2
) ‘
Service redevelopment: Integrated whole system services for people with dementia’
(Mersey Care NHS
Trust, 2012
)
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide46Getting
started: dementia pathway
46
Population groups affected:
Frail elderly and dementia sufferers
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Invest in developing
strong stakeholder buy-in
. Owing to the complexity and scale of this intervention, and the emphasis on multi-agency working, buy-in across the full range of staff and organisations involved is crucial to success. This includes stakeholders in social and acute care and medicines optimisation
Invest in dementia-specific
training and support for staff
, especially front-line staff such as those in care homes, who will be responsible for implementing many aspects of the intervention
Given
its
complexity, the
appointment of a programme manager
is crucial to provide strong leadership and co-ordinate the implementation of the intervention
Have you considered whether the following may be
barriers?
Inappropriate prescribing:
a key element of the intervention is to reduce inappropriate prescribing of antipsychotics, but in practice this can be difficult to effect. Neglecting this aspect of the intervention could lead to reduced cost savings and poorer clinical outcomes
Complexity and scale: given that this intervention requires significant cross-organisation and multi-disciplinary collaboration, it requires clear planning, strong leadership and communication to ensure it is able to gain tractionImpacts on staff morale: without sufficient investment in communications and dementia-specific training, including front-line staff, morale could be impacted by the uncertainty generated by the intervention
Have you considered how you will phase the intervention?It is estimated that this intervention can be implemented in between one and three years, depending on the status quo and the extent of the barriers encounteredBased on a three year implementation, it is expected that a small impact will be evident in the first year of the intervention, but that the full impact will not be achieved until the third yearThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
0.5
0.6
0.4
0.2
0.0
0.3
0.1
0.8
0.7
2018/19
2017/18
2016/17
2015/16
2014/15
2013/14
Planning begins
Intervention launched: initial benefits commence
Further incremental benefits
Main benefits commence
Forecast savings per year Urban CCG (£m)
Slide47Key leads and further reading:
dementia
pathway
47
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
The intervention is based on Mersey Care NHS Trust. They can be contacted by emailing
qipp@nice.co.uk
quoting QIPP reference 11/0009
Oxleas Advanced Dementia Service is another example of good practice (see the study listed below)
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
‘
Service redevelopment: Integrated whole system services for people with dementia’ (Mersey Care NHS
Trust, 2012)
‘Improving services and support for people with dementia’
(National Audit
Office, 2007)
‘Oxleas Advanced Dementia Service: supporting carers and building resilience’
(The King’s
Fund, 2013)
Slide48The
high
i
mpact
i
nterventions
48
1. Early diagnosis
2.
Reducing variability within primary care by optimising medicines use
3.
Self-management: patient-carer
communities
4. Telehealth/telecare
5. Case
management and coordinated
care
6. Mental
Health – Rapid Assessment Interface and Discharge (RAID
)
7. Dementia Pathway
8. Palliative care
Slide49Case study:
P
alliative care
49
The Midhurst MacMillan
specialist
p
alliative
c
are
s
ervice
gives patients the choice to die in their own
home
Name and source of literature
Midhurst Macmillan
Specialist Palliative Care Service – King’s Fund Review, August 2013
http://www.kingsfund.org.uk/publications/midhurst-macmillan-community-specialist-palliative-care-service
Description of intervention
The Midhurst
Macmillan Specialist Palliative Care Service is a community-based, consultant-led palliative care model that allows many more people to die at home and many fewer to die in hospital.
The
service currently serves 150,000 people across three counties in rural Southern England and is funded jointly by the NHS and Macmillan Cancer Support. ‘Midhurst’ is able to maximise patient choice by providing as much treatment and support in the home or community as possible through a multidisciplinary community-based team. The scheme receives ~400 referrals a year, with 85% of these cancer patients.
Clinical outcomesAgreed care plans for 80% of patients, quarterly review of care plans99% of patients allowed to die at homeLess frequent A&E attendances for patientsDecreased hospital admissionsFinancial outcomes~52% reductions in in-hospital deaths~19% reduction in in-hospice deathsRelevance to Any town health systemEffective palliative care solutions are still in their infancy across the UK and largely untested, with variations in both care and patient experience. Midhurst represents a model which provides best practice care, allows the patient control over their passing, and presents an affordable alternative to traditional hospice models.
Slide50Impact of interventions on quality: palliative care
50
Palliative Care
–
Midhurst Macmillan Specialist Palliative Care Service
Ambition
CCG Indicator
Indicator Number
Effect of Intervention
Effect on Quality
1.
Secure additional years of life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Adults
1.1
This interaction
does not target a change in Ambition 1, with a focus instead on quality of care at the end of a patient’s life
Potential years of life lost (PYLL) from causes considered amenable to healthcare - Children and young people
1.1
2.
Increase QoL for People with Long-Term Conditions
Health-related quality of life for people with long-term conditions (EQ5D)
2
There is strong qualitative evidence of improved HRQoL for patients using this
intervention
1
3.
Reduce unnecessary time spent in hospital
Unplanned hospitalisation for chronic ambulatory care sensitive conditions (updated methodology)
2.6
The intervention
has produced a 52% decrease in the number of patients wishing to die at home who ultimately die in hospital. This represents a reduction in unnecessary time spent in hospital. However, based on the unavailability of cause of death data, it is not possible to directly map this effect onto any of the Ambition 3 indicators
1
Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
2.7
Emergency admissions for acute conditions that should not usually require hospital admission (updated methodology)
3.1
Emergency admissions for children with lower respiratory tract infections
3.4
4. Increase the proportion of older people living independently following discharge
[Proxy] Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
2B
Whilst this intervention does not directly target a change in Ambition 4, it does give patients the ability to die outside
of a hospital if they desire
5.
Reduce poor hospital care feedback
Patient experience of hospital care
4b
The intervention almost doubled the number of patients
able to die in their own homes; a major positive along the patient experience dimension
1
7. Significantly reduce hospital avoidable deaths
Hospital deaths attributable to problems in care
5c
This intervention does not target a change in Ambition 7
Source:
(1
)
'Midhurst
Macmillan Community Specialist Palliative Care Service'
(
The King's Fund,
2013
)
−
−
−
Strength of quality
b
enefit:
Strong quantified
b
enefit
Qualitative benefit
Some quantified
b
enefit
No impact
−
Suspected benefit
Slide51Getting
started: palliative care
51
Population groups affected:
Adults with LTCs
Frail elderly and dementia sufferers
The literature suggests that this intervention will have a greater impact in health economies with the following characteristics:
Have you thought about the following enablers and implementation steps?
Building a
strong relationship with an external co-funder and partner
can be a powerful facilitator of this intervention. In the case of Midhurst the partner was Macmillan Cancer Support, providing not only funding but also legal and financial advice, access to grants and volunteer services
A
dedicated care co-ordinator
(usually a clinical nurse specialist) plays a crucial role by:
b
eing the principle point of contact for the patient and their family
c
o-ordinating care from the team and wider network of providers
Rapid access to a multidisciplinary team
is a core element of this intervention, allowing care to be provided to patients in their homes
Clear accountability within teams
enables effective decision-making, which is particularly important given the multidisciplinary nature of the teams
A focus on building awareness and key relationships will ensure maximum impactHave you considered whether the following may be barriers?
Funding: without adequate resources it is unlikely that an effective intervention can be developed – these therefore need to be identified early in the process and secured for the long termRelationships: one lesson from the Midhurst case study is that personalities and relationships are key to a successful intervention, and these need to be cultivated over time to develop a truly effective intervention. A key part of this is a visible presence on the ground by team managersBarriers to information sharing: without an integrated IT system enabling rapid sharing of information on patients between GPs and community staff, time and resources are wasted on inefficient information sharing processesEnsuring the right skills mix: the right staff can be difficult to find, and building an effective multidisciplinary team requires an investment of time and resourcesHave you considered how you will phase the intervention?Because the intervention relies on changing ways of working and building awareness and relationships, the full impact should not be expected to materialise immediatelyBased on previous experience, it is reasonable to anticipate an initial impact in the year after implementation, with the full impact emerging in the following yearThe graph below indicates the likely phasing of this interventionLTCsFrail elderlyDepri-vedRuralUrbanOther
0.0
0.4
0.2
0.6
0.8
1.0
1.2
2017/18
2016/17
2015/16
2014/15
2018/19
2013/14
Planning begins
Intervention launched
Initial benefits commence
Further benefits develop
Forecast savings per year Urban CCG (£m)
Slide52Key leads and further reading:
palliative
care
52
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
Midhurst Macmillan Community Specialist Palliative
Care Service (
http://
www.sussexcommunity.nhs.uk/services/servicedetails.htm?directoryID=16353
, and see reference below)
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
‘Midhurst
Macmillan Community Specialist Palliative Care
Service: delivering end of life care in the community’
(The King’s
Fund, 2013)
Slide53Early Adopter Interventions
Slide54The early
a
dopter
i
nterventions
54
In
addition to the high impact interventions,
we have identified
additional Early Adopter Interventions (EAI)
. Although not fully impact assessed, these are promising ideas which may offer health economies further benefits
Cancer screening programmes
GP
tele
-consultation
Medicines
Optimisation
Norfolk b. PINCER
Safe and appropriate use of medicines
Acute
visiting
service
Reducing urgent care demand24-hour asthma services for children and young peopleService user networkReducing elective Caesarean sectionsAcute stroke servicesIntegration of health and social care for older people
Electronic Palliative Care Coordination Systems (EPaCCS)
Slide55The short-listing exercise – Early Adopter Interventions
55
For the EAIs, a slightly different set of criteria has been used to inform the selection
process
1
2
3
The intervention should be innovative and cutting edge – this means that it may not yet have been impact assessed, but it appears to be a promising idea that has not yet been widely adopted
The intervention must have demonstrated quality impacts, where possible matching one or more of the indicators for the 7 Ambitions, or at least impacts that are mappable onto the Ambition indicators in a qualitative way
The intervention must appear likely to be either cost-neutral or cost-saving, although it is not necessary for this impact to have been demonstrated, and owing to the looser evidence requirements we are not modelling precise savings expected
The intervention must have a clear narrative and be appropriate for widespread adoption by health economies
4
Slide56The early adopter interventions
56
Cancer
screening
programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service user network9. Reducing elective Caesarean section10. Acute stroke services
11. Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide57Overview: early diagnosis of cancer
57
Intervention name
Earlier diagnosis of cancer (Department of Health, Strategy
for Cancer, 2011)
What is it?
One of the reasons for the UK’s generally
lower cancer survival rates than other European countries is the tendency for patients to present with more advanced stages of the disease at diagnosis. Detecting cancer at an earlier stage, when it responds better to treatments designed to tackle the disease locally, greatly improves the patient’s chances of survival. This intervention is designed to improve the public’s awareness of the signs and symptoms of cancer, encourage those with symptoms to seek help earlier than they currently do and support primary care in diagnosing cancer earlier.
Why do
it?
Earlier
diagnosis should result in significantly better outcomes for patients, meaning higher survival rates
The greatest benefit can be achieved by reducing the number of patients diagnosed with late stage cancers, and an increase in the number of patients diagnosed with early stage cancers, which are more easily treated
The Department of Health has concluded that earlier diagnoses should be cost-effective, if not necessarily cost-saving
What are the key enabling factors?
Awareness campaigns
are likely to be most effective when operated on an ongoing basis over a wide area. This intervention, therefore, could be particularly successful if run in
conjunction with a national scheme
or in partnership with neighboring CCGs
An effective approach could be to
identify those cancers for which there is a high prevalence locally
, and run a targeted campaign focusing on prevention, in collaboration with neighboring CCGs
An
initial investment of resources is required, both in additional treatment, and in awareness-raising campaigns among the public and GPs to increase diagnosis ratesWhat are the potential barriers?The intervention is not proven to be cost-saving, and may in fact lead to an increase in treatment costs. This is likely to balance out over time, as early diagnosis leads to patients who would otherwise have been late stage patients avoiding further treatment. However, this
effect will take some time to feed through
(the Department for Health analysis suggests that treatment costs will initially rise)Related to this is the possibility that awareness campaigns may lead to a rise in GP appointments, at least initially – this needs to be factored into planning
Further reading
This intervention is based on the following publication: Department of Health, ‘Improving outcomes: a strategy for cancer’ (January 2011)
Source: ‘Strategy for Cancer’ (Department of Health, 2011)
Slide58The early adopter interventions
58
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide59Overview:
GP telephone consultations
59
Intervention name
Systematic approach to primary care pre-assessment and
telephone consultation
What is it?
The intervention links patients’ perceived accessibility of primary care to their likelihood of self-referring to A&E. A comparison of GP practices showed that those with a ‘systematic’ (specifically organised and managed) approach to telephone consultations exhibit, on average, lower corresponding rates of A&E attendance. Where this benefit was realised, it was apparent that practices had implemented a specific innovation in terms of triaging and allocating time for patients suitable for telephone rather than face-to-face consultation. A number of different micro-interventions were witnessed across the various practices, but common elements included the initial response to all or most patient demand being a phone call from a GP, clear guidelines on how to prioritise patient groups for appointments and structures for most effectively using practitioner time. In some cases this might be done through a software package, for example the Doctor First application.
Why do
it?
Systematic telephone consultations were associated with 20% lower A&E attendance by patients at these practices
Less pressure on GPs and reduced requirement to work long hours, as they are more able to manage workload and demand in primary care by limiting face-to-face appointments to only those patients who specifically want or need one
The intervention was generally popular with patients; it was seen as a useful timesaver for GPs and patient alike, and was associated with improvements in quality of care by improving patient access to primary care
What are the key enabling factors?
The majority of successful telephone consultation systems were the result of a
specifically planned and managed innovation
; those that took a more informal approach were less successful in reducing A&E attendance and doctor stress
Software is available
that can help automate the appointment process, taking into account priority groups and practitioner availability
What are the potential barriers?
While
most patients appreciated the time-saving advantage of a telephone consultation, not all will be as comfortable outside a face-to-face consultation.
Sending the right message to patients
to encourage their use of the system will be critical to successResistance among GPs to use of technology for appointments may also be encountered – this can be assuaged by emphasising the benefits to both patients and GPs
There is likely to be an initial surge in calls following adoption of the system, which may place pressure on staff and lines. This should abate after a month or two, as patients and staff adapt to the new system. However,
it is best to avoid starting the scheme at particularly busy times, such as holiday periodsThere is an initial investment which must be agreed – a focus on the benefits achievable should enable the construction of a strong business case
The case study shows correlation, but not causation, between perceived availability of primary care and A&E attendance. The intervention would need to be trialled over an extended period with the specific aim of measuring reduced A&E attendance to give robust confirmation that the witnessed impact was sustainable
Source: Comparison of mode of access to GP telephone consultation and effect on A&E usage (Patient Access: Simply transformed, 2012); Digital First: The delivery choice for England’s population, NHS (2012)
Slide60How GP telephone consultation system works
60
Reception takes call
Patient problem solved
Source:
http://www.patient-access.org.uk/wordpress/wp-content/uploads/2013/02/Patient-Access-Thurmaston-Case-Study-v7.pdf
Admin question
GP phones patient
Patient given appointment with the nurse
Patient given appointment with the GP
Slide61Key leads and further reading: GP telephone consultations
61
Further reading
To help you read around this intervention, we have assembled a list of the literature that we found most useful:
Comparison of mode of access to GP telephone consultation and effect on A&E usage (Patient Access: Simply transformed, 2012)
Digital First: The delivery choice for England’s population, NHS (2012
) pp. 15-16
http://www.pulsetoday.co.uk/practice-business/how-we-saved-90000-a-year-through-gp-phone-triage/14179545.article#.UpSjZIFFDIU
http://
www.patient-access.org.uk/wordpress/wp-content/uploads/2013/02/Patient-Access-Thurmaston-Case-Study-v7.pdf
http://
www.patient-access.org.uk/wordpress/wp-content/uploads/2013/01/N82070-Elms-v12.pdf
Slide62The early adopter interventions
62
Cancer screening programme
2. GP
tele
-consultation
3. Medicines
optimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
n
etwork9. Reducing elective Caesarean section10. Acute stroke services11. Integration of health and social care for older people
12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide63Overview: medicines optimisation
63
Intervention name
Norfolk Medicine Support Service
What is it?
In 2003, a Norfolk wide multi-agency group created the Norfolk Medicines Support Service (NMSS). This facilitated the
care of people living in their own home by providing a patient-centred professional service
to ensure
safe and appropriate use of medicines. Patients are referred to the service if they are identified as having difficulties managing their medication in their own home and following a pharmacist domiciliary visit they may receive ongoing adherence support. The aim of this intervention
was to improve patient drug adherence, and thus quality of life, while reducing the risk of emergency admissions.
Why do
it?
The study showed a 4.5% increase in patient adherence to medication, thereby improving clinical outcomes
There is also likely to be a saving for commissioners through a reduction in emergency admissions owing to poor patient adherence to medication
Intervention name
A Pharmacist-led information technology intervention for medication errors
(PINCER)
What is it?
This is a pharmacist-delivered information technology intervention designed to reduce prescription and medication monitoring errors. Key features are:
An educational outreach approach and training for pharmacists and clinicians
Strong working relations between pharmacists and general practices, enabling access to patients’ records and empowering pharmacists to make practical changes to patients medications and organise blood tests etc
Built upon an information technology platform, including the use of electronic patient records (cited as an essential prerequisite by the authors of the study)
Why do
it?
The trial indicated that this intervention can substantially reduce the frequency of a range of clinically important prescription and medication monitoring errors
It is therefore capable of improving clinical outcomes and reducing preventable patient harm
Over time it is also likely to generate savings for commissioners, as fewer patients will need emergency care owing to complications arising from prescribing errors. However, the impact of the intervention on activity levels has not yet been assessed (work on this by the authors of the study is ongoing)
Source:
‘Desborough et al, ‘A cost-consequences analysis of an adherence focused pharmacist-led medication review service
’, International Journal of Pharmacy Practice 20 (2011)
Slide64Key leads and further reading: medicines optimisation
64
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Desborough et al, ‘A cost-consequences analysis of an adherence focused pharmacist-led medication review service’ , International Journal of Pharmacy Practice 20 (2011)
Avery et al,
‘A
pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis’, The Lancet vol. 379 (2012)
Slide65The early adopter interventions
65
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide66Overview
: Safe and appropriate use of medicines
66
Intervention name
Eclipse Live (Electronic Care Leading to Improved Patient Safety & Empowerment)
What is it?
Eclipse Live was launched in August 2011 to allow
Prescribing Leads to identify at-risk patients with an
online risk stratification tool. The system would enable new levels of patient analysis to accurately identify those at risk
and feedback the information as alerts to the prescribers.
The group has grown to over 500 surgeries representing more than 3 million patients.
Eclipse Live
includes three main elements:
Risk stratification.
Integrated care.
Self-management plans and personalised records.
Why do
it?
Eclipse
Live is intended to reduce the number of preventable deaths from medication-related incidents. It is intended to enable GPs to:
Identify at-risk patients.Identify patients not fulfilling local guidelines.Undertake performance tracking.Access formularies, guidelines and contacts.Eclipse Live generates lists of patients and virtual wards, which can be visited electronically by specialists or community teams. By analysing millions of calculations on each patient every night it continually identify at-risk patients.Although not fully impact assessed, initial studies indicate significant reductions in admissions in those practices that use the system2. It is in the process of being formally appraised for its ability to prevent emergency admissions from medicine-related events.It should be noted that the impacts of this intervention are derived from literature from the system provider; in the absence of an independent impact assessment this should be borne in mind as a potential limitation.
The opportunity
According to the Eclipse Live impact assessment,
in 2010 there were 4.9 million emergency admissions, costing the NHS £8.8bn. Research has suggested that 6-7% of emergency admissions are related to medication, and 60% of these incidents are preventable
2. At a cost per admission of £5,000, this represents a potential opportunity to save around £1bn if a reliable system could be implemented to identify at-risk patients before they were admitted.
(1
) ‘Eclipse Live impact assessment’ (2013) (2) Value Health. 2011 Jan; 14(1):34-40.) HARM: Preventable hospital admissions related to medication
Slide67Key leads and further reading:
safe use of medicines
67
Further reading
This intervention is based on the following sources:
‘Eclipse Live impact assessment’ (2013)
www.eclipsesolutions.org
Slide68The early adopter interventions
68
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5. Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
n
etwork9. Reducing elective Caesarean section10. Acute stroke services11. Integration of health and social care for older people
12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide69Overview
: Acute
visiting
s
ervice
69
Intervention name
Acute Visiting Service (St Helens CCG)
What is it?
The
aim of the Acute Visiting Service is to provide a rapid access doctor for acute care at home, thus reducing the need to access urgent hospital care. In the case of St Helens CCG,
the service was commissioned from the local out of hours cooperative which provided the driver and vehicle and managed the calls. Local GPs (often
early retirees or those operating independent practices) make the visits. During their visits they discuss with patients options for integrated and community care that would enable them to stay at home. This is in effect “assessing to admit rather than admitting to assess”.
Why do
it?
This
intervention offers a number of benefits tackling some of the most pressing challenges facing health economies, including:
Improving patient access to services
Reducing emergency admissions
Releasing capacity in GP surgeries for planned care
Improving patient satisfaction with the quality of care
The intervention is also likely to be cost-effective, with the St Helens initiative costing £6 per patient and being self-funding, for a population of 50,000, if two complex elderly admissions are avoided per week.
What are the key enabling factors?
The system is patient-focused and uses the patient’s definition of urgentThe success of the intervention in part depends on the speed with which patients can be seen. An effective and adequately staffed system is therefore vitalSufficient resources should also be assigned so as to allow extended consultation times (up to 60 minutes), allowing discussions with patients to allay concerns and discuss alternatives to admission to hospitalReferrals to the service should come from a patient’s own practice, as the GPs there know the patient and can make the most appropriate and informed decision about their needs
What are the potential barriers?
Lack
of available staff, as the system needs to be adequately staffed in order to offer the appropriate speed of response and length of consultations
Quality of care must remain paramount, with patients triaged effectively and admitted to hospital if this is requiredThe initiative challenges traditional models of working in General Practice
– staff need to be reassured that this is the right thing for both patients and healthcare professionalsPatients may express a preference for their ‘usual GP’, but with sufficient patient education regarding the benefits of the service this need not prove a barrier to use
Source:
Dr Shikha
Pitalia
, ‘How our acute visiting service reduced emergency admissions by 30 per cent’
Pulse
(March 14 2013)
Slide70How the acute
visiting service works
70
Patient phones
own surgery
requesting a same day or urgent appointment
Immediate
telephone consultation with own GP or nurse
Triage to assess severity of condition
Routine
Planned practice
visit
Urgent
Refer to AVS
See a GP within 60 minutes
Admission avoided?
Source:
Dr
Shikha
Pitalia
, ‘How our acute visiting service reduced emergency admissions by 30 per cent’
Pulse
(March 14 2013)
Slide71Key leads and further reading: Acute Visiting
Service
71
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Dr
Shikha
Pitalia
,
‘Acute
Visiting
Service: An
Urgent Care Success
Story’ (St Helens CCG)
A good description of the St Helens service
is available
at:
http://www.pulsetoday.co.uk/home/practical-commissioning/how-our-acute-visiting-service-reduced-emergency-admissions-by-30-per-cent/20002277.article#.
UoP9JoFFDIUFurther discussion of the experience of implementing this intervention can be found at:
http://www.gpcaregroup-cic.co.uk/Acute-Visiting-Scheme.aspx
Slide72The early adopter interventions
72
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6.
Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user network9. Reducing elective Caesarean section10. Acute stroke services
11. Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide73Overview:
Reducing urgent care demand
73
Intervention name
Create an acute GP unit to reduce emergency admissions (Pulse: Practical Commissioning 2009)
What is it?
With non-elective emergency admissions rising nationally, this intervention uses a team of acute GPs to screen all incoming emergency referrals. Because the GPs on duty in the acute unit are well acquainted with the community and social services on offer within the NHS locally, they can often recommend an alternative to admission that the referring GP didn’t know about or hadn’t thought of. This could be anything ranging from setting up a visit from the hospital-at-home team, to sending them to a ‘hot’ clinic to see the cardiologist of the week, to reassuring the GP their patient management plan is sound.
Why do
it?
The acute GP unit was able to divert, on average, 16% of GP referrals to A&E. At its peak the unit could divert up to 50% of admissions
During a five month pilot, overall emergency medical admissions were reduced by 30%
Gross savings of £418’320 were made during the same period, equating to £2208 per working day net of costs
What are the key enabling factors?
The acute unit must develop a
comprehensive knowledge of alternatives
to A&E admission to recommend to referring GPs; this can include hospital-at-homes teams, ‘hot’ clinics etc.
The case study Trust (Royal Cornwall Hospital) already had a
telephone referral system
in place. This did not serve a screening function prior to the intervention, but it will have simplified the implementation of the acute GP unit
What are the potential barriers?
Gaining
the support of local GPs is essential to having the acute unit operate effectively. The case study describes an
initial reluctance from primary care staff
to be ‘second guessed’ by a screening function. This was resolved by highlighting the degree of specialisation the acute unit have in up-to-date knowledge of alternatives to admission, as well as the fact that around 70% of savings cycle back to the PBC groupsStartup costs in the subject PCT were £100k, plus an annual budget of £280k. Net saving prove to be significant, however, and the pilot was subsequently extended and given 3 additional GPs
Source:
Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (Pulse: Practical Commissioning, 2009)
Slide74Reducing urgent care demand: Occupational therapists
74
The Acute GP Unit offers alternatives to GP referrals to A&E; in cases where patients self-refer, or where GP referral is unavoidable, case studies demonstrate that a team of Occupational Therapists can help to improve A&E response time and reduce length of stay
Source:
Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (Pulse: Practical Commissioning, 2009)
Intervention name
Providing
Occupational Therapists to offer
initial consultation to
A&E attendees
What is it?
The aim of the service is to provide early assessment to contribute to discharge planning, prevent unnecessary hospital admission and facilitate a safe and timely discharge. Using an OT group to triage some attendees can more quickly identify patients suitable for discharge, reducing the pressure on other A&E staff and improving lead times for patients.
Why do
it?
The service enabled discharge home for 84% of patients seen and 49% required follow-up telephone call or home visit
An average length of stay for a falls admission was quoted as 4 days (at £350 a day) compared with an average length of time by the OT in A&E providing assessment and facilitating safe discharge in 2 hours, costing £15 per hour
In one pilot, fewer than 19% of patients seen by the OT were subsequently admitted to hospital; most of the patients seen were able to be discharged home after assessment and a third were discharged with follow-up
What are the key enabling factors?
The findings of the study led to a recommendation that a
7-day OT service
was valuable in A&E.
O
utside the working days of the study, hospital doctors and nurses referred to the OT department instead which resulted in more individual home visits being required (both time-consuming and costly)
What are the potential barriers?The intervention was deemed most effective when the OT team was available all week on extended hours
. Before this level of staffing can be achieved, the intervention may not demonstrate the full extent of benefits described above.
Slide75Key leads and further reading: Reducing
urgent care demand
75
Further reading
To help you read around this intervention, we have assembled a list of the literature that we found most useful:
Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (
Pulse
: Practical Commissioning,
2009)
A review of the White article appears in ‘Reshaping the System: Transforming
Northern Ireland’s
Health and Social Care
Services’, Department of Health, Social Services and Public Safety, Northern Ireland (2010)
Fact Sheet ‘Occupational therapists working in A&E teams help
reduce admissions
and re-admissions to
hospital’, College of
Occupational Therapists (2013
), http
://
www.cot.co.uk/sites/default/files/commissioning_ot/public/AE-Evidence-Fact-sheet.pdfCarlill et al, ‘
Preventing unnecessary hospital admissions: an occupational therapy and social work service in an accident and emergency department’ (British Journal of Occupational Therapy, 2002)
Slide76The early adopter interventions
76
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide77Overview: 24-hour asthma service for children and young people
77
Intervention name
Integrated 24-hour children and
young people's asthma service
What is it?
This
intervention provides a 24-hour home nursing service for children and young people with difficulty managing asthma. In so doing it is intended to reduce unnecessary hospital admissions, and improve quality of care for this patient group by enabling them to manage their conditions at home.
Key features of the integrated service are a
single point of access and round-the-clock operating hours.
Patients and/or their parents were given a dedicated pager
number to call for urgent advice and treatment of acute asthma
episodes. Following a set template, the duty nurse assessed the
need for telephone triage, a home visit or an emergency
ambulance.
Why do
it?Improved patient experience: visits to hospital can be a distressing experience for children and young people, so avoiding unnecessary hospitalisation is preferable. This intervention offers a means to treat patients in a more comforting home settingCost of admission avoided: reductions in A&E attendances and further hospital admissions generate cost savings, which the case study indicates are likely to exceed the costs of the serviceWhat are the key enabling factors?Cooperation of key stakeholders to enable service redesign is vital – including the trust board of the local primary care organisation and acute hospitalAn effective and adequately-resourced project team will need to be recruitedEffective training for relevant staff, e.g. paediatric nurses, is crucial to enable the service to be effectively deployedA
paediatric community team
is needed to bolt this service ontoWhat are the potential barriers?
Patient
safety must not be compromised – this can be ensured through templates for nurses to follow when assessing and treating patients, so that those who do need to be admitted to hospital are identifiedCommunity and acute trusts will need to work together
to implement the intervention and develop protocols and agreed practicesLack of resources is a potential barrier due to the potential extra workload for nurses – additional recruitment may be required. This may require additional upfront investment, but the case study indicates that the intervention should be net cost-saving due to hospital admissions avoided
The level of existing infrastructure
in the local health economy will influence how appropriate this intervention is for a given CCG and how easily it can be implemented Paediatrics is a key shortage speciality, meaning that there could potentially be issues in recruiting the required staff
Source:
‘Proposed Quality and Productivity: Integrated 24-hour children and young people’s asthma service: Reducing unnecessary hospital attendance’ (South East Essex Community Healthcare, 2011)
Slide78Key leads and further reading:
24-hour asthma service
78
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Proposed quality and production example: ‘Integrated
24-hour children
and young
people's asthma
service: Reducing
unnecessary
hospital attendance’ (South East Essex) – available at: www.arms.evidence.nhs.uk/resources/qipp/601092/attachment
For further information on the case study, email
contactus@evidence.nhs.uk
quoting QIPP reference 10/0059
Slide79The early adopter interventions
79
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8. Service
user
n
etwork9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide80Overview: Service user
n
etwork
80
Intervention
name
Service User Network (SUN) (Croydon)
What is it?
SUN is a support network developed for and by people who have long-standing
emotional and behavioural problems (personality disorders) in Croydon. SUN aims to
help those who feel isolated and let down by mainstream services by bringing together
people who share the same experiences to support one another in formal and informal
ways.
Members of SUN meet in support groups held several times a week. These are
facilitated by professionals, but the emphasis is very much on people learning from
each other. Everyone’s experiences and opinions are valued, making these sessions
open and understanding. Why do it?SUN is an innovative model of patient self-help and co-designed services, which offers the potential to support patients who have struggled within a more traditional model of careThere is evidence that the SUN model decreases planned and unplanned hospital visits, by pre-empting periods of crisis before these culminate in a visit to A&EAn audit looking at the impact of SUN on hospital bed day use after six months of members joining the network showed a total decrease from 330 days to 162 daysA&E attendance was also down by 30 per cent for members after six months in the networkWhat are the key enabling factors?
Involving people in the design of services
from the start is key to fostering a sense of collective ownership: this is a key element of service co-designPeer networks can provide additional and different capacity from professional
support that is often more flexible and accessible to community membersMembers are
a crucial part of delivering the care offered by SUN, by being there for one another in times of crisis, and by challenging people’s responses to crises in the facilitated sessionsWhat are the potential barriers?
Resources
: this intervention has not been costed, but will require some upfront investment of resources, especially in professionals to facilitate the sessions. However, it is reasonable to expect that the intervention will be cost-saving over time if it achieves the expected reduction in planned and emergency admissions
Ownership:
unless patients are genuinely allowed to co-own the network, it will not function as intended. This intervention cannot therefore be delivered from the top down
The intervention may be
most suitable for urban health economies
, owing to generally higher concentrations of complex needs patients
Source:
Nesta
, ‘People Powered Health Co-Production Catalogue’ (April 2012)
Slide81Key leads and further reading: Service
user
n
etwork
81
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Nesta
, ‘People Powered Health Co-Production Catalogue’ (April 2012
) – available at:
http://
www.nesta.org.uk/about_us/assets/features/people-powered-health_catalogue
An overview of useful contacts is available at
http://
www.hear-us.org/aboutthem/croydonslam/slamsservices/touchstoneansthesunproject/pdf/CroydonSunProject.pdf
The homepage for the
SUN project is
http://
www.hear-us.org/aboutthem/croydonsupportgroups/othersupportgroupssun.html
Slide82The early adopter interventions
82
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide83Overview:
Reducing unnecessary elective Caesareans
83
Intervention name
Campaign for Normal Birth (NHS Institute for Innovation
and Improvement;
Royal College of Midwives etc.)
What is it?
The rate of Caesarean sections in England has doubled since 1990
with no associated improvement in outcomes for the baby. Additionally, unnecessary procedures (especially Caesareans) have been shown to carry an increased risk of morbidity for the mother when compared to normal delivery. A number of Trusts have introduced programmes that offer advice and support for expectant mothers, highlighting the risks of unnecessary procedures and the benefits of vaginal birth where possible. A successful programme should include training and guidance for clinical staff; several obstetric professionals have reported that unnecessary sections are often a result of under confidence in the safety of natural birth compared to Caesarean, especially among more junior doctors. The intervention aims to make both mothers and obstetric professionals alike more comfortable in pursuing vaginal birth where risk analysis indicates that this is appropriate.
Why do
it?
Eliminating unnecessary Caesareans is likely to improve morbidity outcomes for low-risk mothers. The consequence of this is likely to be an impact on patient experience of hospital care (indicator 4b)
Typically up to 3 bed days can be saved per patient by offering normal birth over Caesarean
Vaginal birth carries a significantly lower cost than Caesarean; every 1% rise in Caesarean rate costs the NHS £5m per year (excluding cost of consequent extended hospital stay)
Trusts that have piloted the programme have seen significant reductions in Caesarean rate (Blackpool Victoria Hospital achieved a 20.4% reduction, for example). Moderate national targets could equate to £76.8m, or £540’000 per Trust
What are the key enabling factors?
The healthcare
professionals
will
need to open the discussion of birthing method with mothers at an early stage, especially those who have
previously had a Caesarean
and are statistically likely to do so again
Sending the right message to junior doctors is key; some obstetric professionals have suggested that mentoring from senior midwives when consultants may not be available could help improve confidence and reduce Caesarean ratesWhat are the potential barriers?Lack of available staff
, as the system needs to be adequately staffed in order to offer the appropriate level of discussion to midwives, doctors
and patientsReluctance of clinical staff to change working behaviour. Clear guidance will need to be given to overcome a ‘better safe than sorry’ approach to Caesareans – especially given that, in most cases, unnecessary Caesareans are a higher-risk alternative to vaginal birth
Perception
among mothers than Caesarean is a solution offering less problematic delivery. Again, this will need to be built into the guidance offered to ensure that patients can make an informed choice on the safest and most appropriate option (likely to be vaginal birth in the majority of low-risk cases)
Source: NHS Institute for Innovation and Improvement, ‘Toolkit for reducing Caesarean section rates’ (April 2008); Alex Smith and Anna Dixon, ‘Health care professionals’ views about safety in maternity services’ (The King’s Fund, 2008); NHS Institute for Innovation and Improvement, ‘Promoting normal birth’ (2009), http://www.institute.nhs.uk/index2.php?option=com_content&task=view&id=3360&pop=1&page=0&Itemid=3842 (accessed November 2013)
Slide84Key leads and further reading:
Unnecessary Caesareans
84
Further reading
To help you read around this intervention, we have assembled a list of the literature that we found most useful:
NHS Institute for Innovation and Improvement, ‘Toolkit for reducing Caesarean section rates’ (April 2008)
Caesarean section clinical guidance, NICE (2004)
‘Maternity Matters: Choice, access and continuity of care in a safe service’, Department of Health (2007)
Alex Smith and Anna Dixon, ‘Health care professionals’ views about safety in maternity services’ (The King’s Fund, 2008)
Slide85The early adopter interventions
85
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11. Integration of health and social care for older people
12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide86Overview: acute stroke services
86
Intervention
name
Hyper-Acute
Stroke Unit (London Stroke Service)
What is it?
This intervention seeks to optimise acute stroke services to ensure 24/7 access to specialist care (including thrombolysis) and prompt admission to acute stroke units.
Where necessary, service are reconfigured
to ensure high-quality, safe and effective care for all those experiencing stroke
Why do
it?
Stroke costs the UK around £7
bn
per annum, of which £2.4bn are acute care costs.
In addition, stroke is a condition that responds best to early treatment. Creating a hyper-acute stroke unit (HASU) that gets stroke patients into appropriate acute care as rapidly as possible aims to improve clinical outcomes and reduce the time spent by stroke patients in hospital beds.
Evidence from implementation of the London Stroke Service indicates that following implementation, mortality from stroke in London showed a 12% reduction relative to the rest of England.
If the model could be applied to the urban population of England, around 18
million people could benefit from similar services. A 18% reduction of mortality across this population would mean 1,080 lives saved in England annually. Impact assessment suggests that in London the service saves £5.2m in 90-day treatment costs per annum (5.7% reduction per patient)
What are the key enabling factors?
For maximum effectiveness a HASU should be within
maximum 30 minute drive
from anywhere in the regionThere is a need for 24/7 immediate access to specialist care, including all investigation facilitiesHigher volume units are likely to be more effective, enabling high levels of nursing staffing and therapy to begin immediately on admissionEarly supported discharge to shorten time as an in-patient is a key element of the interventionThis intervention is likely to be most appropriate for large cities and conurbationsWhat are the potential barriers?This intervention requires significant capital investment (c.£10m in London). However, as an intervention best implemented at scale, these costs will be distributed across multiple health economies, and evidence from London suggests that break-even is reached in year three post-implementationThere will be ‘winners and losers’ in the process of selecting where to locate the stroke units. In the case of the London Stroke Service, decisions on which hospitals given the services
were
decided on the quality of submitted bids but mainly on geographical locationIn order to ensure that hospitals do not lose out, collaboration is important, for example with joint rotas involving clinicians from ‘losing’ hospitals. To
further avoid resistance, there should be extensive professional and public consultation regarding changes
It should be emphasised that it is equally important that acute stroke unit services are of high quality, as hyper-acute stroke unit services – there is no ‘second class service’
Source:
Damian Jenkinson, ‘The National Stroke Strategy: Half Time Successes and Challenges’; Hunter
et al, ‘Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model’ (2013) PLoS One 8(8
)
Slide87Key leads and further reading:
acute stroke services
87
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Damian Jenkinson, ‘The National Stroke Strategy: Half Time Successes and Challenges’, available at:
http
://
www.rcplondon.ac.uk/sites/default/files/documents/1000_jenkinson.pdf
Hunter
et al,
‘Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model’ (2013)
PLoS
One
8(8)
Further discussion of the London Acute Stroke Service
is available at
https://
www.myhealth.london.nhs.uk/health-communities/londons-health-services/acute-stroke-services-london
Slide88The early adopter interventions
88
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services11.
Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide89Overview
: Integration of health and social
care
89
Intervention name
Integration of health and social care for older people in Torbay
What is it?
Health
and social care provision for older patients in Torbay have been integrated through a series of wide-reaching
organisational, procedural and cultural changes
. Since 2005 all care has been provided under the auspices of the Torbay Care Trust, which benefits from a strong sense of shared purpose and close communication between senior NHS and Local Authority leaders. Integration of patient care is underpinned by the presence of
care co-ordinators
with responsibility for an individual patient’s outcomes and enhanced data-sharing between different service providers and clinical teams. Further,
front-line staff are empowered to modify patients’ care packages
on the basis of changed circumstances, ensuring responsiveness and continuity of care over time.
Why do
it?
Patients experienced more
coordinated and responsive
care, with beneficial impacts both on their health and their experience of interacting with health and social care providers
At the same time, changes in activity produce financial savings which can be
reinvested into the health economy
. Examples of activity changes noted in Torbay include:
The daily average number of occupied inpatient beds fell 33% from 750 in 1998/99 to 502 in 2008/09Emergency bed-day use in the over 65 population was the lowest in the region, at 1,920 per in 2009/10Similarly, emergency bed-day use by the over 75s fell 24% between 2003 and 2008Delays in hospital transfer have been reduced to a negligible numberWhat are the key enabling factors?Base any strategy on the benefits being sought for service users/patientsCommunicate the benefits, listen to staff feedback, and share results and experiences to achieve continual improvementEstablish joint governance
early –
NHS, local authority and primary careEnsure senior and middle managers and clinical leaders are engaged from the start and
avoid separate management arrangements for individual professionsInvest in a professional approach to organisational development/change management
over an appropriate period of timeWhat are the potential barriers?
It is important to note that integration of health and social care in a long-term project requiring
several years of investment and effort before results may be realised. This requires strong and consistent leadership and project management
Financial pressures
may appear to be a disincentive owing to the initial investment and longer pay-off period
Clear
governance
and
accountability
needs
to be established
Cultural differences
between professionals
need to be taken into account
Legal differences
, such as
differing terms and conditions in the workforce, need to be anticipated
Information sharing
may pose challenges,
both because of lack of or incompatible IT systems and absence of protocols and agreements between organisations
Source:
Peter
Thistlethwaite
, ‘Integrating health and social care in Torbay: Improving care for Mrs Smith’ (The King’s Fund, March 2011)
Slide90Key leads and further reading: Integration of health and social
care
90
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
Peter Thistlethwaite,
‘Integrating health and
social
care in Torbay: Improving
care
for Mrs Smith’ (The King’s Fund, March 2011
) – available at:
http://
www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbay
. This is a very useful and readable narrative account of the experience of Torbay in integrating health and social care, with an emphasis on practical lessons for those looking to follow the same path
Slide91The early adopter interventions
91
Cancer screening programme
2. GP
tele
-consultation
3.
Medicines o
ptimisation
4.
Safe and appropriate use of medicines
5.
Acute
visiting
s
ervice
6. Reducing urgent care demand
7.
24-hour asthma services for children and young people
8.
Service
user
network9. Reducing elective Caesarean section10. Acute stroke services
11. Integration of health and social care for older people12. Electronic Palliative Care Coordination Systems (EPaCCS)
Slide92Overview:
Electronic Palliative Care
Coordination
Systems
(
EPaCCS)
92
Intervention name
Electronic Palliative Care Coordination Systems (
EPaCCS
)
What is it?
EPaCCS
are a shared electronic
record designed to improve end-of-life care and help patients to die in the location of their choice.
They provide instant access to patient information for key healthcare providers, assisting coordination of care. Patients are able to record their preferred place of death, ensuring that all those involved in provision of care are aware of patients’ preferences and wishes. They also provide a record of treatment, improving patient safety and ensuring that patients only need to have ‘difficult conversations’ once.
Why do
it?
Improved
quality of care and patient safety:
by reducing harm through coordinated communication, in standardised format, to reduce the risk of inappropriate interventions
More patients die in their place of choice:
as those involved in care are aware of the patient’s wishes
Reduced unnecessary hospital admissions and ambulance trips: recorded patient preferences means that they may be allowed to remain out of hospital towards the end of their lives, reducing admissions and bed daysImproved clinician productivity: reduced duplication of effort as information on patient preferences and previous treatment is stored centrally, reducing the time spent by clinicians gathering this informationWhat are the key enabling factors?Patients, family and carers should all be involved in discussions about the care planning process; and patients’ consent to sharing their personal information is vitalTo be useful, the record needs to be kept up to date and integrated into everyday ways of working for all those involved in the patient’s careThe standards set by the national information standard should be adopted to ensure consistent recording of information and safe and effective management of sharing of information (see further reading for full guidance)
EPaCCS
should be seen as one part of a wider suite of interventions enabling effective end-of-life care, including appropriate training and support for clinicians
What are the potential barriers?
Interoperability: different suppliers and systems may cause compatibility issues when sharing data. The DH Informatics Team toolkit (see further reading) offers guidance on specifications to avoid this
Patient and carer buy-in: initial doubts, for example over sharing data, may need to be overcome through discussion and explanation of the benefits and the safeguards in place
Clinician buy-in: this can be gained through training and support for clinicians in using the new systems, and clear articulation of the benefits for both clinicians and their patients
Costs: adequate budgetary resources need to be allocated to cover start-up and running costs
Source:
Millington Sanders
et al
, ‘Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK’ (2013) (
London Journal of Primary Care
, 5:106–10
Slide93Case studies:
EPaCCS in practice
93
Case Study
1
A patient with
COPD, who had a life expectancy of a further 12 months, was seen at a clinic on a Tuesday. He stated that he did not want to die at home, as he thought his
wife wouldn’t be able to cope, but also did not want to go to hospital. When the time came, he wanted to
go the local hospice. A couple of days later the patient had a crisis and because his details were
on the
EPaCCS, OOHs and his GP knew what he wanted and a bed was found for him at the
hospice, where he
died
a
few days after. If the Hospital Palliative Care Nurse Specialist didn’t hold the
clinic and
hadn’t been able to record his wishes, he would have been admitted to hospital and died there.
Case Study 2An elderly man with lung cancer was admitted to hospital when he developed
a chest infection, which was treated. When he was discharged home, he decided he didn’t want to
go into hospital again and wanted to die at home when the time came. His details were added to EPaCCS by his GP and a Just in Case box organised. The multi-disciplinary team discussed his ongoing care at their monthly Gold Standards Framework meetings. During a crisis at the end, Out of Hours were contacted. As they were able to see his preferences, they contacted his GP and
District Nurses who enabled him to die peacefully at home.Source: Millington
Sanders et al, ‘Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK’ (2013) (London Journal of Primary
Care, 5:106–10
Slide94Key leads and further reading:
EPaCCS
94
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful.
The
National End of Life Care Programme’s report ‘EPaCCS
: Making the case for
change’ (2012) offers helpful guidance and links to a range of other resources
: available at
http://
www.endoflifecare.nhs.uk/search-resources/resources-search/publications/epaccs-making-the-case-for-change.aspx
NHS Improving Quality has also published an economic evaluation of the ePaCC early implementer sites, available at:
http
://
www.thewholesystem.co.uk/docs/3economic-eval-epaccs.pdf
Information on the national information standard
is available
at:
http://
www.endoflifecare.nhs.uk/search-resources/resources-search/publications/end-of-life-care-co-ordination-implementation-guidance.aspxAn interoperability toolkit developed by the DH Informatics Team
is available at: http://www.connectingforhealth.nhs.uk/systemsandservices/interop
Millington Sanders et al, ‘Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK’ (London Journal of Primary Care 2013;5:106–10) provides a good case study: available at http://www.radcliffehealth.com/ljpc/article/electronic-palliative-care-co-ordination-system-electronic-record-supportsAn example ePaCC project brief for East Cheshire CCG is available at: http://
www.cheshire-epaige.nhs.uk/ePaige%20Documents/EPaCCS%20Early%20Adopter%20Project%20Brief%20v11%20Final.pdf
Slide95Further Ideas
Slide96Further transformational ideas
96
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide97Further Ideas
97
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide98Urgent and emergency care networks
98
Fragmented and diverse
urgent and emergency services
present a confusing and complex picture to patients, who may find it extremely difficult to access care when they need it
most. Consolidating emergency care onto fewer sites
may result in an improved experience for patients, as well as a more efficient system overall. Networks have senior clinicians consolidated onto fewer
sites, a range of urgent care services in the community and within primary care, and linked reporting & patient information systems.
Networks
Patient experience
An Australian study showed that increasing the number of consultants in the Emergency
Department decreased
complaints by 41%
Waiting times
An Australian study showed that increasing the number of consultants in the Emergency Department
decreased
waiting times by 15%
Financial
savings
The literature shows a decrease in
admission rates (from the ED) of 27% for children, and a reduction of 11.9% in admissions amongst adults
Improving patient safety
Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flowWhat are the potential benefits of networks?Source:
Positive impact of increased number of emergency consultants’. Geelhoed G and Geelhoed E, Archives of Disease in Childhood (September 2008); 93: 62–4.White AL, Armstrong PAR, and Thakore S. “The impact of senior clinical review on patient disposition from the emergency department” Emergency Medicine Journal, 2010;27:262-265 The concept
Slide99Further Ideas
99
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide100Elective Orthopaedic Centre (EOC)
100
The EOC is an NHS Treatment Centre providing regional elective orthopaedic surgery services (including inpatient, day-case and outpatient). Established by the four South West London acute Trusts to deliver strategic change in the delivery of planned orthopaedic care, the EOC provides high quality, cost efficient, elective orthopaedic services amongst the best in the world. Since opening in January 2004, the EOC has earned a reputation as a centre of excellence for elective orthopaedic surgery with excellent outcomes, low complications and high patient satisfaction. It has consistently achieved operational targets and length of stay, infection rates and PROMs are amongst the best in the world.
The concept
EOC
Quality improvements
Improvements to the quality of patient care are likely to be seen, in particular:
Reduced waiting times for operations.
Reduced post-surgery complications.
Improved quality of surgery, meaning that replacement joints are likely to last
longer.
Procurement savings
There are potential savings through exploiting scale to reduce procurement costs, e.g. for joints. The
EOC leads a London Procurement Programme initiative for prosthetic purchasing. This has resulted in an annual saving for London of some £
3m.
Reduced patient
complications
According to EOC calculations, EOC quality agenda reduces post operative complications, saving over £700 per patient compared to UK averages. If replicated nationally, this could save up to £92m across England and
Wales
.
Improved efficiency
On average each consultant performs four operations per day, compared to a national NHS average of around three per day. This saves cost by increasing productivity, and reduces waiting times. [not quantified]. There is also a reduction in length of stay.
What are the potential benefits of EOC?
Source: Deloitte analysis
Slide101Aravind
Eye Care - overview
101
Aravind
Eye Care is one of the best-known examples of health care intervention, and has been extensively impact assessed
. From it’s origins in south India
Aravind has provided end-to-end eye-care
services for 20 years. It now screens more than 2.7 million people annually, and performs some 285,000 surgeries per year.
Aravind
uses the principle of ‘
paraskilling
’, whereby many technically less-demanding medical processes (such as eye washing prior to surgery) are performed by trained nurses paramedics, but not by consultants. By adopting this approach, each doctor is freed up to treat many more patients (seeing each patient only at diagnosis and during surgery, where two patients are operated on simultaneously), reducing operating time and unit costs without compromising clinical quality.
Financial savings
Aravind’s
cost-effective approach performs cataract surgeries at one sixth of the cost to the NHS
Productivity improvements
Aravind’s high-throughput approach significantly improves productivity compared to other Indian hospitals. On average, each doctor conducts 2,600 operations per year, compared to 400 in standard Indian clinic.
What are the potential benefits of
Aravind
?
Aravind
The concept
Source: ‘Emerging Markets, Emerging Models’ (Monitor Group, 2010); http://www.innovationunit.org/blog/201106/innovation-healthcare-aravind-eye-care-system
Quality improvementsAravind carefully emphases clinical quality. Indeed, it has demonstrated infection rates comparable with those achieved in UK eye clinics (4 per 100,000 operations vs. 6 per 100,000 operations in the UK).
Slide102LifeSpring
Maternity Hospitals - overview
102
LifeSpring
Hospitals is a no-frills six-hospital chain of 20-bed facilities founded in 2005 and based in the suburban areas around Hyderabad, India, specializing in maternal and child paediatric, particularly labour and delivery.
By using standardized procedures, ensuring only the most specialized tasks are undertaken by consultants and a cross-subsidization model (private, semi-private and general wards),
LifeSpring has been able to significantly lower costs without compromising clinical quality. It is
now the largest chain of maternity hospitals in South India. More than 300,000 patients have been treated and 18,500 healthy babies delivered to date.
Productivity improvements
In
LifeSpring
hospitals, theatres
accommodate 22-27 procedures each week compared to
4-6
in a private clinic.
Each doctor conducts 17-26 surgeries per month: four times the private clinic rate.
Financial savings
LifeSpring’s
cost of delivery is 20-35% the cost of private Indian clinics
What are the potential benefits of LifeSpring?
LifeSpring
The concept
Source: ‘Emerging Markets, Emerging Models’ (Monitor Group, 2010)
Slide103Narayana Hrudayalaya heart surgery
103
Narayana is an
innovative hospital in Bangalore which specialises in cardiac procedures. The brainchild of Dr. Devi Shetty,
the hospital
is based on a healthcare model which Shetty has sometimes described as the ‘Walmartisation’ of cardiac
care. The large size of the hospital (around 1000 beds, compared to 160 in an average US hospital) gives rise to economies of scale which enable cardiac procedures to be delivered much more cost effectively, without compromising quality and patient safety. This is an example of the ‘focused factories’ method of healthcare, focusing on performing one type of procedure efficiently and to a high standard.
The concept
Narayana
Quality improvements
Because the hospital is specialised in delivering cardiac procedures, it delivers a high quality of care – the mortality rate within 30 days of coronary artery bypass surgery is 1.4%. at
Narayana
, compared with and average of 1.9% in the US.
Procurement savings
Because ‘focused factories’ concentrate the provision of a given procedure, they increase the purchasing power of these providers, enabling them to obtain better deals which can equate to a significant reduction in spend – for example, in this case there could be savings in the procurement of heart valves [not separately quantified].
Reduced cost of cardiac procedures
Narayana
has been estimated to reduce the cost of cardiac procedures by around 50%. Theoretically, in the UK, where cardiovascular disease was estimated to cost £13.6 billion in
2006
Improved efficiency
Surgeons become experts in particular types of heart surgery, meaning they can perform more operations in the same, leading to cost savings [not separately quantified].
What are the potential benefits of Narayana?
Source:
http://www.innovationunit.org/blog/201104/innovation-healthcare-narayana-hrudayalaya-heart-surgery
Slide104Further Ideas
104
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide105Discovery Health’s Vitality programme
105
The Vitality programme is a wellness programme that encourages covered members to complete a personal health review, set bespoke health goals and set a personal pathway that looks at disease management, smoking cessation, mental health, nutrition, preventative care and physical activity. Engagement is rewarded with Vitality points that can be turned into further incentives.
Discovery Health’s Vitality programme
Lifestyle & customer benefits
Vitality points can be cashed in with a large number of partners, including travel, store cards, healthy food, cinema, and
retail
Exercise
The programme has showed increases in fitness engagement
Financial savings
Engaged Vitality members experience 14% lower healthcare costs compared with non-Vitality
members
Nutrition
The programme has showed an uptake in the consumption of healthy foods
What are the potential benefits of the
Vitality programme?
Source:
Discovery Health
The concept
Slide106Partnerships for Older People Projects (POPP)
106
The POPPs programme, financed by the Department of Health between
2006 and
2009, funded activities aimed at promoting the health and well-being
and independence
of older people, and preventing or delaying their need for higher intensity or institutional care. Twenty-nine local authorities were involved.
One-hundred and forty-six core local services were established for people needing significant support, such as people (and their carers) with long-term conditions. A further
530 small
‘upstream’ projects commissioned from the third sector were described as
low level preventative
programmes and were open to all older people
.
The concept
POPP
Promotion of healthy living
By creating a ‘network of information’, the intervention volunteers help promote healthy living and raise awareness of mental health conditions. In so doing they may reduce future pressure on the healthcare system by changing behaviours, enabling people to live healthier lives and manage their own conditions.
Co-design in action
This intervention is a strong example of putting the patient at the centre and involving them in their own care, helping them to become active managers of their own health. This has the potential to improve care and reduce pressure of health services for a range of other conditions and patient groups.
Improving access to services
The projects help vulnerable, isolated older people access health services they might otherwise not be able to. As well as improving quality of care and tackling inequality of access, this may reduce demand for emergency services by pre-empting the development of more serious health issues.
Reduction in emergency bed
days
Evidence from the studies indicates that for every pound spent on the POPP services, there was a £1.20 additional benefit in the form of savings on emergency bed days. Overnight hospital stays were reduced by 47% and A&E usage was reduced by 29%.What are the potential benefits of POPP?Source: Nesta, ‘People powered health co-production catalogue’
Slide107Prevention and Access to Care and Treatment
107
Prevention and Access to Care and Treatment (PACT),
a US initiative drawing insights from NGO programmes in Haiti, originally serving the sickest and most marginalized HIV-positive patients in Greater Boston. PACT has helped raise the standard of care, while cutting costs in some of the poorest parts of Boston. It does this by supplementing comprehensive medical care with “wraparound” antipoverty services. Its model is built on accompaniment: CHWs are trained and paid to provide clinical care and deliver social support services, health promotion, and harm reduction services within patient homes and communities. From its origins in Boston HIV patients, PACT
now
serves patients
with multiple chronic diseases and
behavioural health comorbidities in
New York City, Miami, and the Navajo Nation.
Quality improvements
70% of PACT-enrolled patients showed significant improvement in disease-specific indicator of clinical improvement (e.g., reduced viral load, reduced A&E visits, etc.)
Financial savings
Patients enrolled in the PACT programme have demonstrated a 60% reduction in hospitalization and 16% net cost savings
What are the potential benefits of PACT?
PACT
The concept
Source:
http://www.ssireview.org/articles/entry/realigning_health_with_care
Slide108Further Ideas
108
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide109Interoperability of systems and patient records - overview
109
NHS Westminster
Since 2009 NHS Westminster has used a system provided by Vision 360, which enables cross-sector records for patients.
Initially designed
to provide authorised clinicians in local out-of-hours and unscheduled care settings with access to patient records held by their
GPs, it has now been extended to clinicians in other settings. Although in its early stages, improvements to patient care and resource planning are expected.
Key lesson: a successful pilot can generate further buy-in from clinicians and organisations, allowing it to be extended further.
Birmingham Central Care Record
Care professionals in the Heart of Birmingham
area now
have access to a
shared record
for patients,
including
Sandwell and West Birmingham Hospitals NHS Trust and over 70 local GP practices. This
is part of wider initiative to develop a Central Care
Record across the area, giving health and social care professionals access to clinical information when they need
it.
Key lesson: expensive and disruptive new systems can often be avoided in favour of adapting existing systems.Interoperability of systems and patient records aims to break down the barriers between social, residential, community, mental health and hospital care,
enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care. This process is supported by the NHS Interoperability Toolkit (ITK). The ITK is a collection of specifications, implementation guides and related documents
, and is intended to bring consistency to system integration within the NHS.
The conceptCase study 1
Case study 2
Slide110Interoperability of systems and patient records – further info
110
Providers of interoperability services and technologies should be
compliant with the latest release of the ITK
, to ensure consistency in system integration across the NHS. The ITK provides
further specifications and information guides
to assist with the process of integration
Look at how the intervention interacts with the
whole health economy
– what are the political, personal and institutional enablers and barriers?
‘Start small and iterate’
– the most successful systems are often those which evolve according to the needs of clinicians and other users, and into which existing systems can be plugged, rather than attempting to transform everything at once
Buy-in may be most easily gained by focusing on the
benefits to patients
, as well as savings to GP time through efficiencies, and opportunities for income generation for the local health economy
Experience indicates that getting
information governance, testing and project work
going can be more challenging than the actual implementation of the technology system
To be effective, interoperability schemes require
buy-in from clinicians and administrators
across several different organisations, which may be especially challenging following poor experiences with previous national schemes. Time needs to be allowed to
negotiate access to data: an opt-out agreement may be the most effective way of achieving thisThe benefits, while potentially significant, are
as yet largely unproven owing to the early stage of most pilotsBarriersThe Salford health economy has integrated primary, community and acute care through a real time shared patient record
. Patient data is uploaded to a central database every night, allowing clinicians in A&E to access a patient’s primary care record, while GPs are able to access records of patient use of acute services. While this faced initial technical and political challenges – with access to the data taking two years to negotiate - it has paid dividends in improvements in the the quality of patient care. In addition, through the NorthWest EHealth health informatics spin-off company, the use of anonymised data has enabled the injection of £30m into the local health economy, including through a world-leading clinical trial of respiratory medication using real-time data (the Salford Lung Study). There have also been benefits in savings of GP time through greater efficiency and reduced duplication of effort.Case study 3Enablers
Slide111Interoperability of systems
/
patient records – resources
111
NHS
Interoperability Toolkit (ITK):
http://
www.connectingforhealth.nhs.uk/systemsandservices/interop
The Power of Information
(DH, May 2012):
http://webarchive.nationalarchives.gov.uk/20130802094648/https://
www.gov.uk/government/publications/giving-people-control-of-the-health-and-care-information-they-need
Case study 1:
http://www.inps4.co.uk/vision360/case-studies/nhs-westminster
/
Case study 2:
http://www.graphnethealth.com/news/NewsItem.aspx?Name=Graphnet%20scores%20interoperability%20success
Case study 3: details of the Salford Lung
Study available
at: http://www.rdforum.nhs.uk/confrep/annual13/SalfordLungStudy.pdf
Resources
Slide112Further Ideas
112
1
Urgent and emergency care networks
Regional networks of urgent and emergency care
centres
,
consolidating specialist expertise onto fewer major
centres
2
Elective specialty
centres
Centres
of excellence for single specialties focusing on strong clinical
outcomes and operations excellence
3
Wellness programmes
Prevention programmes that
incentivise
healthy behaviours,
improve quality of life, and reduce the overall cost of healthcare
4
Interoperability of systems and patient records Interoperability of systems and patient records aims to break down the barriers between types of care, enabling presentation of patient information in a way that is accessible and cross-compatible for all those involved with patient care.5Public Health England case studiesAdditional interventions received from Public Health England, covering a variety of conditions and points of delivery.
Slide113Management of foetal growth retardation
113
Name and
s
ource of literature
QIPP: Reducing perinatal mortality and morbidity through improved antenatal detection of fetal growth restriction.
Perinatal Institute, 2011
www.pi.nhs.uk/cogs/IUGR_QIPP.pdf
,
http://www.perinatal.org.uk
, BMJ article
http://bmjopen.bmj.com/content/3/12/e003942.abstract
Description
of intervention
Improved antenatal identification of pregnancies
which are at risk due to fetal growth problems in the West Midlands. This includes increased monitoring of fetal growth by using customised growth charts, ultrasound scanning protocols towards the end of the pregnancy, escalation protocols to obstetric consultant care and in some cases the management of delivery up to two weeks early. Designating and reporting on a performance indicator of
antenatal detection of fetal growth restriction underpinned this.
Health Outcomes
The West Midlands was the only region which showed a year on year drop in stillbirth rates, reaching in 2012 its lowest ever rate, 4.47/1000. This represents a 1.27/1000 reduction from the pre-2009 10-year average (2000-2009: 5.74/1000).
In addition to the reduction in stillbirths, analysis by the Perinatal Institute also estimates:
Reduced asphyxia during childbirth – better detection of Intrauterine Growth Restriction (IUGR) would result in an estimated 25% fewer such cases (36 per year fewer in the West Midlands region)
Reduction in cerebral palsy – better detection of IUGR and timely delivery would lead to at least 12% reduction in cases of cerebral palsy occurring after term delivery (12 fewer cases per year in the West Midlands region)
Cost EffectivenessThe Perinatal Institute estimate a potential net saving of £5.4m per annum in the West Midlands primarily due to reduced neonatal intensive care, cerebral palsy and reduced costs of obstetric litigation. This does not account for the value of fewer perinatal deaths.Costs of an estimated £1.2m per annum, primarily for ultrasound resources, implementation of protocols and training, and additional inductions and caesarean sections are more than offset by the £6.6m per annum savings.Relevance to Any town health system
Stillbirths
are the largest contributor to perinatal mortality. 39% of all stillbirths (approximately 1,400 per year nationally) are now known to be the result of fetal growth retardation (babies who are not growing as well as they should be in the womb).
Other UK examples
Yorkshire and Humber have rolled out a comprehensive approach to the antenatal identification and management of babies at risk of restricted growth, through the leadership and supervision of midwives. This initiative has resulted in 2012 stillbirth rates being the lowest ever recorded in the region, a statistically significant improvement. [BMJ
paper shortly to be published]
Slide114Information sharing to reduce violent injury (Cardiff model)
114
Name and
s
ource of literature
Anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury
http://www.bmj.com/highwire/filestream/380358/field_highwire_article_pdf/0/bmj.d3313.full.pdf
http://injuryprevention.bmj.com/content/early/2013/08/22/injuryprev-2012-040622
Description
of intervention
The overall objective of
the Cardiff project was
to prevent violence of
all types. By enhancing information available from the police with relevant data from emergency departments, and by including health professionals responsible for treating the injured as advocates for prevention, more violence can be prevented than from police effort alone.
In essence, primary prevention of injury can be achieved by collecting and sharing unique information: each day, reception staff gathered 24-hour electronic data on the precise location and time of violent incidents; on a monthly basis, this anonymised data can be shared by an in-house ED analyst and the police, through a member of the Community Safety Partnership (CSP) (ideally a senior medical consultant). The CSP can then combine police and ED data to produce a map and a report, illustrating violence times, locations, and weapons. Finally, the prevention action plan can be updated and improved by the CSP violence task group.
Published
e
valuations have found that the best way to do this is for ED reception staff to collect data from patients who present with
violence
related injuries, and those who accompany them when they first arrive. This means that busy clinical staff are not diverted from their core duties.
Health Outcomes
This model has recently been evaluated in an experimental study and time series analysis that demonstrated a 42% reduction in hospital admissions relative to comparison cities where information sharing and use were not implemented
There has been a 50% reduction in violence related A&E attendances in Cardiff (from around 80 per month in 2003 to around 40 per month in 2013)Cost EffectivenessAnonymised information sharing and use led to a reduction in wounding recorded by the police, reducing the economic and social costs of violence by £6.9 million in 2007 compared with the costs the intervention city, Cardiff, would have experienced in the absence of the programme. This includes a gross cost reduction of £1.25 million to the health service.By contrast, the costs associated with the programme were modest: setup costs of software modifications and prevention strategies were £107,769, while the annual operating costs of the system were estimated as £210,433 (2003 GBP). The cumulative social benefit-cost ratio of the programme from 2003 to 2007 was £82 in benefits for each pound spent on the programme, including a benefit-cost ratio of 14.80 for the health service.
Relevance to Any town health system
There is a
reduction in unscheduled attendances to A&E. Anonymised information sharing for violence prevention can produce substantial cost savings to health services and the criminal justice system. The Cardiff model work has been adopted as part of the Coalition Programme for Government.
Other UK examples
http://www.alcohollearningcentre.org.uk/LocalInitiatives/projects/projectDetail/?cid=6433 – Addenbrookes
data sharinghttp://www.alcohollearningcentre.org.uk/Topics/Latest/Resource/?cid=6396
– Data sharing LondonMore resources at
https://www.gov.uk/government/news/resources-to-support-information-sharing-to-tackle-violence
Slide115Further info: Information sharing to reduce violent injury
115
Population Groups affected:
All population groups,
however as
violence mainly results in injury of those aged 18-35, the principle beneficiaries are in this age groupLogistic barriers to collection of evidence:These include lack of appropriate software in ED reception and elsewhere, and lack of electronic links with crime analysts working in crime reduction partnerships. These barriers can be overcome by receptionist training, simple adjustments to software by IT staff, and establishment of formal links between ED consultants and local crime reduction partnerships
.
A lack of professional analysts:It has become apparent that there is currently a lack of qualified analysts able to quantify data, collate reports and communicate the outcomes to ED staff. There is currently a call for the formation of a professional body to register analysts, set standards and promote professional
development.
Funding
:
Relevant data collection, IT support and links with crime reduction partnerships can be achieved at no extra cost to local
EDs.
Unjustified concerns about funding can get in the way of responsible practice. Solutions
are, however,
available from local crime reduction
partnerships, who are all funded to facilitate data sharing.Time constraints:Evaluations indicate that whilst doctors and nurses may be too busy to collect information about the circumstances of violence, reception staff have opportunities during waiting room waits and also have access to appropriate IT systems. Data collection by reception staff obviates the need for clinical staff to collect information, but responsible clinical care should still include enquiry about cause of injury, police reporting and finding out whether one injury may be part of a series of attendances after injury at the hands of the same attacker.
Slide116Alcohol identification and brief
a
dvice
116
Name and
s
ource of literature
Alcohol Identification and Brief Advice (IBA) as part of a comprehensive, multidisciplinary Alcohol Care Service at Royal Bolton Hospital
http://fg.bmj.com/content/2/2/77.full.pdf+html
/
http://arms.evidence.nhs.uk/resources/qipp/29420/attachment
Description
of intervention
The Royal Bolton Hospital has an integrated system of interventions, ranging from specialist care for dependent drinkers through to an industrial scale roll-out of IBA in the hospital, with over 600 staff in the Royal Bolton delivering IBA. All of which is linked to primary care, where a GP champion leads large scale delivery of IBA by his colleagues.
Alcohol IBA is both an intervention in and of itself and a necessary precursor for the provision of enhanced intervention and specialist treatment. In the Royal Bolton Hospital, the provision of IBA training and specialist support to a wide variety of staff enables the hospital to offer alcohol support within all departments of the hospital and equips staff with information that may help to reduce alcohol harm amongst the staff themselves, their friends and family. The on-going support provided by the alcohol specialist team ensures that alcohol IBA continues to be delivered effectively and in line with best practice and the evidence base. Supporting effective delivery is essential to realising the benefits of large scale preventative interventions.
Health Outcomes
Research has found that for every eight people who receive simple alcohol advice, one will reduce their drinking to within lower risk levels. NICE guidance (PH24) provides evidence in support of IBA delivery in any setting and recommends that all health and social care staff should deliver it.
It is difficult to disaggregate the impact of the industrial scale use of IBA in the Royal Bolton Hospital from the allied interventions. Overall, the comprehensive package of care for those who might benefit from an alcohol intervention in Bolton realised a 37% increase in ward discharges; length of stay has fallen from 11.5 days to 8.9 days, and mortality from 11.2% to 6.0%.
A NW NHS Chief Executives Challenge Review identifies two principal patient cohorts who might benefit from intervention for which IBA is a necessary first step. The first cohort is patients staying in hospital for 0–1 days, where effective intervention would result in 400 fewer alcohol- related admissions per year, equating to a 1% reduction in alcohol-related admissions and liberating 2 hospital beds, saving £698,000 annually. The second cohort was patients whose admission has an alcohol-attributable (or aetiological) fraction and a length of stay of 10 days or more. These patients made up 17% of alcohol-related admissions, but occupied 66% of bed days. The service focus is on providing assertive outreach support to reduce the number or repeat admissions to hospital. IBA forms a necessary first step in identifying these cohorts and can deliver wider health benefits for those who do not require immediate clinical intervention.
Cost Effectiveness
£1.6 million savings for a district general hospital serving a population of 250,000. This equates to £640,000 per 100,000 population.
Based on national indicators and length of stay costs, on average an alcohol-related admission costs a Primary Care Organisation (PCO) £1824; an alcohol-related A&E attendance costs a PCO £80; and each avoided admission will save a provider £300.
Relevance to Any town health system
It is estimated that the annual cost of alcohol- related harm to the NHS in England is £3.5 billion. Of this amount, 78% of the costs were incurred as hospital- based care. A comprehensive Alcohol Care Service, including IBA can tackle this.
Other UK examples
For other examples of Alcohol Care Teams see Royal Liverpool
Hospital; Salford Royal Hospital; St Mary’s Hospital, Paddington; Nottingham University Hospitals NHS Trust
Slide117Prevention of venous thromboembolism in hospitalised patients
117
Name and
s
ource of literature
The
national VTE Prevention Programme, analysed in Roberts et al,
‘Comprehensive VTE Prevention Program Incorporating Mandatory Risk Assessment Reduces the Incidence of Hospital-Associated Thrombosis’ (2013) Chest
144(4):1276-81
Description
of intervention
Implementation of the national VTE Prevention Programme in England, incorporating mandatory VTE risk assessment, standardised guidance for
thromboprophylaxis
(NICE CG92) and patient information together with system levers to drive implementation. These included development of a CQUIN target around VTE risk assessment and latterly root cause analysis as well as a NICE Quality Standard to define high quality care.
Health Outcomes
Current data reveal >95% adult patients admitted to hospital are risk assessed for VTE
Local audit and ST data shows a corresponding uplift in appropriate
thromboprophylaxis
rates and patients made aware of their VTE risk
ONS data demonstrates a 25% reduction in VTE deaths since implementation of the national programme
Data from the QUORU unit in Birmingham links reduced deaths from hospital-associated thrombosis to attainment of the national VTE risk assessment target
Local data from root cause analysis at King’s College Hospital shows improved outcomes upon implementation of the national VTE prevention programme
Cost EffectivenessTreatment of non-fatal symptomatic VTE and related long-term morbidities is associated with considerable cost to the health service, estimated at £640 million (House of Commons Select Committee, 2005). Costing analysis for NICE Clinical Guideline 92 (VTE - reducing the risk in hospitalised patients) estimated that providing preventative treatment to patients at risk of VTE in England would result in savings per 100,000 population of £12,000.Relevance to Any town health system
Support for i
mplementation of the national VTE prevention programme by CCGs will result in better quality care, improved patient outcomes and is cost-effective. A toolkit to inform CCGs about VTE prevention is available at: http://www.vteprevention-nhsengland.org.uk/commissioning/toolkit
Slide118Falls prevention
118
Name and
s
ource of literature
NHS Confederation
http://www.nhsconfed.org/Publications/Documents/Falls_prevention_briefing_final_for_website_30_April.pdf
Description
of intervention
In 2006, attending to fallers in the community within the Newcastle Primary Care Trust’s boundary cost North East Ambulance Service NHS Foundation Trust (NEAS) £376,000 (£145 per fall). That year, NEAS received 1,979 calls from fallers over the age of 65 in Newcastle alone, with ambulance crews spending an average of 40 minutes on the scene with fallers.
NEAS, in partnership with Newcastle Upon Tyne Hospitals NHS Foundation Trust (NUTH), introduced an integrated falls prevention strategy to provide a seamless route into established falls prevention services in Newcastle upon Tyne for fallers over the age of 50. It involves ambulance crews based in Newcastle using a ‘first-line assessment’ tool to screen and triage fallers to the appropriate falls service. Where three or more risk factors are identified, this is deemed an indication of a high risk of a future fall. The screening sheet completed by the ambulance crews is sent to a single point of access referral centre.
For Newcastle patients this is the Falls and Syncope Service (FASS). FASS evaluates and triages the referrals to the most suitable falls prevention team, either in primary care day hospital facilities services or secondary care specialist syncope services.
Professionals in health and social care and those working in the community, such as library staff, housing wardens, and community alarm services, across the NEAS operational area now have a seamless route into established falls prevention services by using the same first‑line assessment tool.
The ambulance service has developed the strategy in conjunction with falls service physicians. Ambulance clinicians
who take fallers to A&E due to clinical needs recommend to A&E staff that falls assessments are carried out after treating the faller.
Health Outcomes
Older people who fall are receiving the right care, with a considerably reduced risk of a future fall
Cost Effectiveness
Reduced attendance from fallers has resulted in cost savings for commissioners
Between 2006 and 2011, 999 calls for falls fell by over 75 per cent. This has enabled NEAS clinicians to be available more often for higher priority (category A) calls
The reduction in fallers has had a positive impact on A&E services. Fewer fallers are admitted by ambulance and, with recurrent fallers receiving the right care, they do not fall as frequently or need transferring back to A&E
Also see:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424053/ - The community falls prevention service delivered in this trial (not NEAS) was cost-effective with little decision uncertainty. This study further justifies the development of clinical pathways linking the emergency ambulance services to community therapy services note this was for people over 60 years of age living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital.Relevance to Any town health system
Falls represent the most frequent and serious
type of accident in people aged 65 and over.
Furthermore, falls are the main cause ofdisability and the leading cause of death from
injury among people aged over 75 in the UK .Integrated falls prevention strategies can have a positive impact on demand for ambulance services and emergency admissions due to falls.
Other UK examples
http://www.rospa.com/about/currentcampaigns/publichealth/info/hs3-casestudy2-bristol-falls.pdf -
Bristol case studyhttp://www.ageuk.org.uk/Documents/EN-GB/Campaigns/Stop_falling_report_web.pdf?dtrk=true
– various UK
case studies
Slide119Inhaler Technique Improvement Project
119
Intervention name
Inhaler Technique Improvement Project:
http://www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme/documents/120904%20CIREM_ITIP_HIEC_Evaluation.pdf
What is it?
Inefficient inhaler technique is a common problem resulting in poor drug delivery, decreased disease control and increased inhaler use. The costs to the nation and to patients are significant.
Based on original work in the Isle of Wight a number of PCTs in the South adopted the project to support patients to use their inhalers via a community pharmacy intervention.
Why do
it?
The evaluation found that the Inhaler Technique Improvement Project was a success on a number of levels:
At the level of the individual patient (improved outcomes and quality of life).
At a health systems level (improvements in emergency admissions).
In innovation (use of IT system and inhaler devices).
In education terms (enhanced skills applied in respiratory and other health related areas).
In a more generic sense of the HIECs bringing together and integrating all component areas into a cohesive and effective entity (Section 4.1.1).
The project delivered substantial improvements in the management of both asthma and COPD.
Other potential
Data on emergency admissions suggests a positive association between the introduction of the inhaler technique improvement project and changes in hospital emergency admissions. A more detailed analysis would be required to look at any more meaningful (i.e. statistically) significant correlation (Section 4.1.3).
The training delivered by the project was well received by patients and, following the training, pharmacists were able to deal effectively with patients’ concerns (Section 4.1.3).
Other skills benefits which were reported included the view that patients: increased their knowledge of respiratory conditions and how to control them better, developed greater confidence in controlling these conditions and were able to use “simple tools”
Further
potential - COPD
One person dies from COPD every 20 minutes in England - around 23,000 deaths a year. If the whole NHS were to deliver services in line with the best around 7,500 lives could be saved.
Death rates from COPD in the UK are almost double the EU average. 15% of those admitted to hospital with COPD die within three months and around 25% die within a year of admission.
COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient conditions to be treated by the NHS.
Further potential - asthma
There are around 1,000 deaths from asthma a year in the UK, the majority of which are preventable.
The UK has the highest prevalence of asthma in the world, at around 9-10% of adults.Just under £1billion is spent on respiratory inhalers with £170 million spent on one product alone (the Seretide 250 evohaler).