Right Care Deep Dives NEW Devon CCG Infectious Diseases

Contents 1. Introduction 2. Deep Dive Methodology Right Care Deep Dives, Unwarranted Variation, Using the Evidence 2. Deep Dive Methodology Data Extraction and Processing, Analysis and Presentation 3. Deep Dive Findings: Infectious Diseases The Challenge, Population, Activity/Spend, Outcomes, Opportunities Who’s Doing Well? What Does This All Mean?

Introduction: Right Care Deep Dives Commissioning for Value packs help identify Programme Areas in which to look Analytical Deep Dives form part of phase two: ‘What to Change’ Further, specific analytical requests would also support the ‘How to Change’ phase Commissioning for Value Packs Deep Dives Where to look What to change How to change

Introduction: Unwarranted Variation Aim to understand what can’t be explained by patient choice or illness of population A four-stage process Identify the variation Understand if it is warranted What is driving it? How do we eliminate it?

Introduction: Using the Evidence Using evidence to move from: “How can I explain this?” to “What can I do to improve this?”

Methodology: Data Extraction and Processing Downloaded data for NEW Devon and comparator CCGs from a host of national sources: Programme Budgeting HSCIC/iView Prescribing Quality and Outcomes Framework Public Health Profiles Many more! Process this data into formats which allow ease of comparison and further analysis

Methodology: Analysis & Presentation Where NEW Devon CCG is: In ‘worst’ quintile Where a related set of indicators show a tendency toward poor performance Focus on key areas and/or indicators National median Median of national upper quintile Median of ‘most similar 10 CCGs Median used instead of mean to reduce impact of extreme outliers Present comparative data against different scenarios Against national position and benchmarks Similar CCGs Provider Practice Review data at a range of levels to better understand variation at a macro and micro level

Methodology: Analysis & Presentation Inquiry approach Exploring data using key lines of enquiry (KLOEs) Identify ‘golden threads’ present throughout the data Working with partners to understand local issues Identify poorly performing area for KLOE using programme budgeting as a base Review related indicators from other data sources to refine detail Analyse provider and practice level data to illustrate local variation Assess scale of opportunity against various scenarios

Infectious Diseases Programme

Areas for investigation Septicaemia Other viral infection HIV/AIDS Retrovirus infections Measles Rubella Tuberculosis Haemophilus influenzae Mumps Meningococcal infection Herpesviral infection Other infectious diseases

The Challenge • CCG in highest quintile for Outpatient spend and second highest quintile for Day Case and Elective spend • Primary Care Prescribing also shows opportunity • In other areas where spend benchmarks well (Non-elective, A&E) there may still be opportunity to reduce variation or improve value

Primary Care Prescribing Spend in middle quintile nationally Spend on antibacterial drugs - by far the largest category – is within second lowest quintile The other four areas are all within the highest quintile for items, and some for spend suggesting potential opportunity Items Spend Opportunity = £70k - £513k

Outpatient Opportunity = £1.1M - £1.6M Outpatients Outpatient costs in highest national quintile Significant variation across CCGs which could be down to the availability of specialist clinics Given high spend there is opportunity, however it would need careful review Outpatient Opportunity = £1.1M - £1.6M

Inpatients (Elective/Day Case) Elective spend within the second highest national quintile Some small opportunity has been identified, however there are no obvious areas to focus attention Highest volume HRGs are: ‘Other Viral Illness with CC’ (39 spells) and ‘Septicaemia with Intermediate CC’ (25 spells) Reduction scenario Spend per 100,000 (£000s) Difference with NEW Devon spend per 100,000 (£000s) Saving opportunity (£000s) National median 36.8 -3.1 None National best quintile median 9.3 24.4 221.5 Similar 10 CCGs median 27.8 6.0 54.1 Elective/Day Case Opportunity = £0k - £222k

Inpatients (Non-elective) Non-elective spend benchmarks well nationally (second lowest quintile) and admission rates are around the middle of the national distribution There is however, a six-fold variation in standardised non-elective admission rates across NEW Devon CCG practices. Addressing this could deliver some savings. Non-elective Opportunity = £0k - £472k

A&E (1) A&E spend is also low (lowest national quintile). Volumes in this area are low, and overall attendances show a decrease for the Programme Budgeting category across years Diagnosis 2012-13 2013-14 2014-15 Infectious disease 404 330 318 Viral infection of unspecified site 10 6 2 Fever of unknown origin 4 1 3 Other septicaemia Zoster [herpes zoster]   Unspecified parasitic disease Bacterial infection of unspecified site Other diseases caused by chlamydiae Grand Total 422 343 325

A&E (2) It should be noted however that Septicaemia diagnoses, for which inpatient activity is high, are not categorised under 01X Infectious Diseases but under category 03X – Blood Disorders When this category is broken down further, Septicaemia can be seen to be on the rise Row Labels 2012-13 2013-14 2014-15 Septicaemia 84 123 199 Haematological conditions 20 30 Other 4 3 Grand Total 108 147 232

Outcomes The percentage of all antibiotic prescription items in primary care that were for key antibiotics: NEW Devon = 12.3% (fourth worst quintile) Goal = 10% National Median = 11% (10 similar CCGs 10.9%) The percentage of people newly diagnosed with HIV who had a CD4 count test within one month of diagnosis: NEW Devon = 93.2% (second best quintile) British HIV Association target is >95% Median of 10 similar CCGs = 90.3%

Outcomes Immunisations with the 5 in 1 vaccine: At 12 months = 96.4% (second highest quintile) At 24 months = 98.2% (top quintile) Booster at 5 years = 92.1% (third national quintile)

Overall Infectious Diseases Opportunity: £1.2M - £2.8M Opportunities Primary Care Prescribing: £70k - £513k Elective/Day Case: £0 - £222k Non-elective: £0 - £472k Outpatients: £1.1M - £1.6M Overall Infectious Diseases Opportunity: £1.2M - £2.8M

Primary Care Prescribing Who is doing well? Primary Care Prescribing NHS Dorset NHS Somerset NHS Southern Derbyshire Daycase and Elective NHS Gloucestershire NHS West Hampshire Outpatients NHS Kernow CCG performance based on age-sex standardised information

What does this all mean? Opportunity in Prescribing in four sub-categories along with potential for quality improvements around antibiotic prescribing  sub-categories are small so intervention would need to be targeted Outpatient spend benchmarks high when compared to a variable national picture  work to understand whether this is because of service provision or data recording before deciding how to address Rising Septicaemia attendances at A&E  tackling this could help reduce emergency admission demand

Any Questions?