We have had 2 healthcare revolutions, with amazing impact The First was the public health revolution The Second has been the technological revolution supported by 50 years of increased investment & 20 years of evidence based medicine, quality and safety improvement eg Antibiotics MRI & CT Coronary artery bypass graft surgery Hip & knee replacement Chemotherapy Radiotherapy Randomised controlled trials Systematic reviews

after 50 years of progress all societies still face three massive problems. The first is unwarranted variation in healthcare ie ”Variation in utilization of health care services that cannot be explained by variation in patient need or patient preferences.” Jack Wennberg Variation reveals the other two problems

The first is Underuse of high value interventions which results in 1. Preventable disability and death eg if we managed atrial fibrillation optimally there would be 5,000 fewer strokes and10% reduction in vascular dementia,(2012) and 2. inequity This was in the NHS Atlas of Variation

The second is overuse which 1. always wastes resources and 2 The second is overuse which 1. always wastes resources and 2. can cause harm BENEFIT Effect Size The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in 1980. Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality. This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICUTE IN HEALTHCARE Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce Antibiotics Chemptherapy ion the last week of life Elderly people with multiple disorders dying in intensive care Rarely do the comment on The last 10% in the increase in imaging ( going up at 8-10% per year) The last 10% in the increase in lab testing ( going up at 8-10% per year) Emphasise THIS HAS NOTHING TO DO WITH MONEY [raise the choosing wisely campaign http://www.choosingwisely.org amd the BMJ’s too Much medicine http://www.bmj.com/too-much-medicine Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency Medical Knowledge Patient care Professionalism Interpersonal and communication skills Practice-based learning and improvement Systems-based practice Proposed new competency: cost-conscious care and stewardship of resources   Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:386-388. Resources

BENEFIT HARM Effect Size Resources The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in 1980. Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality. This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce Antibiotics Chemptherapy ion the last week of life Elderly people with multiple disorders dying in intensive care Rarely do the comment on The last 10% in the increase in imaging ( going up at 8-10% per year) The last 10% in the increase in lab testing ( going up at 8-10% per year) Emphasise THIS HAS NOTHING TO DO WITH MONEY [raise the choosing wisely campaign http://www.choosingwisely.org amd the BMJ’s too Much medicine http://www.bmj.com/too-much-medicine Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency Medical Knowledge Patient care Professionalism Interpersonal and communication skills Practice-based learning and improvement Systems-based practice Proposed new competency: cost-conscious care and stewardship of resources   Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:386-388. Resources

BENEFIT HARM BENEFIT -HARM Effect Size Resources UNDERUSE OVERUSE The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in 1980. Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality. This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce Antibiotics Chemptherapy ion the last week of life Elderly people with multiple disorders dying in intensive care Rarely do the comment on The last 10% in the increase in imaging ( going up at 8-10% per year) The last 10% in the increase in lab testing ( going up at 8-10% per year) Emphasise THIS HAS NOTHING TO DO WITH MONEY [raise the choosing wisely campaign http://www.choosingwisely.org amd the BMJ’s too Much medicine http://www.bmj.com/too-much-medicine Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency Medical Knowledge Patient care Professionalism Interpersonal and communication skills Practice-based learning and improvement Systems-based practice Proposed new competency: cost-conscious care and stewardship of resources   Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:386-388. Resources POINT OF OPTIMALITY UNDERUSE OVERUSE

NHS or nHS? Is the service for people with seizures & epilepsy in south East London better than the service in North West? Who is responsible for the service for people with dementia in Southwark ? How many liver disease services are there in London and how many should there be? Which service for people at the end of life in London provides the best value? Is the service for people with type 2 diabetes in London better than the service in Manchester?

In the next decade need and demand will increase by at least 20 % so what can we do? Well, we need to continue to 1. Prevent disease, disability, dementia and frailty to reduce need 2.Improve outcome by provide only cost-effective, evidence based interventions 3. Improve outcome by increasing quality and safety of process 4. Increase productivity by reducing cost These measures reduce need and improve efficiency BUT we also need to increase value

The Aim is triple value Personal value, Allocative value ,   Personal value, Allocative value , Technical value , It is useful to emphasise that there are two types of value , allocative and technical relate primarily to populations, personalised to the individual This report from the academy of medical royal colleges in 2015 calls for a culture of stewardship waste is anything that does not add value and as the Academy’s re[port emphasises we need to develop a ‘culture of stewardship’ to ensure the NHS will be with us in 2028 and 2038

FOR EXAMPLE , AVERAGE DURATION OF STAY FOR KNEE REPLACEMENT Productivity Outputs/Costs

Efficiency Productivity Outcomes/costs Outputs/Costs FOR EXAMPLE, % OF PATIENTS WHO HAVE A KNEE REPLACEMENT AND REPORT THAT THE OUTCOME IS GOOD OR VERY GOOD v Efficiency Outcomes/costs Productivity Outputs/Costs

Technical Value Efficiency Productivity Are the right patients being seen or is there either 1. harm from over diagnosis or 2. inequity from underuse v Efficiency Outcomes/ Resources Productivity Outputs/ Resources Quadruple Resources Financial Environmental (carbon) Social Time, not only clinician time but also time of patients and carers

  Personal value isdetermined by the value the individual places not only on the outcomes of their treatment, both beneficial and harmful, related to the problem that was bothering them most but also to the investment they have made , for example the time they have spent and their experience of care and decision making

THE Better Value Healthcare METHOD OF INCREASING VALUE FOR POPULATIONS Be clear about which population is being served Shift resource from budgets where there is evidence of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity Develop population based systems that not only deliver high quality care efficiently but also Address the needs of all the people in need, Implement high value innovation funded by reduced spending on lower value intervention Increase rates of higher value intervention funded by reduced spending on lower value intervention eg shift resources from treatment to prevention

2. Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity

ANNUAL SPEND PER MILLION ” Cardio £100M Respiratory £78M Gastro- Intestinal £68M Eyes & vision £30M Mental health £11 Bn directly, perhaps another £5 Bn in hidden costs of people with physical problems with significant psychological factors at this point participants will say , rightly, that lots of people have more than one condition , so move on to the next slide ANNUAL SPEND PER MILLION 21

ANNUAL SPEND PER MILLION ” Mental Health £145M Cardio £100M Respiratory £78M Gastro- Intestinal £68M Mental health £11 Bn directly, perhaps another £5 Bn in hidden costs of people with physical problems with significant psychological factors at this point participants will say , rightly, that lots of people have more than one condition , so move on to the next slide Eyes and vision £30M ANNUAL SPEND PER MILLION 22

2. We are working to develop programme budgets determined by characteristic such being elderly with frailty Mental Health Many people have more than one problem ; they have complex needs. GP’s are skilled in managing complexity but when one of the problems becomes complicated the Generalist needs Specialist help Cancers Respiratory Gastro- intestinal You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 23

Rhythm CVD Neurology Gastro- instestinal STEMI Coronary Disease Heart Failure Rhythm CVD Neurology Gastro- instestinal The first point is to point out that allocative decisions are also made within each system of care and and there was an excellent piece of work done by the london respiratory clinical community using the STAR tool http://www.health.org.uk/learning/star/ to move resources from triple drug therapy to smoking cession and rehabilitation. Now ask the group what they would do if asked to fund more resources for glaucoma and use the next ppt 24

Rhythm CVD Neurology Gastro- instestinal STEMI Coronary Disease Heart Failure Rhythm CVD Neurology Warfarin DOACs Gastro- instestinal Ablation The first point is to point out that allocative decisions are also made within each system of care and and there was an excellent piece of work done by the london respiratory clinical community using the STAR tool http://www.health.org.uk/learning/star/ to move resources from triple drug therapy to smoking cession and rehabilitation. Now ask the group what they would do if asked to fund more resources for glaucoma and use the next ppt 25

Warfarin Drugs Warfarin drugs DOACs Warfarin clinics Warfarin drugs Clinics clinics Genomics DOACs

Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental Health Cancers Respiratory Gastro- intestinal You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 28

Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental Health Cancers Respiratory Gastro- intestinal You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 29

Cancers Respiratory Gastro- intestinal Beds DNCA ITU drugs Mental Health Cancers Respiratory Gastro- intestinal You can often see the GPs in the room concerned about the focus on single conditions so emphasise that we also need to focus on subgroups of the population defined by a comon characteristic such as having multipl conditions 30

THE Better Value Healthcare METHOD OF INCREASING VALUE FOR POPULATIONS AND INDIVIDUALS IS BY Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered Shifting resource from budgets where there is evidence of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity Develop population based systems that not only deliver high quality care efficiently but also Address the needs of all the people in need, with the specialist service seeing those who would benefit most Implement high value innovation funded by reduced spending on lower value intervention Increase rates of higher value intervention funded by reduced spending on lower value intervention eg shift resources from treatment to prevention

All people with the condition People People who receiving The service People who would benefit most from the service Here isan example of the type of problems that clinicians need to tackle , particulatrly because … next ppt

All people with the condition who do not need to see the specialist service practice healthcare supported by generalists who are themselves supported by specialists The right People receiving the specialist service Here isan example of the type of problems that clinicians need to tackle , particulatrly because … next ppt

TECHNICL VALUE AFTER THE RESOURCES HAVE BEEN ALLOCATED Effect Size BENEFIT HARM BENEFIT -HARM The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio One of the benefits of evidence-based medicine was that it emphasised the need to ensure that the only interventions being offered were those for which there was strong evidence that they did more good than harm. However, the balance of good to harm changes as the amount of resources invested in a health service increases. This was first demonstrated by Avedis Donabedian in 1980. Donabedian called the point beyond which further investment of resources would not increase value for the population the point of optimality. This is illustrated in the figure on the ppt - emaphasise that THISIS THE MOST IMPORTANT PICURE IN HEALTHCARE Ask the participants to identify examples working in pairs for 2 minutescommonly the y produce Antibiotics Chemptherapy ion the last week of life Elderly people with multiple disorders dying in intensive care Rarely do the comment on The last 10% in the increase in imaging ( going up at 8-10% per year) The last 10% in the increase in lab testing ( going up at 8-10% per year) Emphasise THIS HAS NOTHING TO DO WITH MONEY [raise the choosing wisely campaign http://www.choosingwisely.org amd the BMJ’s too Much medicine http://www.bmj.com/too-much-medicine Table. The 6 General Competencies of the Accreditation Council for Graduate Medical Education/American Board of Medical Specialties, and the Proposed Seventh Competency Medical Knowledge Patient care Professionalism Interpersonal and communication skills Practice-based learning and improvement Systems-based practice Proposed new competency: cost-conscious care and stewardship of resources   Source: Weinberger, S.E., (2011) Providing high value, cost-conscious care: a critical seventh general competency for physicians. Annals of Internal Medicine 155:386-388. Resources POINT OF OPTIMALITY UNDERUSE OVERUSE

BENEFIT HARM The Effect Size Resources CLINICAL VALUE ECONOMIC VALUE The service provider needs to know that the options for a particular intervention are not static . As we treat more people we treat less severely affect people who have a different benefit to harm ratio Resources CLINICAL VALUE ECONOMIC VALUE Necessary appropriate inappropriate futile Higher lower low Zero Negative

Deliver Care through high quality Systems Develop clinical focus on populations IMPROVED OUTCOMES WITH NO MORE MONEY FOR BOTH INDIVIDUALS & POPULATIONS LOW VALUE BUREAUCRACY BASED CARE DIGITALLY MANAGED KNOWLEDGE Personalise Care & Decision -making Create a collaborative Culture of stewardship

 

The Care Archipelago GENERAL MENTAL COMMUNITY PRACTICE HEALTH SERVICES SOCIAL HOSPITAL CARE SERVICES COMMUNITY SERVICES Probably do this and the next ppt quite quickly showing the impossibility of solving the problems of healthcare through the bureaucratic approach alone Emphasise that bureaucracies have an important role to play , but only to ensure the fair and open employment of staff and the uncorrupt management of money ; they cannot solve complex problems like providing better care for people with epilepsy

The Professional Archipelago NURSES DOCTORS PHYSIOS Probably do this and the next ppt quite quickly showing the impossibility of solving the problems of healthcare through the bureaucratic approach alone Emphasise that bureaucracies have an important role to play , but only to ensure the fair and open employment of staff and the uncorrupt management of money ; they cannot solve complex problems like providing better care for people with epilepsy PSYCHOLOGISTS OTs FINANCE

The Commissioning Archipelago 152 Local Authorities 211 CCG’s GP/ Pharmacists/ optometrists You can point out that even small and straightforward health challenges , like deafness in children have four different types of commissioner involved Public Health Specialist commissioning

SELF CARE INFORMAL CARE GENERALIST SPECIALIST

SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER

TYPES OF CARE BUREAUCRACIES SELF CARE INFORMAL CARE e.g family GENERALIST (primary) SPECIALIST (secondary) SUPER CCG Spec NHSE PHE Trust LA GPs STP Com BUREAUCRACIES

PROGRAMMES AND SYSTEMS FOR POPULATIONS DEFINED BY NEED, eg PEOPLE WITH… Mental health problems Frailty Cancer Eye problems TYPES OF CARE SELF CARE INFORMAL CARE e.g family GENERALIST SPECIALIST SUPER CCG Spec NHSE PHE Trust LA GPs STP Com BUREAUCRACIES How many population based networks are there for people with heart failure in London?

CHOOSING CRITERIA & SETTING STANDARDS It took several years to develop because sickle cell is a complex problem, for example in some parts of the country the condition is so uncommon that many professionals were unfamiliar with it.   Having formulated objectives and chosen criteria to measure those objectives, the next stage in the development of a system is to set standards. (Standards can be set for process criteria even in the absence of outcomes.) Donabedian, in many ways the founder of the healthcare quality movement, said in a lecture that ‘the quality of a health service is the degree to which it conforms to pre-set standards of goodness’. When setting standards, it is important to be aware that standards are subjective, and different perspectives exist. A manager may think a service is of good quality, but patients and carers may regard its quality as poor, or vice versa. Many people rate their experience with alternative or complementary medicine as high in quality, whereas many clinicians would regard the service provided as low in value. It is often useful to set more than one level of standard. In a book popular in the 1990s entitled In Search of Excellence people were exhorted to be excellent. However, exhortations to excellence can be de-motivating to people working in difficult circumstances aware that excellence is the result not only of hard work but often of the chance coalition of skilful individuals working in a propitious environment. For this reason, it is advisable to set three levels of standard: a minimal acceptable standard, below which no programme of care should fall; an excellent standard, which is reached by the best; and an achievable standard, for example the cut off point between the top quartile and the rest This is an example of a national service set up as a system

Hierarchy Network The network is the set of individuals and organizations that delivers the system to the populations. It is useful to go through the hierarchy of the 20th century to the network of the 21st century, with the patient at the centre “professor, specialist and GP, with the patient invisible” In the 21st century all the professionals, all the nodes in the network are of equal importance with the patient in the middle

Map of Medicine - COPD Work like an ant colony; Neither markets nor bureaucracies can solve the challenges of complexity

Ban old language Introduce new language AcuteCommunityManagerOutpatientHubandSpoke Introduce new language A SYSTEM is a set of activities with a common set of objectives and outcomes; and an annual report. Systems can focus on symptoms, conditions or subgroups of the population (delivered as a service the configuration of which may vary from one population to another ) A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation) A PATHWAY is the route patients usually follow through the network A PROGRAMME is a set of systems with ha common knowledge base and a common budget Now introduce the new language Here are the new terms Acute and community implies the hospital is not part of the community Primary and secondary ignores the point that A&E is for many people their primary port of call Out patients is a 19th century term Hub and spoke implies a power relations hip; in a network all the constituent elements are nodes

We need a new set of skills and tools what is the relationship between value and efficiency? What is the relationship between value and quality ? what is meant by the optimal use of resources? How would you assess the culture of an organisation? What is a system and what is a network? What is the relationship between a system and a service?

ABILITY THERE IS NO STABLE PHASE IN LIFE BIOLOGICALLY THE TURNING POINT Best possible rate of decline due to ageing alone ABILITY Development Ageing THERE IS NO STABLE PHASE IN LIFE BIOLOGICALLY

ABILITY AGE THE TURNING POINT THE FITNESS GAP Best possible rate of decline Actual rate of decline ABILITY AGE

THE TURNING POINT THE FITNESS GAP Best possible rate of decline after onset of heart failure ABILITY The Line THE LEVEL REQUIRED TO GET TO THE TOILET IN TIME Rate of decline after onset of heart failure AGE ONSET OF HEART FAILURE THE FITNESS GAP OFTEN GETS WIDER FASTER AFTER THE ONSET OF A LONG TERM CONDITION, AND MAY DRAG THE PERSON BELOW THE LINE

AGEING DISEASE LOSS OF BELIEFS, FITNESS ATTITUDES & EMOTION

ABILITY AGE The Line THE TURNING POINT THE FITNESS GAP Best possible rate of decline after onset of heart failure ABILITY The Line THE LEVEL REQUIRED TO GET TO THE TOILET IN TIME Rate of decline after onset of heart failure AGE ONSET OF HEART FAILURE

ABILITY AGE Best possible rate of decline after onset of heart failure The Line LEVEL OF ABILITY REQUIRED TO GET TO THE TOILET IN TIME NARROWING OF THE FITNESS GAP AND PREVENTION OF LOSS OF ABILITY TO GET TO THE TOILET IN TIME AS RESULT OF TRAINING AT ANY AGE AND WITH ANY NUMBER OF LONG TERM CONDITIONS PEOPLE CAN IMPROVE FITNESS AND STAY ABOVE THE LINE

THE KEY DOCUMENT WAS PRODUCED BY THE ACADEMY OF MEDICAL ROYAL COLLEGES IN 2015

THE BENEFITS OF ACTIVITY THERAPY, Activity Therapy AFFECTS THE DISEASE PROCESS DIRECTLY IN SOME CONDITIONS PREVENTS THE LOSS OF FITNESS AND ACCELERATED DECLINE THAT OFTEN FOLLOWS DIAGNOSIS REDUCES THE RISK OF OTHER LONG TERM CONDITIONS EG REDUCING THE RISK OF HEART DISEASE AND DEMENTIA MAKES PEOPLE FEEL BETTER