Delivering better value in the NHS Chris Ham Chief Executive 15 June 2016

http://www.kingsfund.org.uk/publications/better-value-nhs/summary

% of primary care prescribed items by generic/proprietary prescribing and dispensing: England, 1976-2013

As well as allowing 490m more item to be prescribed Estimated saving in 2013 total net ingredient cost due to increases in generic prescribing, 1976-2013 As well as allowing 490m more item to be prescribed

Trends in acute medical and surgical average length of stay: English NHS, 1974-2013/14

Estimated impact of LoS reductions on the number of acute beds, 1998/9-2013/14 Nearly 10,000 (+10.5%) more beds would have been needed to treat same number of patients

Proportion of all patient activity carried out as day cases: England, 1974-2013-14 If the % of patients treated as day cases had remained unchanged from 1998/9, NHS spending in 2013/14 would have paid for 1.3m fewer elective episodes

Too much medicine NHS wastes over £2bn a year on unnecessary or expensive treatments Leading medical body cites overtreatment and over diagnosis as key problems, along with patients who demand treatment now

Inappropriate care Overuse Overuse happens when health care is delivered even though the potential for harm outweighs the benefits. Examples in the NHS include: Prescribing antibiotics for people with coughs, colds and sore throats. While evidence tells us that antibiotics rarely make a difference, GPs often prescribe them. c£4m could be saved by following NICE guidelines Diagnostic testing. Why is there more than 100 fold variation in rates that some tests are used? For others, why is it more like 1000 fold? Part of the answer is overuse Some care delivered in acute hospitals. This includes overtreatment in hospital at the end of life and some elective procedures of low clinical value

Inappropriate care Underuse Underuse happens when effective care isn’t delivered when it’s needed. It can lead to people needing more complex care as they get worse. Examples in the NHS include: Diabetes care. Only c60% of people with diabetes get all of the recommended care processes to improve their health. Even less (36%) achieve all three treatment targets Underdiagnosis. Take COPD, where DH guidance suggests that around 1 in 8 people with COPD over the age of 35 has COPD but doesn’t know about – with 15% only diagnosed after turning up in A&E Underuse (and overuse) of effective drugs. Eg warfarin and statins, where evidence shows underuse in high risk patients and overuse in low risk patients

Inappropriate care Misuse Misuse happens when services are poorly delivered, resulting in preventable harm to patients. Examples in the NHS include: Falls. The majority of patients admitted to hospital because of a fall (or who had already fallen in hospital) don’t receive the right assessments to help prevent further falls. Direct cost of falls in hospital is c£15m Medication errors. There are 50 million prescribing errors in the community, 45,000 prescribing errors in an average acute hospital, and around 2,500 potentially preventable deaths related to medication every year Venous thromboembolism (VTE). In 2005, the HoC HSC estimated that there could be as many 25,000 avoidable deaths from VTE in hospitals every year

Key service areas Care for people with long term conditions Opportunities for: Earlier detection and diagnosis Involving patients in decisions about their care Supporting patients to manage their own health Improving coordination of services and reducing fragmentation Integrated approaches to mental, physical and social needs

Key service areas Care for older people living with frailty and complex needs Opportunities for: Avoiding preventable and inappropriate hospital admissions Improving the flow of patients within hospitals Better discharge and reablement As well as many of the opportunities outlined on the previous slide

Key service areas Care for people at the end of life Opportunities for: Reducing time spent in hospital at the end of people’s lives Better care coordination Training generalist staff in end of life care Ensuring that care is delivered in line with patients’ preferences

Examples of teams, organisations and systems already doing this stuff Improving care for children with severe abdominal pain in Liverpool Improving patient flow for older people in Sheffield Improving the management of repeat prescriptions in Walsall Redesign of stroke services in Plymouth And many more…

Opportunities for the future What do they tell us? The evidence suggests that there are a range of opportunities for the English NHS to get better value from its £116bn budget through changes in clinical practice This is because the NHS, like all other health systems, sometimes fails to deliver high‑quality care, leading to poor outcomes for patients, wide variation, and wasted resources Rather than finding new ways of cutting costs, these opportunities focus on improving quality and outcomes Some of these opportunities can be achieved more quickly than others and in some cases will require investment Collaboration across services and organisations is critical

Organisations and systems

An agenda for improving value in the English NHS Our report calls for a new focus on reform from within the NHS, rather than relying on top-down approaches to stimulate change. At a high level, this means: Clinical teams leading improvements in care and reducing unwarranted variation Providers placing improving value as their overriding priority and investing in LD and QI training for staff Organisations working in collaboration to develop new models of care across local systems Commissioners aligning financial incentives and targeting low value care National bodies creating the right policy environment for these changes to happen Patients and the public being involved at all levels

The bigger picture What approaches are there to reforming and improving health care systems? What do we know about what’s worked and what hasn’t? Where should national leaders in England and other countries now focus their efforts?

Key messages QI must be a priority for every NHS organisation – not just another national initiative Every organisation must commit time and resources to QI Organisations should share expertise and learning via networks A small national centre should provide leadership and coordination QI requires long term commitment and constancy of purpose

Back to Batalden QI happens in clinical microsystems and among teams delivering care Teams need time, space and skills to bring about QI Investment in training and development for staff is a critical ingredient Visible commitment by top leaders at all levels is also essential

In summary High quality care often costs less The focus should be on clinical practices Care should be appropriate Variation should be reduced Waste should be eliminated Many small changes are needed, not a big breakthrough Leadership and cultures should support Realistic medicine should be the aim

c.ham@kingsfund.org.uk @profchrisham