10 ways to use your CfV packs – 1 to 4

‹#› 1. Use CfV packs to prioritise improvement programmes – Where to Look

‹#› 2. Use the variation highlighted in the CfV packs to destabilise complacency and define opportunity

CVD Focus Pack headlines - Wigan 1.Enhance/ redesign/ manage prevention and primary care system to optimise Prevention (11,100 more with low activity levels than peers, 1,300 more eating unhealthily) Detection (600 fewer Stroke patients on registers) Systemise care planning and self/ case management (1,100 fewer >40yr old patients with BP record, 650 fewer with <75yr old hypertension patients with brief intervention) Local referrals triage and pathway navigation 2.Specify whole service and thresholds, with particular attention on Admission rates (CVD – 840 more, CHD – 300, HF – 140) Procedure rates (Angioplasty – 70 more, CABG – 30) 3.Specify robust discharge thresholds and protocols, in particular to manage LOS(CVD – 800 more beddays, CHD – 550, Angiography – 650, Angioplasty – 200, CABG – 200. Total = 2,400 days or 6 beds) Rehabilitation services (130 fewer stroke patients discharged to usual place of residence)

‹#› 3. Use CfV to show The Art of the Possible

6 Where Bradford are now (and where West Cheshire were)…

7 Where West Cheshire are now (and where Bradford could be)

‹#› 4. Use CfV as the catalyst for clinicians to design optimal

9 Canterbury & Ashford CCGs – Optimal Design Event February 2015 Adopted RightCare December 2014 and in Feb GPs 40 hospital clinicians 10 tables 5 priority work streams (taken from CfV packs) Designing the optimal system for their population Prevention to end of life Collective design - collective agreement Challenge system (including selves) to deliver

‹#› 5. Use CfV to identify where in the pathway to focus clinical engagement

NHS Bradford City CCG Heart disease pathway = 95% confidence intervals Initial contact to end of treatment

‹#› 6. Use CfV to identify peers to find good practice

NHS North Kirklees CCG Heart disease pathway = 95% confidence intervals Initial contact to end of treatment

14 7. Use CfV to galvanise the system into immediate action

15 CfV pack to delivery in 7 months – Hardwick CCG Now implementing – Agreed and specified COPD pathway Enhanced nebulisers service in primary care Primary care COPD audit and support service to implement findings practice by practice Improved promotion of self-management Improved self-management support Enhanced organisation of Breathe Easy Groups (with British Lung Foundation) Delivered (so far – only just begun) – 30% reduction in emergency admissions

16 8. Use CfV to improve primary care whilst progressing secondary care engagement

‹#› Diabetes in Slough CCG “The Right Care methodology has been successfully applied to the primary care management of diabetes in Slough” – Slough CCG Diabetes Lead Following primary care pathway reform – Of patients with pre-diabetes whose results are available for evaluation, 100% saw a reduction in their HbA1c levels Of the patients with type 2 diabetes, 89% saw a reduction in their HbA1c levels 15 out of 16 practices showed an increase in the number of patients whose diabetes was controlled 15 out of 16 practices saw an increase from 72.25% to 80.06% of patients whose blood pressure was <140/80

18 9. Use CfV to identify which Patient Decision Aids to implement first

19 Cochrane review update studies across 6 countries (>34,000 participants) Found good evidence that PDAs Increase patient knowledge Improve accuracy of patient expectations Improve communication between patient and practitioner Reduce volume of elective surgery DO NOT worsen health outcomes

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21 PDAs supporting Cancer, Circulation, Respiratory, include… COPD High BP High cholesterol Localised prostate cancer Lung Cancer Smoking cessation Stable angina Stroke prevention for AF

22 Patient Decision Aids – Implementation Process 1.Identify best PDAs for local impact Use CfV and AoV to id. high use of discretionary surgery and/ or sub-optimal primary care condition management (LTCs) 2.Localise with local GP leads and add referrals criteria and protocols C. 50% of unwarranted activity dealt with by PDAs, 50% by protocols (Capita) 3.Implement in key practices and prove impact 4.Spread across practices 5.Implement more PDAs (in phases or collectively) Optional (innovative): 6. Design own, use and spread

Use CfV to check you are doing (or did) the right things

24 Stress-testing action and proposals – Blackpool Stroke review CfV Pack 1 – Will the recommendations in the local Stroke review lead to: An increase in the number of stroke patients spending 90% of their time in hospital on a stroke unit and a reduction in overall admissions? CfV Pathways on a Page Pack – Will the recommendations lead to: Increased numbers of stroke/TIA patients with BP < 150/90, cholesterol < 5mmol/l and on anti-platelet agent? Increased numbers of atrial fibrillation patients with a stroke risk assessment? Reduced elective and non- elective spend? Reduced emergency readmissions? CVD Focus Pack Prevention - does the review seek to highlight and/ or tackle the significant lifestyle drivers of CVD? E.g. smoking, obesity, exercise, healthy eating, binge drinking, all of which Blackpool is a material outlier for? Until these issues are confronted, population level impact will not occur. Detection – does the review tackle the shortfall in identified stroke patients (100’s fewer on registers in Blackpool than cluster best practice)

25 Stress-testing action and proposals – Blackpool Stroke review CVD Focus Pack contd. Primary Care Management – in addition to above, does the review seek to impact on the primary care management of e.g. flu vaccicinations for CHD patients and/ or brief intervention numbers for HF patients? Secondary Care Management – do the recommendations resolve the status of Blackpool CCG as the least good performer amongst its demographic peers on emergency admissions and lengths of stay? Diagnostic AoV Will the recommendations lead to an increase in the number of stroke patients receiving a brain image within one hour of arrival in hospital?

And why are we doing this?

NHS xxxxxxxxxx xxxxxxxxx CCG Why act: Patient case study – Long Term Conditions Paul Adams is a typical patient in a typical CCG. The following story is seen across the country in many long term condition pathways. Journey one tells of a standard care pathway. Journey two tells of a pathway that has been commissioned for value. Journey One At the age of 45, and after 2 years of increased urinary frequency and loss of energy, Paul goes to his GP. The GP performs tests, confirms diabetes and seeks to manage with diet, exercise and pills. This leads to 6 visits to the practice nurse and 6 laboratory tests per year Paul knows that he is supposed to manage his diet better but is not sure how to do this and does not want to keep bothering the GP and the practice nurse By the age of 50, Paul has given up smoking but continues to drink. His left leg is beginning to hurt. His GP prescribed insulin a year ago and now refers him for outpatient diabetic and vascular support At 52, Paul’s condition has deteriorated further. He has to have his leg amputated and he now has renal and heart problems. His vision is also deteriorating rapidly. He is a classic complex care patient. This version of Paul’s patient journey costs £49,000 at 2014/15 prices… 27

NHS xxxxxxxxxx xxxxxxxxx CCG Why act: Patient case study – Long Term Conditions If Paul Adam’s CCG had adopted Commissioning for Value principles and reformed their diabetes and other long term conditions pathways, what might Paul’s patient journey have looked like? Journey Two The NHS Health Check identifies Paul’s condition one year earlier, at the age of 44 and case management begins… Paul is referred to specialist clinics for advice on diet and exercise and he has this refreshed every 2 years. He is also referred to a stop smoking clinic and successfully quits Paul has a care plan and optimal medication and retinopathy screening begins 18 months earlier He is supported in his self management via the Desmond Programme and a local Diabetes Patient Support Group Journey One cost £49k and managed Paul’s deterioration Journey Two costs £9k and keeps Paul well

Right Care Impact in Warrington – one example of one programme Respiratory Care in Warrington Health Economy 2010/11 – £1.5M OVER spending V. demographic peers Only 2/3s of asthmatics known Worst quintiles – COPD rate of em admns, deaths within 30 days, %age receiving NIV, readmns 2012/13 – £0.6M UNDER spending V. demographic peers Delivered by focus on variation – problems fixed or improving (e.g. 30% less COPD NEL admissions, MDT, 70+ p.m. triaged away from acute sector) HSJ Commissioner of the Year 33