QIPP national workstream – briefing paper Slide 1 of 4 WorkstreamRight Care Workstream LeadSir Muir Gray and Philip DaSilva 1. The opportunity QUALITY Right Care is designed to seize the opportunity provided by the tight financial climate to improve the way we use resources in the NHS whilst improving health outcomes and patient experience. By focussing on commissioning care pathways as whole systems instead of commissioning activity from bureaucratic structures and by collaborating with clinicians, within the context of programme budgets, we can eliminate wasteful spend on low value activities and focus resources on high value activities, maximising value for the population as a whole. We can also improve patients’ care and outcomes by ensuring they do not undergo inappropriate or unnecessary interventions. Right Care will encourage a debate between the public, clinicians and managers in order to achieve a common agreement about what is high and low value. The Shared Decision Making project will empower patients to make rational healthcare decisions, based upon a fuller understanding of the risks and benefits of treatment options. There is clear international evidence that patients, when supported with decisions aids, increasingly choose less invasive and therefore less costly treatments which result in a better patient experience and at least as good outcomes as usual care. EFFICIENCY Right Care will produce estimated efficiency savings of £2.4 billion by 2013/14. This estimate is based on reducing unwarranted variation in PCT spend in the first instance on elective activity – i.e. by high-spending PCTs reducing their spend to the average – and by reducing spend on low value interventions. For example, this graph shows the distribution in spend on inpatient cardiac valve procedures (adjusted for age, sex and need). There is a 5- fold variation in spend between PCTs Cardiac valve procedures cost £12,343 each – so small drops in activity offer large savings. The potential savings are £19m by reducing high spend to the median.

QIPP national workstream – briefing paper Slide 2 of 4 WorkstreamRight Care Workstream LeadSir Muir Gray and Philip DaSilva 2. The case for change NHS management has often focussed on organisations and structures. Clinicians have held the balance of power, creating clinical systems of an ever increasing sophistication. Historically, use of NHS resource has been driven by un-checked demand, often supported by clinician and health organisational imperatives which have a tendency towards expanding and providing more services or use of new technology, sometimes without a sound evidence base and with little regard to ceasing other ways of working or paying much attention to the impact on the health system as a whole. Currently patients undergo treatment in the face of “avoidable ignorance” and consent to interventions which they would not undergo if they were provided with a fuller understanding of the risks, benefits and alternatives to fully exercise their values and preferences. The ambition of Right Care is to change thinking on commissioning care away from organisations and contracts to commissioning high value, whole system pathways, under-pinned by networks rather than institutions and putting the citizen and the patient at the centre of this discussion. Those systems and networks can begin to take on programme budgetary financial risk and rewards in addition to whole pathway clinical quality accountability. A key component is the provision of tools and analysis which highlight the often large and unexplained variations in spend on healthcare and health outcomes for the commissioner’s population. It is also evident that the public and patients have not always been included in the debate about the development or design of services. The NHS is unlikely to hold sufficient resource to meet ever rising demand and thus we need to change the nature of the debate between the public and the NHS about how resources are utilised for their care - to do the right things, at the right time and place, safely and effectively. This activity will also increase the sustainability of healthcare. Evidence from the Public Health Commissioning Network shows that clinical networks are cost effective and feasible and that integrating systems of care are an effective means of delivering value and quality. They can help us to address problems such as: failure to adopt and implement strong evidence; massive unknowing duplication of effort in appraising new technologies; a lack of focus on common expensive problems such as epilepsy or headache.

QIPP national workstream – briefing paper Slide 3 of 4 WorkstreamRight Care Workstream LeadSir Muir Gray and Philip DaSilva 3. The planned approach WHAT Right Care will create better value programmes and systems of care within programme budget areas by supporting networks of lead clinicians and commissioners in local health economies to develop and commission high value pathways for specific clinical programmes. Right Care will support this work with learning programmes, knowledge management tools and Accelerated Design Events. It will also support clinical commissioners with a range of tools including the NHS Atlas of Variation, the Annual Population Value Review, lists of high and low value interventions and the systematic use of the Map of Medicine and NHS Evidence. A project on Shared Decision Making, led by East of England SHA, complements and feeds into Right Care. This will deliver a National Strategy for Shared Decisions and at least six new NHS decision aids on a national platform (see screenshot). HOW Right Care will provide the focus, leadership and support to drive momentum and accelerated change in clinical commissioning, where improvement is currently recognised to be slow and sporadic. The work will become core to the review of World Class Commissioning with the extension and enhancement of WCC competencies. A small national reference group will advise on using national levers (e.g. standard contracts, tariff, ring-fenced budgets) to drive change. Sir Muir Gray Chief Knowledge Officer of the NHS, DH Philip DaSilva National QIPP Lead, Primary & Community Services Sir Muir has worked in public health for 35 years. He helped pioneer Britain's breast and cervical cancer screening programmes and was knighted in 2005 for the development of the foetal, maternal and child screening programme and the creation of the National Library for Health. Phil has a nursing background and brings more than 30 years’ NHS experience to the team, operating at all levels including as a PCT Chief Executive and in a range of senior Executive Director positions.

This workstream sets out to increase value by improving clinical commissioning - the right allocation of resources to different clinical specialties; clinical management - the right use of allocated resources each group of patients; and patient choice - to ensure that the patient makes the decision that is right for them Central Lancashire PCT is taking this approach to increase the value it derives from the £34m it allocates for respiratory disease, initially by improving the quality and health outcomes of the chronic obstructive pulmonary disease (COPD) service. It is working to reduce readmission rates by 10% and at the same time ensure that more people are cared for at home. In this PCT the COPD spend is £7million a year. This is 17% more than neighbouring PCTs. The main hospital has a COPD admission rate of 46% compared with a 27% national admission rate. Emergency hospital admissions due to exacerbations of COPD account for 70% of the total costs for COPD patients. Quality outcome: Productivity outcome: A team of clinicians and commissioners is using clinical evidence to redesign the COPD pathway ensuring that access to health care is improved for patients that will result in fewer readmissions. Central lancashire PCT has identified three interventions to reduce cost on the COPD pathway: 1. Invest in community health care 2. Reduce readmissions 3. Work to reduce length of stay of hospitalised patients COPD patients receive appropriate care in a community setting and are less likely to need emergency admission to hospital By redesigning the clinical pathway for COPD and commissioning more community based care this PCT has an aspiration to reduce its spend on hospital readmissions for COPD patients by £500,000 a year. QIPP national workstream – briefing paper Slide 4 of 4 WorkstreamRight Care Workstream LeadSir Muir Gray and Philip DaSilva 4. Case study The workstream will work to derive increased value from three programmes: Respiratory disease, current cost £4.27bn a year Gastrointestinal and liver disease, current cost £4.10bn a year Genito-urinary disease including kidney disease, current cost £4.0bn The above costs do not count GP costs other than prescribed medication