Sir John Oldham National Clinical Lead Quality and Productivity NHS England

Quality Trinity improved clinical outcomes improved patient experience maximise use of resources, human and fiscal (C) John Oldham 2000

© Sir John Oldham and Terema Ltd 2007 Evidence ++ Improvement Methods Human Factors = Outcomes ValuesLeadership The Equation (Oldham J JAMA 04 March2009)

Levers for large system change Staff engagement Changed requirements - create discomfort with status quo Financial flows aligned with the change required Human resource policies aligned with the change required

Primary Care Collaborative Results 32 million patients in 44 months 72% improvement in access to GPs 4 fold greater reduction of mortality in patients with CHD cf rest of England Multiple 1ry/2ry pathway redesigns and wait reductions

and Patients with HbA1c <7 up 17% Patients with cholesterol <5 up 30% Patients with BP<140/80 up 27% Patients having diagnostic spirometry up 148% Patients recorded smoking intervention in last 12 months up 60%

Principles of large system change Oldham J Sic evenit ratio ut componitur 2004 Kingsham Press Pushing the boundaries; framing the issue Clarity and purpose Recruit opinion leaders Shape the environment; aligning policies Systematic transfer of knowledge Apply discipline and rigour to measurement Communicate success Creating infrastructure for spread; recruit and pollute Optimism and agility around obstacles Taking calculated risk Visible credible leadership

QIPP activity Procurement Back office functions Medicines Urgent care Long term conditions Safety and reliability Right care (reducing variation)

Long Term Conditions

Paradigm shift Part of care system to whole of care system NHS effect on people with long term conditions is only a part of the care system Biomedical model to sociomedical model of care Whole of patient not part of patient

QIPP Workstream ignition phase Whole health and social care economies Teams should include patients, social care, community services, ahp’s, acute trusts, mental health general practices GOALS 20% reduction in unscheduled admissions 25% reduction in length of stay Reduction in readmission within 30 days Measured improvement in care planning

Primary drivers Risk profiling Integrated care teams at locality level Single point of contact for patients Systematic empowerment of patients to self manage

Long Term Needs patients’eye  “I want you to deal with the whole of me, decide who sees me, and for you to work as one team” Commissioner E-Learning Disease specific pathways Brokerage for individual patients Neighbourhood care teams Single point of contact Joint delivery teams, community services, social services, ahp practices,mental health Continuity of personnel for individual patient Care plan Broader skill mix “I determine who provides services to me” Self-management is default Remote monitoring Personalisation

Effects of Self Management 29% reduction in heart attack recurrence 34% fewer arterial disease related deaths Statistically significant improvements in BP and cholesterol levels Statistically significant improvements in exercise, diet and smoking. 50% better management of anticoagulant therapy (ref: Care Management Institute Kaiser Permanente, Cochrane institute)

Benefits of patient- centred care Reduced length of stay Lower cost per case Decreased adverse events Higher employee retention rates Reduced operating costs Decreased negligence claims (Increased market share) 16 Charmel P, Frampton S. Building the Business Case for Patient Centered Care. HFM. March, 2008

Benefits of patient centred care A positive patient experience is associated with better long term outcomes (for patients with myocardial infarction) Fremont, Cleary et al J. Gen. Intern. Med 2001:16:

Benefits of patient centred care Cochrane institute: patients self managing their anticoagulant therapy showed a 50% reduction in number of clots and a 36% reduction in deaths c.f control.

Behaviours we need Systematise empowering patients Whole systems Whole patients Co-operative Resources are what you use, not just bid for Assume others are trying to do the right thing to Relentless about reducing errors Look around and compare; learn Systematise good behaviours