Populations or Pathways? Liane Langdon Anthony Lawton NHS Leeds North CCG Together we’re better

Local Strategic Context – Leeds Joint Health and Well Being Strategy Together we’re better

What did we do with Commissioning for Value? Together we’re better

Use CFV but also locally what fits – the life expectancy gap by cause of death Together we’re better

NHS LEEDS SOUTH AND EAST CCG Local Data: GP audit and healthy living service referral data summarised by CCG NHS LEEDS NORTH CCG NHS LEEDS SOUTH AND EAST CCG NHS LEEDS WEST CCG Leeds CHD prevalence 3.3% 3.8% 3.1% 3.4% Health checks uptake 60.2% 65.2% 51.5% 57.7% Smoking 18.6% 27.0% 22.0% 22.7% Smokers referred to smoking services (including prompted self referral) 9.0% 9.1% 4.2% 7.0% Obesity 19.5% 25.7% 19.9% 21.7% Recorded BMI >30 referred to weight management service 2.2% 2.1% 1.5% 1.9% Alcohol Short screening (FAST or AUDIT-C) 6.3% 6.7% Completed full AUDIT screening 1.1% 0.7% 4.1% 2.3% Screened as positive (Hazardous/harmful/dependant drinkers) 9.9% 21.5% 34.9% 30.8% Brief intervention (in GP practice) 4.5% 8.7% Scoring 20+ on AUDIT who have been referred for specialist advice for dependant drinking 1.8% 0.4% 0.5% Local Data

Local Data: Obesity prevalence Obesity prevalence versus % weight management referrals Local Data Low obesity prevalence High weight management referrals High obesity prevalence High weight management referrals Practices which have high obesity prevalence and low percentage of weight management referrals : (For a full list of all practice's see appendix 5) Practice cluster GP practice name % Obese Referrals Pentagon Dr Rickards A F & Partners 21.7% 0.9% Triangle Oakwood Lane Medical Practice 22.7% 1.7% Kite Dr Fellerman S M 21.3% 0.4% Hexagon Dr Brady & Partners 20.4% 0.6% Charles Street Surgery 20.0% Dr Pearson R E & Partners 25.7% Dr Hall G I & Partners 19.5% 2.2% Wetherby Surgery 1.6% Circle One Medicare Llp (Hilton Road) 23.1% 0.7% Dr Nicholls J A J 26.7%* 0.0% Low obesity prevalence Low weight management referrals High obesity prevalence Low weight management referrals * Statistically different to the CCG Practices within the dotted line do not have statistically different level of obesity prevalence and % of weight management referrals to the CCG as a whole Together we’re better

Local Data: Smoking prevalence Smoking prevalence versus % smoking referrals Local Data Low % smokers High% smokers referred High % smokers High% smokers referred Practices which have a high % of smokers and low percentage of smokers referred: (For a full list of all practices see appendix 5) Practice cluster GP practice name % Smoking Smoking referrals Triangle Dr N Dumphy & Partners 30.3% 8.3% Dr Iwantschak A & Partners 33.2% 4.7% Dr Pg Darbyshire & Partners 29.1% 8.1% Dr S J Brown & Partners 34.2% 1.4% Dr S J K Renwick & Partners 34.1% 3.3% Oval Dr S M Laybourn & Partners 6.6% Dr Boonin A S & Partners 39.9% 4.6% Dr Bhandary L V & Partners 37.1% 3.4% Dr Srivastava S K Circle Dr Y F S Wong 33.4% 3.8% Dr A R Sooltan & Partner 31.5% 2.0% Dr Ali S A 33.6% 5.3% Lincoln Green Medical Centre 32.3% 6.9% Dr H U Pai 37.4% 4.1% No cluster Shakespeare Medical Practice 27.8% 3.6% Low % smokers Low% smokers referred High % smokers Low % smokers referred Practices within the dotted line do not have statistically different level of smoking prevalence and % of smoking referrals to the CCG as a whole Together we’re better

So Summary: Overarching messages for Leeds Summary on a page Public health focus on prevention; specifically smoking prevalence (Leeds South & East and Leeds West) smoking cessation (All) and Obesity (Leeds South & East) Significant benefit to patients if improvement to Primary Care management indicators were made (All) High emergency admissions for CVD (Leeds South & East), costs (Leeds North and Leeds South & East) and lengths of stay (All) High costs for CHD emergency admissions (Leeds North and Leeds South & East) and high costs for CHD elective admissions (Leeds South & East) High emergency admissions for Heart Failure and Stroke (Leeds South & East and Leeds West) High costs for Angiography procedures (All), CABG procedures (All) and Angioplasty procedures (Leeds West) High lengths of stay for Angiography procedures (Leeds West)

Actions ………….. Public Health – challenge to jointly re look at commissioning of healthy living services key priority for the Council. Primary care – variation target work with key practices and embed into engagement schemes in each CCG Whole pathway – flow and variation – LIQH. CCG commissioning – using packs as part of prioritisation framework Transformation work streams -Acute – elective care value approach; Integrated Care – Pathways work. Together we’re better

The LIQH approach Together we’re better

LIQH – focussed areas CVD improving the management of chest pain; optimise outcomes and quality of care for people requiring interventions/ treatment for suspected/confirmed arrhythmia and to prevent inappropriate use of secondary services. COPD support people with COPD to manage their own condition and to reduce the likelihood and impact of exacerbations; reduction in variation of approach to COPD patients in crisis; Improving the early and accurate diagnosis of COPD whilst improving patient experience. Together we’re better

Pathways So, for pathways But, is this enough? The data gives us some clear indication of pathways to consider We have established clear programmes of work But, is this enough? Together we’re better

Populations Great for quality improvement But – is this enough for transformation? What about complex populations? CfV tells us where the challenges are But we know that with populations, pathway approaches are not always enough What can CfV do to inform work with the frail elderly? Together we’re better

Liberating CfV for Populations What we did next: Used the CfV intelligence Used part of the £5 per head for primary care (£2.36) Identified our target population – frail elderly 2% Applied Outcomes Based Accountability to liberate practices to use CfV knowledge creatively to tackle an issue requiring transformation, not quality improvement Look for contribution not attribution – asked practices to work in localities to give something a go Together we’re better

Overview of OBA Outcome Based Accountability™ was first developed in the early 1990s by Mark Friedman Principles: SIMPLE COMMON SENSE PLAIN LANGUAGE Together we’re better

Definitions OUTCOME A condition of well-being for adults, children, families, communities i.e. Being Healthy, Staying Safe, Safe Communities, Clean Environment INDICATOR A measure which helps to quantify the achievement of the outcome. i.e. Rate of diagnosis of Dementia in Primary Care, Rate of teenage pregnancies Population ENDS PERFORMANCE MEASURE A measure of how well a program, service is working Based on the 3 following questions: How did we do? How well did we do it? Is anyone better off? Performance MEANS Together we’re better

Leaking Roof Experience: Measure: Story behind the baseline (causes): Not OK Experience: ? Fixed Measure: Turning the curve Story behind the baseline (causes): Partners: What Works: Action Plan: Together we’re better

What now? Supported practices in locality groupings to identify meaningful local measures relating to how they are contributing to the issues identified within CfV Practices are all enhancing community nursing – but in different ways Measure and look for learning and impact – and share Worry about contribution, not attribution Do more of whatever works! Together we’re better

Questions