business case and applied economic evaluation Mike Firn – Health care Consultant

Overview Brief economic imperative Pathway/ blended model of Skype and conventional Methods Costs and benefits in monetary terms of the blended model Who benefits financially? Commissioning implications? Conclusions

Cliché of the burning platform? 3 Total number of people with diabetes in Newham is rising by >800 each year. Prevalence of Diabetes in Newham is high at 5.7% Limited patient engagement and self-management Yet Hba1c levels continue to improve despite the challenges

Study question and methods 5 quantify the comparative costs and consequences between conventional F2F and Skype appointments Mixed methods- pragmatic and applied; to promote adoption Light green and dark green $ distinctions (IHI) $“when is a saving not a saving” National and local costings £unit costs medical consultant hour £101, DSN £51, receptionist £21. HRG 307 diabetic medicine New £225, FU F2F £101(national so local + MFF), non face to face £26.

Headline findings- productivity 6 Light green or dark green, or even more complicated ?

Headline Findings- DNA 7

Headline findings- Diabetes related complications 8 Empirically linked to engagement and treatment adherence. Skype confers advantages for engagement and adherence through reduced DNAs for scheduled appointments but also the facility for unscheduled appointments Sensitivity analysis on avoided A&E and DKA episodes Complication eventLow n (£ saving)Base n (£ saving)High n (£ saving) A&E attendance n5 (£610)10 (£1,220)20 (£2,440) DKA admission n5 (£8500)10 (17,000)20 (£34,000) Total saving to CCG£9,110£18,220£36,440

Other avoidable complications 9 Diabetes is estimated to have cost the UK £9.8 billion in direct costs in 2010/2011, this equates to approximately ten per cent of the total health resource expenditure. It is estimated that 80 per cent of these costs are incurred in treating potentially avoidable complications. Premature mortality with over 22,000 additional deaths each year. Doubles the risk of cardiovascular disease (heart attacks, heart failure, angina, strokes). Most common reason for end stage kidney disease and the most common cause of blindness in people of working age. Up to 100 people a week have a limb amputated as a result of diabetes, and in many cases this is avoidable. Nearly 1 in 5 people with diabetes have clinical depression and for those with anxiety and/or depression health care costs increase by around 50%. (Source Action for Diabetes-NHS England in 2014)

Headline findings - patient pocket 10

Set up costs versus savings 11

Commissioning considerations- Incentive example 12 Virtual clinic example from orthopaedics. Incentivised by agreement of a CQUIN incentive payment in The face to face tariff of £72 has also been retained pro tem. Agreement of a virtual tariff is deferred until fuller evaluation of benefits in a mature service has been established.

Commissioning considerations- disincentive examples 13 1.Block contract (DSNs) 2.Commissioner determines that skype calls are not eligible for the standard PbR tariff payment and would therefore have to be charged as non face to face.Local price agreed for non face to face appointments £26. Negotiations on a virtual / online/ skype tariff delayed by poor commissioner engagement

Conclusion 14 In most contexts project set up and ‘retooling’ costs can be recovered in year 1 and a return on investment surplus in subsequent years. This is over and above the benefits from keeping up with rising demand. Commissioning contract arrangements complicate the business case and make some of these financial gains opaque to clinicians