1. Commissioning for value: Mike Ward Winter BTS 2013

2. Commissioning Evidence based medicine Quality Variation & Healthcare spending Value

5. Fig 1 Total (public plus private) health spending as a percentage of GDP in OECD countries, 1960-20101. Appleby J BMJ 2012;345:bmj.e7127 ©2012 by British Medical Journal Publishing Group

6. Commissioning Evidence based medicine Quality Variation & Healthcare spending Value

7. Commissioning Value – New paradigm Optimising the value of interventions for populations. All clinical groups should estimate which interventions are most beneficial and give best value Muir Gray BMJ 2012

10. Commissioners/ providers Ration care Reduce quality Cut pay /Redundancy Improve Value Whole pathway Reward correct use of pathway

12. Optimising value of interventions for populations M Gray BMJ 2012 All clinical groups should estimate which interventions are most beneficial Clinicians have a role in making decisions about ‘value’ – on behalf of the populations they serve. Marginal benefit + High incremental cost Low value

13. Decision Conferencing Agree segments within typical 300,000 population – Interventions – Analyse results Benefit of intervention – VAS Number who might benefit

14. costs Population benefit Benefit per person Numbers who benefit VfM Rectangle of population health gain and value for money triangle Value

15. Low population health gain High population health gain Poor VfM Good VfM Low costs Triangles with good & poor value for money High costs 15

16. Evidence

17. Diagnosis in primary care Register is a problem in up to 30% of cases FEV1 and FEV1/FVC FEV1 % predicted Restrictive Poor quality 580 422 94 23 39 Jones RCM Respiratory Research 2008;9:62

18. LABA or LABA/ICS in COPD FEV1 < 50% pred FEV1 >50% pred

19. % of Patients prescribed each drug class by COPD severity Lung Health - National uk

20. Relative value of interventions for COPD -Agreed on and described population segments: -undiagnosed -diagnosed with mild-moderate disease and -diagnosed with severe-very severe disease -Defined a list of interventions for each population segment -Researched the cost-effectiveness of these interventions -Drew rectangles that described the segmented population health benefit of selected interventions -From the population health benefit figure, added in the cost dimension to create value triangles 20

24. Incremental cost, benefit & value Total cost Population to benefit / harm

25. Acute trust CCG Community trust Social care Organisations Targets Incentives Structures Integrated Fragmented Value

26. Conclusion Responsibility for the population Commissioners – Use “value” to inform decisions – Waste and underuse Integration of services “cycles of care” Pulmonary rehabilitation & stop smoking

27. Sian Williams Noel Baxter Steve Holmes Louise Restrick Jane Scullion Mike Ward Alec Morton Mara Airoldi

28. 28

29. Vertical vs. horizontal integration Mental health COPDCancerCHD… GP Hospital Tertiary care 29

30. Manageable and disabling cases 30