1. Commissioning for Value Focus Pack
Clinical Commissioning Group:
NHS Northern, Eastern and Western Devon CCG
Focus Area:
Mental Health
August 2015 version 1.1

2. What is a “Deep Dive” pack?
The first Commissioning for Value packs - released in October clearly showed CCGs and area teams ‘where to look’ as a first stage to identify real opportunities to improve outcomes and increase value for local populations.
The ‘Pathways on a Page’ packs – published in November 2014 – provide in depth data for 13 patient conditions, within those programmes that were most commonly identified as offering the greatest potential improvements in the first pack.

3. What is a “Deep Dive” pack?
Deep Dive packs further examine areas chosen by the CCGs, using the latest 2013/14 data in order to gain a deeper understanding of issues within specific programmes of work or clinical pathways - What to change.
The packs are produced by Arden & GEM CSU analysts working with consultants in public health medicine from Solutions for Public Health (an NHS enterprise hosted by Arden & GEM CSU).
The packs continue to follow the right care methodology and are designed to support the principles of the national Commissioning for Value programme –

4. Contents Background and context Aims of the packs - Slide 5
Packs as part of transformation process Slide 5
Methodology
Analysis methods Slide 7
CCG Benchmarking and Opportunities Slides 8-10
CCG Analysis
Mental Health – the context for the deep dive analysis - Slides 11-12
Summary messages for pathway stages:
Prevalence Slide 13
Management in Primary Care Slide 14
Management in Secondary Care Slide 15
Opportunity table for indicators in the ‘worst’ quintile of benchmark group - Slides 16-17
Top financial opportunities table Slide 18
Bringing it all together, National Guidance Slide 19
Annexes
Annex 1 – Spine charts Slides
Annex 2 – CCG Cluster Classification Slide
Annex 3 – Indicator List Slides
Glossary Slide

5. Background and context
Aims of the Packs:
The Commissioning for Value phase one packs, produced by NHSE, PHE and NHS Right Care, included an offer to work with CCGs to develop this Focus Pack, or ‘deep dive’. The first packs – released in October 2013 – clearly showed CCGs and area teams ‘where to look’ as a first stage to identify real opportunities to improve outcomes and increase value for local populations. The ‘Pathways on a Page’ packs – published in November 2014 – provide in depth data for 13 patient conditions, within those programmes that were most commonly identified as offering the greatest potential improvements in the first pack. The deep dive uses the latest data available and looks at an agreed programme area to understand variation across the pathway. Working with local intelligence teams, the deep dive will look to identify opportunities for improvement and support the CCG's discussion on methods of improving clinical pathways. Further support is available to use and explore the intelligence in this pack.

6. Background and context
How these Packs Support Service Improvement
NHS England ‘Pathways on a Page’ packs
Arden & GEM
‘deep-dives’ and service reviews

7. Methodology:– Analysis Methods
Analysed wide range of indicators from across the pathway focusing on risk factors, spend, primary and secondary care usage and quality
Identified ‘cluster groups’ of 25 CCGs with similar characteristics to the CCG (see slide 31)
Analysed wide range of national benchmarked data (2013/14 where possible) to identify indicators where CCG is below the average for its CCG cluster group
Identified indicators where CCG is in ‘worst’ quintile within its cluster group
Identified opportunities for value improvement and quantified potential impact:
Listed all the indicators where CGG is significantly below average for CCG cluster
Quantified opportunity for indicators in ‘worst’ quintile moving to the CCG Cluster average
Quantified additional opportunities for indicators moving to the top 20% for the CCG Cluster
Quantification does not mean that the ‘saving’ or improvement can actually be made, but may however answer the question ‘Is it going to be worth focussing on this area?’
Reviewed national evidence base to identify potential interventions linked to opportunities
Pulled together examples of ‘what works’ against ‘opportunity’ areas across the pathway

8. Methodology:– What do we mean by ‘worse’?
In this pack we often describe the CCG’s indicator as ‘better’ or ‘worse’ than the benchmark value. Sometimes it is clear that being an outlier in a particular direction really is ‘worse’. For example, high mortality is obviously worse than low mortality.
Sometimes it is less obvious whether being an outlier in a particular direction really is ‘worse’, especially when the indicator reflects NHS activity or spending. For example, if a CCG spends more than the benchmark average on joint replacement surgery, is that ‘better’ or ‘worse’ than average? In terms of financial pressure on the CCG it is ‘worse’, but if all the operations are being done on the right patients at the right time, the CCG may be clinically ‘better’ than average. Additional indicators that measure the clinical outcomes of surgery will help to interpret the finance and activity indicators.
For brevity, in this pack we describe an indicator as ‘worse’ when the CCG has higher activity or spend than the benchmark average. Whether it is truly ‘worse’ is something we will explore during our workshop.

9. Methodology:– CCG Benchmarking and Opportunities
CCGs are compared to a cluster group containing 25 CCGs. These are the other CCGs in England which have the most similar demographics to your own e.g. total population, age profile, deprivation, ethnicity and population density.
We adopt two different perspectives when selecting indicators that are worth focusing on. In the first perspective we ask ‘Which CCG indicators are definitely outliers compared with the benchmark group average?’. In the second perspective we ask ‘Which CCG indicators point to the greatest potential financial savings if the CCG were to move to the benchmark group average?
Both perspectives are important. The first perspective ensures we avoid focusing too much on ‘outlier’ indicators that may just reflect a one-off bad year, by using statistical significance testing. The second perspective ensures that we take a thorough look at all indicators where there may be large potential savings, even if we are less sure whether the ‘outlier’ indicators just reflect a one-off bad year.

10. 2. Methodology – CCG Benchmarking and Opportunities
Only indicators which are significantly different from the benchmark are shown in the table (slides 16-18), i.e. if the 95% confidence intervals for your CCG and the benchmark average do not overlap then your CCG is an outlier.
Only indicators where the CCG’s value is significantly ‘worse’ than the benchmark are shown as an improvement opportunity. The table shows the improvement opportunity using both benchmarks, the average value for the Cluster and the ‘top quintile’ of your CCG’s cluster.
The improvement opportunities for each indicator which are worse and significantly different to the benchmark are shown in the tables. 

11. 3. Summary – Context for Deep Dive Analysis
The Commissioning for Value ‘Pathways on a Page’ pack highlighted that, compared to their comparator CCGs, NEW Devon CCG had:
Significantly higher prescribing cost/items for Mental Health
Significantly worse levels of management of MH patients in primary care
Significantly worse Mental Health Secondary Care admissions
Significantly worse Mental Health Secondary Care spend
Significantly worse Emergency admissions with mood affective disorders
Significantly worse Emergency admissions with schizophrenia and delusional disorders
Significantly worse Emergency admissions self-harm

12. 3. Mental Health – 2013/14 Deep Dive Analysis
If the CCG were to move to the benchmark group average, the following improvements would be seen:
£5M reduction in Mental Health Secondary care spend per 100,000 population.
£2.5M reduction in Mental Health Elective spend per 100,000 population.
£850K reduction in Mental Health Emergency spend per 100,000 population.

13. 3. Analysis Summary: Prevalence
4/4 indicators are statistically significantly ‘worse’ than the benchmark group average.
Prevalence of mental health is statistically significantly higher than the benchmark average.
Prevalence of dementia is statistically significantly higher than the benchmark average.
Prevalence of depression is statistically significantly higher than the benchmark average.
% reporting a long-term mental health problem

14. 3. Analysis Summary: Management in Primary Care
10/19 indicators are statistically significantly ‘worse’ than the benchmark group average – 7 of these are also in the bottom quintile of the cluster benchmark group (*)
Mental Health Disorders prescribing cost per 1000
Mental Health Disorders prescribing items per 1000
Patients on MH register with comprehensive care plan (MH 02) *
Patients on MH register who have a record of blood pressure (MH 03) *
Patients aged 40 years and over with SMI with record of total cholesterol:hdl ratio (MH 04) *
Patients aged 40 years with SMI with record of blood glucose or HbA1c (MH 05)
Patients on MH register who have a record of alcohol consumption (MH 07) *
Patients diagnosed with dementia whose care has been reviewed (DEM 2) *
Patients with a new diagnosis of depression with assessment of severity at the time of diagnosis *
% patients aged 18 or over with new diagnosis of depression who have been reviewed (DEP 02) *
Summary: Management in Primary Care

15. 3. Analysis Summary: Management in secondary care
11/17 indicators are statistically significantly ‘worse’ than the benchmark group average – 2 of these are also in the bottom quintile of the cluster benchmark group (*)
Mental Health Secondary care admissions per 100,000 population *
Mental Health Emergency admissions per 100,000 population *
Mental Health Elective admissions per 100,000 population
Mental Health Secondary care spend per 100,000 population
Mental Health Emergency spend per 100,000 population
Mental Health Elective spend per 100,000 population
Mental Health LOS (All admissions)
Mental Health LOS (Emergency)
Emergency admissions with mood affective disorders
Emergency admissions with schizophrenia and delusional disorders
Emergency admissions self-harm

16. 3. Analysis
CCG Indicators and Opportunities statistically significantly ‘worse’ than the average for benchmark cluster group
Indicators in ‘worst’ quintile of cluster group

17. 3. Analysis
CCG Indicators and Opportunities statistically significantly ‘worse’ than the average for benchmark cluster group
Indicators in ‘worst’ quintile of cluster group

18. 3. Analysis – Top financial opportunities against Benchmark Average
Indicators statistically significantly worse than benchmark average.
Indicators in ‘worst’ quintile of cluster group

19. 4. Bringing it all together – Where to focus, what could work, who should we speak to?
CCGs should consider what local intelligence is available to further triangulate with the intelligence in this pack. This may include:
Practice variation analyses
Reviewing referral protocols and guidelines
Analysis from Acute Trust quality dashboard or other provider data
Contract monitoring data
Next step is to move from intelligence to action
CCG needs to identify from the summary slides where to focus and what could work and which CCG may be an exemplar to follow

20. Annexes Annex 1 – Spine charts – Slides Annex 2 – CCG Cluster Classification – Slide 28 Annex 3 – Indicator List – Slides Glossary – Slide 32

21. Annex 1: Spine Charts

22. Annex 1: Spine Charts

23. Annex 1: Spine Charts

24. Annex 1: Spine Charts

25. Annex 1: Spine Charts

26. Annex 2: CCGs in Cluster group ‘nearest 25 CCGs’
The most similar CCGs to NHS Northern, Eastern and Western Devon CCG are:
For information on the methodology used to calculate the most similar CCGS please go to:

27. Annex 3: Full indicator list

28. Annex 3: Full indicator list (cont.)

29. Glossary
QOF Exceptions : Total exceptions across all management indicators
Spend and Admissions: The rate in terms of activity and Payment by Results (PbR) tariff based cost per 1000 practice population. Denominator data: Population based on GP list data. Numerator data: Count of completed spells and sum of PbR tariff.
DSR per 100,000: Directly age standardised rate calculated by taking the age-specific crude rates and applying them to the European Standard Population. Age-standardised rates take into account the variation in the age structures of populations
Emergency admissions with schizophrenia and delusional disorders: F20-F29
Emergency admissions with mood affective disorders: F30-F39
Emergency admissions Self-Harm: Underlying diagnosis of X60-X84
Emergency admissions Dementia: F00-F03