1. Presentation title: 32pt Arial Regular, black Recommended maximum length: 1 line International efforts to improve quality, reduce costs and increase transparency On the theme of “shift” in the National Health Service of England Helen Bevan Bipartisan Congressional Health Policy Conference

2. How did we spend our healthcare resources last year? Acute care £45bn Primary care £15bn Social care £12bn Total expenditure: £72bn ($138bn) Social care £12bn Primary care physicians and other primary care (including drugs) £15bn Community care £10bn Mental health £7bn Elective and ambulatory (outpatient) £12bn Non-elective and critical care £14bn Accident and emergency, Out of hours, emergency transport £3bn

3. How did we spend our resources last year? Expenditure 2005/06 Total: £72bn ($138bn) Social care £12bn Primary care physicians and other primary care (including drugs) £15bn Community care £10bn Mental health £7bn Elective and ambulatory (outpatient) £12bn Non-elective and critical care £14bn Accident and emergency, Out of hours, emergency transport £3bn 75% 25%

4. How will this change in future? Expenditure 2005/06 Total: £72bn ($138bn) Social care £12bn Primary care physicians and other primary care (including drugs) £15bn Community care £10bn Mental health £7bn Elective and ambulatory (outpatient) £12bn Non-elective and critical care £14bn Accident and emergency, Out of hours, emergency transport £3bn 75% 25% 70% 30%

5. The 2006 White Paper represents an ambitious new direction better prevention services with earlier intervention a greater proportion of care outside of hospitals and in the home more support in the community for people with long term needs more choice and a louder voice for service users tackling health inequalities and ensuring access to high quality care for all integration between health and social care

6. Shifting location, process and provider of care focus on treatment professionally driven care care in specialist hospital settings assume care will be provided by a doctor variation in access, clinical quality, resource utilisation focus on prevention and early intervention patient-driven care and self-care care in local community settings assume care will be provided by a professional with the right skills high quality, cost effective care for all fromto

7. Quality and Outcome Framework: reward and incentive programme for General Practitioners Established in 2004 as a core component of the new GP Contract around 30% of a GP’s compensation package voluntary 8,500 practices, covering 53 million patients at level of practice, not individual GP via Quality Management and Analysis System

8. Quality and Outcome Framework: reward and incentive programme for General Practitioners Covers 4 domains: Clinical: 76 indicators in 11 areas: coronary heart disease; left ventricular dysfunction; stroke and transient ischaemic attack; hypertension; diabetes; pulmonary disease; epilepsy; hypothyroidism; cancer; mental health; asthma. Worth up to 550 points Organisational: 56 indicators in 5 areas: records and information; patient communication; education and training; medicines management; clinical and practice management. Worth up to 184 points Patient experience: 4 indicators in 2 areas: patient survey and length of time with the doctor. Worth up to 100 points Additional services: 10 indicators in 4 areas: cervical screening, child health surveillance; maternity services; contraceptive services. Worth up to 36 points

9. Quality and Outcome Framework: examples of points availability in clinical domain Disease registers – maintaining a high quality disease register for each disease category (2-6 points) Asthma – percentage of patients aged 8 and over diagnosed as having asthma with measures of variability or reversibility (6 points) Depression – in those patients with a new diagnosis of depression in the previous year, the percentage who have had an assessment of severity (appropriate to primary care) at the outset of treatment (25 points) Mental health – percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review, there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status (23 points) Stroke – percentage of patients who have had a stroke or TIA in whom the last blood pressure reading (in the last 15 months) is 150/90 or less (5 points) World class clinical database

10. Quality and Outcome Framework: results from the first 2 years Average points per practice No. of practices scoring the maximum 1,050 points Average score in the clinical domain (of 550 available) 2004/5 2005/6 958.7 (91.3% of available total) 1,010.5 (96.2%) 222 (2.6% of total) 813 (9.7%) 507.7 (92.3%) 534.2 (97%)

11. GP compensation average salary from NHS <$200,000 significantly higher than average NHS salary for hospital specialist GPs have had 40% increase in compensation in 2 years

12. Case study one: supporting people with long term conditions in the county of Cornwall People with long term conditions who are at “high risk” are proactively supported in the community by nurses with advanced skills who: work as part of the primary healthcare team refer patients directly to specialist doctors in hospitals order diagnostic investigations prescribe medicines and treatments As a result: 50% reduction in hospital admissions for this group growth in emergency admissions down from 9% to 1% (-3% in over 75s) 72% reduction in no. of visits this group made to their primary care physicians 61% reduction in home visits 42% reduction in contacts made with the emergency primary care (“out of hours”) service higher patient satisfaction, more “joined up” care, better quality, lower costs

14. Case study two: East Midlands Ambulance Service “avoidable admissions” project Aim to reduce unnecessary hospital admissions amongst patients who dial 999 but who do not have a life-threatening condition Action “core” ambulance crews who answer 999 calls were replaced with paramedics with advanced skills (“emergency care practitioners” - ECPs) As a result: 60-70% reduction in the proportion of patients taken to hospital and subsequently admitted a largely elderly group of patients avoid the trauma and knock-on consequences of hospital admission no increase in risk; no decrease in patient satisfaction and significant cost saving from hospital admissions avoided In addition: scheme set up with British Red Cross Society to enable ECPs to call in trained volunteers to watch patients in their homes overnight until they see the GP the next day

15. Quality and outcomes framework + champions prevention and quality based on evidence creates good practice across the system: –high compliance –low variation quality of local and national database – basis for decision making moving towards longer term health and well-being outcomes – the bar is rising foundation for shift to primary care and other policy directions enables role redesign and other new ways of working - underestimate of baseline performance rise in GP compensation administrative workload GPs taking a higher proportion of practice income as personal income question some indicators – not stretching enough – not high impact – need to move to more outcome focused measures focuses on only a minority of patients