1. Commissioning for Value 24 th March 2015 Dr Stephen Liversedge NHS Bolton CCG

2. Commissioning for Value in Primary Care in Bolton Where we looked What we changed How we changed it Examples – CKD – At risk of Diabetes

3. Background Big Bolton Health Check 2007-2008 73,000 83% of population over 45 years Established ‘Triple Aim’ Industrial scaling, Systematically applied Transparent sharing of data Modest incentivisation Help, Education, and Support for practices

4. Where we looked Concentrated on 7 Health Outcome areas – CVD – Diabetes – Respiratory Disease – Mental Health – Child and Maternal Health – Cancer – Alcohol Peer CCG comparisons – Oldham, HMR, Tameside, Walsall Atlas of Variation, QOF data But mainly interrogation of Practice data – No exception reporting

5. Peer Cluster RED CLUSTER BME Ethnicity > 50%; High deprivation scores 42 -54 RED CLUSTER BME Ethnicity > 50%; High deprivation scores 42 -54 ORANGE and YELLOW CLUSTERS BME Ethnicity > 12%; Ranked on deprivation scores ORANGE and YELLOW CLUSTERS BME Ethnicity > 12%; Ranked on deprivation scores BLUE and GREEN CLUSTERS White; Ranked on deprivation scores BLUE and GREEN CLUSTERS White; Ranked on deprivation scores INDIGO CLUSTER White; low deprivation scores 6 - 20 INDIGO CLUSTER White; low deprivation scores 6 - 20

6. Primary Prevention of CVD

7. What we changed Individual practice performance when at variance to peers Atrial fibrillation registers – 3100 in 2009 – 3757 in 2011 Heart failure registers – 1579 in 2009 – 2096 in 2011 CKD registers AUDIT C programme – 96,363 completed Best care indicators – ‘Beyond QOF’ – CHD – Diabetes – COPD – Asthma – Heart failure – CKD

8. How we changed it Transparent sharing of Data Leadership Education programme - every month Practice visits - multiple LES schemes

9. Examples CKD – Early identification – Education – Pathway developed – Best care process Diabetes – Early identification – Education – Best care process – Prevention

10. CKD Prevalence

11. CKD prevalence

12. Register size Total with proteinuria Total without proteinuria QoF target BP 140/85 With proteinuria NICE target 130/80 With proteinuria NICE target 130/80 Without proteinuria NICE target 140/90

13. Best Care in CKD

15. NHS Bolton Nephrology Referrals per 1,000 patients March 2009March 2014 2.570.96

16. Actual Diabetes Prevalence in Bolton 16,725

21. Why work with IGT patients? Tsunami of Type 2 Diabetes on the horizon Patients with IGT are 5-10 times more likely to develop Type 2 diabetes In the absence of any intervention - 50% of IGT patients will develop Type 2 Diabetes in 5-10 years

22. Blood sugar/ HbA1c screening Coded as “at risk of diabetes” Total at risk register

23. IGT Project 2010-2011 A Small Scale Study 134 IGT patients 6 month comprehensive Health Trainer intervention Follow up GTT at 6 month sign off from intervention

24. Evaluation – 2010 IGT/at risk of diabetes (Small scale study) 2010 Sample size134 Follow up bloods – 2 hour blood sugar in Glucose Tolerance Test (GTT) 6 months Results Reverted back to normal 2 hour blood sugar in GTT47% Reduced 2 hour blood sugar in GTT18% Overall Improvements in 2 hour blood sugar in GTT65% No change in 2 hour blood sugar in GTT 7% Increased 2 hour blood sugar in GTT/developed diabetes28%

25. Other Achievements Weight Change Average weight reduction 2.75kg Weight change No.% No change1512 Weight gain2318 Weight loss8970 TOTAL127

26. Other Achievements Waist Measurement Average reduction in waist circumference 2.88cm Change in waist circumference No.% No change13 Increase2221 Reduction6966 TOTAL104

27. Other Achievements BP Average change in blood pressure of 5.1/2.1 mmHg

29. IGT/at risk of diabetes registers

30. Evaluation – 2013 IGT/at risk of diabetes (Small scale study 2013 Sample size134 Follow up bloods – HbA1c12 months Results Reverted back to normal HbA1c (≤38 mmol)42% Reduced HbA1c40% Overall Improvements in HbA1c82% No change in HbA1c14% Increased HbA1c/developed diabetes 4%

31. Supporting IGT/at risk of diabetes patients IGT register March 2014 – 19,989 Increasing demand on the Health Trainer Service Primary Care fully engaged – patients referred directly from GP or Practice Nurse Targeted lifestyle interventions involving weight loss strategies and dietary modification and/or physical activity are cost effective Estimated Cost - £123 per patient

34. The future Commissioning for Value in Primary Care The Bolton Quality Contract An investment of £3.4 million 19 standards including – Access – Prescribing – Demand Management – Health Improvement – Screening 40 KPIs including – Reduction in A/E attendances – Reduction in referrals – Reduction in follow-ups – Reduction in prescribing