1. Oldham Doing It Differently
Dr Hugh Sturgess
Director, Pennine MSK Partnership

2. Context New White Paper Deep seated failings in the NHS
Root and branch reform of NHS in England
Unprecedented financial challenge for NHS
Deep seated failings in the NHS
Model of Care
System of Care

4. What’s wrong with the system?
System of Care
“Disintegration!”
Micro-commissioning complex pathways
Perverse incentives – PbR
KPIs process driven not population level improvement or patient experience
No effective performance management of care

5. Variation in MSK Spend

6. Programme Budget Commissioning
Different from standard approach
Commission with the lead accountable provider for defined programmes of care with a defined budget
Commissioners have population quality based KPIs
Lead accountable provider shares responsibility for care co-ordination, quality and performance management across the entire pathway

7. One thing I have always found is that you have got to start with the customer experience and work backwards to the technology.
Steve Jobs

8. Patients want more involvement9

9. Analysis: Satisfaction with Total Knee Replacement (NJR)
Satisfaction questions were completed by 8095 patients
Overall
- 81.8% were satisfied
- 11.2% were unsure
- 7.0% were not satisfied
The OKS varied according to patient satisfaction (p<0.001)
Source: National Joint Registry

11. Challenges Lack of faith in new system
Lack of interest/support from grass root GPs
Dismantle existing systems
Financial instability
Threat of competition
Ageing population, more expensive treatments, increasing co-morbidities and LTCs
Lack of integrated care
Much spoken of – hardly ever delivered
Need to shift investment from Acute trusts to community and primary care

12. Oldham

13. Pennine MSK Partnership
Primary Care based organisation commissioned by NHS Oldham to provide non admitted care in rheumatology, orthopaedics and chronic pain
Consultant led – provide 97% rheumatology and take patients to point of listing in Orthopaedics
From May 2011 control £23m programme budget for MSK using prime vendor model
Psychological medicine for chronic pain
11,000 new referrals a year
Deliver traditional hospital based services from community – biologics and infusions
GP and Specialist training
Research

14. COMMUNITY MULTIDISCIPLINARY SPECIALIST SERVICE (Pathway Hub)
Primary care holistic assessment and care
COMMUNITY MULTIDISCIPLINARY SPECIALIST SERVICE (Pathway Hub)
Prime contractor
Highly specialised, intensive, episodic hospital care
Referral triage
SUBCONTRACTING
Hub functions:
Skilling up 1’ care
Specialist Assessment
Specialist integrated care
Shared Decision Making
Personal Health Planning
Supported Self Care
Patient & carer support
Voluntary sector provision
PATHWAY MANAGEMENT
Referral

15. NHS Oldham Programme Budget
MSK - £23m - Pennine MSK 1st May 2011
Primary Care
Local enhanced services
Community Care
Pennine MSK
Physiotherapy, podiatry
Secondary Care
All activity included

16. Outcomes Of Programme Budget
We are incentivised to performance manage the entire pathway
Invest in Shared Decision Making and Self Management
Work with primary care to reduce variation
Work with secondary care to ensure best practice is followed
Work with commissioner – high value care within budget

17. Delivering Integration
Commissioner will focus on clinical outcomes rather than process metric
Patients at the centre of our redesign
Work with third sector
Use self management and self referral were clinically appropriate

18. Challenges and Opportunities
Acute Trust attitude
Change in commissioning
Financial constraints
GP support
Initial suspicion
Wider support as triage spreads to all referrals
Clinician support

19. Listing – after choice – 18 week compliance by week 7
Knee Pathway (O/A)
Triage of Referral within 24 hours on CaB – Signpost patient to NHS PDAs
Face to face assessment ESP with 2 weeks with diagnostics – telephone FU if needed
Listing – after choice – 18 week compliance by week 7

20. Shared Decision Making
Tested and Implemented the AQuA model past 2 years
Looked at impact of implementing SDM on patient reported outcomes for those who have had knee arthroplasty, year before implementation compared to the two years since
Already know SDM results in patient expectations being more realistic
High dissatisfaction in knee arthroplasty (19% of patient ambivalent about or regret surgery)
Joint project with NHS England

21. Shared Decision Making Implementation
Developed and trialed the NHS patient decision aids
Staff training
Organisation changes – standard board reports, staff induction, measuring decisional conflict
Patient empowerment – Ask three questions
AQuA collaborative
All patients:
Given A3Q leaflets
Signposted to PDAs
All front line staff trained in SDM, many in Motivational Interviewing too

22. Better Health Outcomes
Used Patient Reported Outcome Measures (PROMs) data on EQ-5D index to show:
Oldham’s knee replacement patients received an average health gain of 0.27 in 2009/10 and by 2011/12.
A statistically and clinically significant increase in Oldham’s patients health outcomes.
The England average health gain was 0.30 throughout the period.
Period of improvement matches the introduction of SDM.
Involving patients in decision to treat appears to lead to better outcomes.
Treated increasingly sicker patients in Oldham, but restored to same good health level.
Improvement delivered within financial constraints in period with:
Arthroscopies growing at 8% in Oldham compared to 12% nationally.
Musculoskeletal spend per head decreasing by £10 in Oldham compared to an increase of £10 nationally.

23. Reducing per capita cost whilst maintaining quality
Pennine MSK Impact
Reducing per capita cost whilst maintaining quality

24. Reducing per capita cost whilst maintaining quality
Pennine MSK Impact
Reducing per capita cost whilst maintaining quality

25. Thank You
Dr Hugh Sturgess Tel: Mob: