4. Great innovations of the first and second healthcare revolutions MRI and CT scanning Statins Antibiotics Coronary artery bypass graft surgery & stents Hip and knee replacement Chemotherapy Radiotherapy Randomised controlled trials Systematic reviews The First The Second

5. - But all health services, world wide, still face 5 major problems- FAILURE TO PREVENT PREVENTABLE DISEASE INEQUITY PATIENT HARM, EVEN WHEN QUALITY IS HIGH WASTE OF RESOURCES UNWARRANTED VARIATION IN – ACTIVITY – QUALITY, SAFETY – OUTCOME & COST = VALUE AND THERE IS AN ICEBERG AHEAD

7. Phone Knowledge Citizens the Third Healthcare Revolution is already underway the Third Healthcare Revolution will come out of the barrel of the Smartphone

8. Population Based Systems Focus on value Engage patients Change culture New Paradigm Healthcare

9. There are two perspectives on value 1. the patient’s perspective 2. the population perspective there are two types of value for populations 1. allocative 2. technical

10. Cancer Musculoskeletal Gastro- intestinal Mental Health Between Programme Marginal Analysis and reallocation is a commissioner responsibility with public involvement

11. Cancers Musculoskeletal Gastro- intestinal Mental Health Many people have more than one problem ; GP’s are skilled in managing complexity

12. Cancers Musculoskeletal Gastro- instestinal Prevention Inflammatory Multiple Joint disease Back pain Within Programme, Between System Marginal analysis is a clinician responsibility Hip & Knee Upper limb

13. Cancers Musculoskeletal Gastro- instestinal Prevention Inflammatory Multiple Joint disease Back pain Within System Marginal analysis is a clinician responsibility With patient involvement Hip & Knee Upper limb Partial Knee Arthro- scopy/ ligaments Total Knee

14. Value = Outcomes / Costs Outcome = Good – Bad Outcome= Effectiveness (EBM +Quality) – Harm (Safety ) Costs = Money + time + Carbon Costs = Opportunity Lost

15. Rate of anterior cruciate ligament reconstruction expenditure per 1000 population by PCT Weighted by age, sex, and need; 2008/09 The variation among PCTs in the rate of expenditure for anterior cruciate ligament reconstruction per 1000 population is 50-fold.

16. The law of diminishing returns Benefits Investment of resources

17. Harmful effects increase in direct proportion to the resources invested Harmful or Side effects Of care Investment of resources

18. After a certain level of investment the health gain may start to decline; the point of optimality Benefits Investment of resources Harms Benefits - harm

19. Evidence The values this patient places on benefits and harms of the options The clinical condition of this patient; other diagnoses and risk factors and their social circumstances Choice Decision The patient’s perspective Value based and shared decision making

20. As the rate of intervention increases the balance of benefit and harm changes for the individual patient Low High Rate of Intervention Benefit than can be expected Probability and magnitude of harm

21. The Healthcare Archipelago

22. GENERAL MENTAL PRACTICE HEALTH COMMUNITY HOSPITAL SERVICES

23. The Healthcare Archipelago PRIMARY SECONDARY COMMUNITY ACUTE SERVICES

24. SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST

25. SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST Fractured Tibia

26. SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST People With Long Term Knee Pain

27. BetterValueHealthcare A SYSTEM is a set of activities with a common set of objectives and an annual report. Systems can focus on symptoms, conditions or subgroups of the population (also known as a service) A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation) A PATHWAY is the route patients usually follow through the network A PROGRAMME is a set of systems with ha common knowledge base and a common budget

28. BetterValueHealthcare Is epilepsy care in Herefordshire better than epilepsy care in Derbyshire? Who is responsible for the service for people with back pain in Northumberland? Did the service for people who are inflammatory arthritis in Luton improve last year? How many knee replacement services should there be in England and is that different from the number of services for inflammatory bowel disease or rheumatoid arthritis ? NHS or nHS?

29. This is an example of a national service set up as a system

30. BetterValueHealthcare OBJECTIVES FOR AN ASTHMA SYSTEM To prevent asthma To diagnose asthma quickly and accurately To slow the process of the disease by effective and safe treatment To help the individual afflicted adapt to the challenges To involve patients, both individually and collectively, in their care

31. BetterValueHealthcare To prevent asthma To diagnose asthma quickly and accurately To slow the process of the disease by effective and safe treatment To help the individual afflicted adapt to the challenges To involve patients, both individually and collectively, in their care To make the best use of resources To mitigate inequity To promote and support research To support the development of staff To report annually to the population served

33. BetterValueHealthcare Hierarchy Network

34. Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and provided evidence based, patient centred care, and to improve effectiveness, productivity and safety

35. Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit ; she needs to practise population medicine

36. All people with the condition People receiving the specialist service People who would benefit most from the specialist service

37. Dr Jones, the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources (1 day a week and support ) for Network development Localisation of the Map of Medicine Quality of patient information Professional development of generalists, and pharmacists Production of the Annual Report of the service She is keen to improve her performance from being 27 th out of the 106 COPD services, and of greater importance, 6 th out of the 23 services in the prosperous counties

38. SYSTEMS FACILITIES CANCER RESPIRATORY MENTAL HEALTH STROKE FRAIL ELDERLY CHILDREN IT REAL ESTATE FINANCE TRANSPORT HR F F Chief Accountable Officer

39. BetterValueHealthcare “Culture… the shared tacit assumptions of a group that it has learned in coping with external threats and dealing with internal relationships. Schein, E.H (1999) The Corporate Culture Survival Guide Leadership … and a company’s culture are inextricably interwined. Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System www.ocht-glossary.net ”

40. BetterValueHealthcare IF YOU ASKED EVERY KEY PERSON TO WRITE DOWN THE MEANING OF Equity, and how it differs from Equity Quality, of care & how it differs from Value Efficiency, and how it differs from How consistent would be the response?

44. BetterValueHealthcare Map of Medicine - COPD Work like an ant colony; Neither markets nor bureaucracies can solve the challenges of complexity

45. Paradigm Shift 26/6/12 after information standards meeting 21 st Century Care Patient-centred Citizen as co-producer of wellbeing Focus on prevention, care & harm Reduce waste and increase value Equitable care for populations Focus on systems Pluralistic networks Driven by knowledge Low carbon usage Challenges met by transformation 20 th Century Care Clinician-centred Patient as passive complier Focus on cure and effectiveness Increase quality Good care for known patients Hospital as focus Public sector bureaucracy Driven by finance High carbon usage Challenges met by growth