1. Philip DaSilva – Co-Founder NHS RightCare Odense - Denmark June 2015
Understanding Variation – Increasing Value
The Right Care Programme - Transforming Health Care by Exploring Medical Practice Variation – Does it work?
Philip DaSilva – Co-Founder NHS RightCare
Odense - Denmark
June 2015

2. Understanding Variation – Increasing Value
This Session will Cover: A brief overview of the NHS in England What is the Problem with Variation? Why is it Important to respond? The Genesis of the RightCare Programme Good Data Delivers Change Case Studies

3. A Brief overview of the NHS in England
Themes: Reform(s) Market Principles – Commissioning & Providing Evolving Structures but Static Organisations 5 Key Challenges Never Forget your Patients & Population

4. Is it All about the Structure?

5. When I Last Looked……

7. The NHS, as do most countries, faces 5 key challenges:
There is no new money – Tightening Budgets
An aging population and rising demand for healthcare
A service that is frequently “dis-integrated” with patients transferred between care providers
Inequity
Widespread variation in healthcare in terms of quality, activity and outcomes

8. The Curse of Variation Who Decides the classification?
What is the Problem with Variation?
The Curse of Variation Who Decides the classification?
Is it really a Problem – to who?
Is it just a Challenge for England?
Data driven Decision Making

9. The New Show in Town?
Variation is not a new phenomenon – it has been highlighted as an issue since the beginning of the NHS in 1948….
indeed it has been around since Glover’s seminal paper in 1938……
Many articles and commentators have put the story together….
….but it continues to puzzle policy makers, politicians, professional and our patients.

10. The Good The Bad & The Unknown
We need to remember that not all variation is bad (Mulley 2009) ……
if it were all bad it may be easier to resolve.
The view of variation as either being good or bad does not help……we need to distinguish between that variation which is common cause or random and that which is unwarranted leading to a waste of resources, duplication of effort, poor quality and lower value health care.

11. Wennberg’s Framework to Explore the Root of Variation
EFFECTIVE CARE
SUPPLY - SENSITIVE CARE
PREFERENCE - SENSITIVE CARE
Effective Care – which is based on the assumption of evidence, based interventions where the benefits of the intervention can be demonstrated to outweigh the perceived harms, a good example is immunisation of school children where as close to 100% rate is considered effective, but variations reveal some areas not achieving that rate.
Supply-sensitive care – refers to that area of variation where supply of a specific resource has an influence on utilisation rates, often due to differences in local supply of health care resources and incentivisation processes.
Preference-Sensitive Care - which reflects the choices made by well-informed patients and is related to patient’s choices and appreciation of the benefits/harm of particular interventions and how the individual’s attitudes towards outcomes may vary.

12. Is variation only the curse of the NHS in England?

13. The Answer is NO……Many countries are facing the same challenge, to identify and reduce unwarranted variation in their health care system…….

14. So, why is it important to explore variation and identify unwarranted variation?
So that we can do the right thing for the right patient at the right time
When organisations use the wrong data or don’t explore variation the resulting decisions often tend to increase costs, reduce quality and efficiency leading to lower value healthcare for both patients and the population.

15. The topic of variation and unwarranted variation requires better understanding and improved coordination through the application of technical, political and regulatory responses which are too important to leave to chance. ….
….only then can we begin to do the right thing for the right patient at the right time……. That was ground that the RightCare programme established itself..

16. Rising to the 5 key Challenges - An Introduction to the Right Care Programme
Building the Programme team
The Development of the Programme
Lessons from the Atlas of Variation
Atlas of Variation – Is it the only show in town?

17. A Transformation Programme to Increase Value & Improve Outcomes
RIGHT CARE
Population Planning
Commissioning for Value
Systems Thinking
Understanding Variation
The Four Domains of Right Care Programme

18. Design and Deliver Care through Systems – not organisations
Develop clinical focus on populations – including unidentified patient need
HIGHER VALUE = PERSONALISED AND POPULATION BASED CARE
LOWER VALUE =
BUREAUCRACY BASED CARE
Search for unwarranted variation – eliminate waste and duplication
Personalised care planning- shared decision making
Culture Change – Transformation Programme

19. Proof of Concept and Development
Right Care: The Road Map
Awareness and Agenda Setting
Local and National uptake
Spread and adoption
Develop the approach
Developing Capacity
Population Healthcare
Un-warranted variation
Adapting to the System
Variation Knowledge Service
Developing CSUs
2 National Atlases of Variation
Evolved and rolled across Y&H PHO
6 Themed Atlases
Area Team CfV packs
Network/pathway based CfV packs
New Atlas Programme
Proof of Concept and Development
211 CCG CfV packs
HIPs
Derbyshire Pilot
CfV packs
Peer-to-Peer networking
Learning resources
Academic Collaborative
Commissioning for Value Insights
Academic underpinning
Increasing spread and adoption
Yr1
Yr2
Yr3
Yr4
Yr5

20. How to change What to change Where to look PRINCIPLES OF APPROACH BPE
Clinical Leadership & Engagement
AICS (manage, devolve, focus on outcome)
EVIDENTIAL DATA:
Service Reviews
Viability
Case for Change
INDICATIVE DATA:
Atlas of Variation
PBMA & SPOT

21. The NHS Atlases of Variation
Phase One - Where to Look
The NHS Atlases of Variation
Reducing unwarranted variation to increase value and improve quality
Awareness is the first step towards value.
If the existence of clinical and financial variation is unknown, the debate about whether it is unwarranted cannot take place. 21

22. 34 maps of variation 11 disease areas
First Atlas 2010
34 maps of variation 11 disease areas
Series now covers 7 themed Atlases & 3 Compendium (2015)
Interactive version:

23. Right Care - Delivering Better Value
Building a receptive culture
Right Care - Delivering Better Value
Shared Decision Making
Empowering patient decisions
Improved outcomes
Patient & Public Involvement
Right Care
Better Decisions
Better Value
Addressing variation:
Atlas series
Identifying opportunities: CfV tools
Insights packs
QoF CQUIN
Empowering population decisions
Improved Patient Experience
Knowledge Sharing Framework:
Who’s doing it now
Engagement tool: EG STAR Tools
Programme budget and
Outcome based commissioning
Commissioning Guidance
EG for elective Surgery

24. Useful Tools to Help….
Awareness is the first important step in addressing unwarranted variation; if the existence of variation is unknown, the debate about whether it is unwarranted cannot take place.
211 CfV packs & Pathways on a Page
27 pieces of surgical commissioning Guidance with FSSA and RCS
Shared Decision Making: 36 PDAs

25. Supporting the system

26. National messages from CfV packs
Across England, if all CCGs achieved at least the average of those CCGs similar to them:
Over 10,000 lives would be saved every year including 3,500 from heart disease and 2,500 from cancer
90,000 more women would be screened for breast cancer
200,000 more patients with hypertension and 80,000 more coronary heart disease patients would be identified early. They would benefit from earlier interventions including blood pressure and cholesterol testing
90,000 more COPD patients would be identified and there would be 30,000 fewer emergency admissions for respiratory conditions 33

27. Where West Cheshire are now (and where Bradford could be)

28. Where Bradford CCG are now (and where West Cheshire CCG were)…

29. Initial contact to end of treatment
Heart disease pathway
= 95% confidence intervals
Initial contact to end of treatment
NHS Bradford City CCG

30. Now, you may be hearing… “The data are wrong” “The data are old”
“Some of the data are for PCTs”
“We’ve already fixed that area”
The data is “indicative”, they do not need to be 100% robust to indicate that improvement is needed in an area, especially where more than one indicator (triangulation) suggests the same.
The data are the most recent available.
Have you done anything since to improve the pathway?
If not, the opportunity remains and, if others have improved.
CCG data are used wherever they are available.
If you think that your CCG population is different – determine where you should be on the comparator before concluding that you need not act.
Great news!
Double-check that the reforms have worked and move on to the next priority area identified by the indicators. 30

31. RightCare Helping Diabetics in Slough CCG
“The Right Care methodology has been successfully applied to the primary care management of diabetes in Slough” – Slough CCG Diabetes Lead
Following primary care pathway reform –
Of patients with pre-diabetes whose results are available for evaluation, 100% saw a reduction in their HbA1c levels
Of the patients with type 2 diabetes, 89% saw a reduction in their HbA1c levels
15 out of 16 practices showed an increase in the number of patients whose diabetes was controlled
15 out of 16 practices saw an increase of patients whose blood pressure was managed <140/80

32. RightCare Impact in Warrington – one more example of the programme
2010/11 –
£1.5M OVER spending V. demographic peers
Only 2/3s of asthmatics known
Worst quintiles – COPD rate of emergency admissions, deaths within 30 days of admission, readmission rate high
2012/13 –
£0.6M UNDER spending V. demographic peers
Delivered by focus on variation – problems fixed or improving (e.g. 30% less COPD admissions, MDT focus, increased triage for care away from acute sector)
HSJ Commissioner of the Year! 33

33. How does searching for Variation Transform Care?
The indicative data revealed that if NHS Hardwick could deliver respiratory care that was ‘at least equivalent to the national average’ then circa £884,000 of resources could be released for investment in higher value health care…..

34. THE NEW MODEL
INCREASING VALUE
POPULATION FOCUS
REFERRRED PATIENTS
MOST IN NEED
MOST SEEN & KNOWN

35. The Situation we found
Patient as passive complier
Focus on treatment
Short term aim to improve quality
Good care for known patients
Hospital as the focus
Plans driven by finance
Challenges met by waiting for growth
RightCare Principles
Citizen as co-producer of wellbeing
Focus on prevention, care & reducing harm
Reduce unwarranted variation and increase value
Equitable care for populations
Focus on systems
Driven by knowledge
Challenges met by transformation, releasing resources to invest in higher value health care.

36. THE NEW MODEL
INCREASING VALUE
POPULATION FOCUS
REFERRRED PATIENTS
MOST IN NEED
MOST SEEN & KNOWN

37. DETAILED CASE STUDY: From Plan to Delivery
The data was showing.. as highlighted in the Indicative data (NHSE Commissioning for Value pack, October 2013) that the top opportunity for Hardwick CCG was Respiratory Care.
a predominately deprived area with a 102,000 population
a CCG with high prevalence of chronic obstructive pulmonary disease…. with many individuals un-diagnosed
A lower than average number of patients correctly diagnosed with COPD
AND the respiratory pathway was dependant upon hospital care with too many patients admitted for urgent and unplanned care leading to a longer length of stay and higher number of readmission rates

38. Service Review Pathway – Diagnostic steps
Step 1 – define:
Step 2 – define:
Step 3 –
categorise:
Step 4 –
recommend:
CURRENT
SERVICE
FUTURE
SERVICE
Fit for
Purpose
Fit for
Purpose
Maintain
Efficiency
and
market
options
Efficiency
and
market
options
Redesign,
Contract,
Procure
Supply
and
capacity
options
Supply
and
capacity
options
Contract,
Procure,
Divest
No/ low
benefit
Divest

39. CASE STUDY: Plan to Delivery in 7 months –
Now implementing –
Agreed and specified COPD pathway
Enhanced nebulisers service in primary care
Primary care COPD audit and support service to implement findings practice by practice
Improved promotion of self-management
Improved self-management support
Enhanced organisation of Breathe Easy Groups (with British Lung Foundation)
Delivered (so far – only just begun) –
30% reduction in emergency admissions

40. RIGHTCARE: Next Steps –
Exploring Variation & Highlighting unwarranted variation in quality, outcomes, activity and spend
Empowering patients through shared decision making
Engaging clinicians and commissioners to shift from “rationing” to “rational commissioning”
Focus is on allocative efficiency and technical
efficiency i.e. doing the right thing as well as doing
things right.

41. The primary objective for Right Care is to maximise value
the value that the patient derives from their own care and treatment
the value the whole population derives from the investment in their healthcare
To successfully increase value for both patient and population, health service reform must integrate both in an single model; separately, they become opposing imperatives

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43. Questions & Discussion