1. Copyright 2011 Right Care Delivering High Value Pathways Standard versus Optimal – A typical Long-Term Conditions story and how the NHS Right Care approach can help to achieve optimal Professor Matthew Cripps National Programme Director, NHS Right Care Dr Peter Brambleby, Independent public health consultant & Right Care Associate Mr. Anthony Lawton – Right Care Associate

2. Five Key Ingredients: 1.Clinical Leadership 2.Indicative Data 3.Clinical Engagement 4.Evidential Data 5.Effective processes 1 key objective + 3 key phases + 5 key ingredients = COMMISSIONING FOR VALUE 2 OBJECTIVE - Maximise Value (individual and population)

3. 3 Commissioning for Value - Slough CCG

4. 4 Granularity – Population to Patient Where to LookHow to Change SDM Care Planning Manage care out of hospital CfV Pack Atlas Programme Budgets Populations Systems What to Change Individuals Deep Dive Path- way Provider

5. 5 Paul’s story – Journey 1 Paul: 45, bricklayer, local employer Smokes 10/day, drinks 4 pints/day, overweight Council house, supports Leeds United Wendy: 42, barmaid David: 16, schoolboy GP: small practice, 17 miles from DGH Village shop: limited food options

6. 6 Paul’s journey starts when ….. Prompted by Wendy, sees his GP  2 years of increased urinary frequency and loss of energy  GP performs tests and confirms diabetes  Initial management with diet, exercise, pills  6 visits per year to practice nurse  6 lab tests per year  GP has lower than average prescribing and referral rates – seen as economical

7. 7 Context & Variation

8. 8

9. 9 In the local population, who has overall responsibility for:  Preventing diabetes?  Raising awareness and screening for diabetes?  Quality assurance of diabetes care?  Getting best value for money from the investment by caring agencies in diabetes?

10. 10 Paul is now 50  Not smoking but still drinking and has not lost weight; recreation is watching football and pub  Has been on insulin for a year  Left leg hurts (vascular problem)  Not walking far, not driving, missing work  Referred to hospital diabetes service and vascular surgeon – OPD at hospital  Wendy drives him  David is at university

11. 11 Spot Tool

12. 12 Paul is now 52  Leg suddenly goes white and painful; amputated below knee  Significant heart and renal complications  Vision deteriorating  Loses his job with little chance of retraining  Applies for more suitable housing  Wendy gives up job  David takes a year off university

13. 13 The Impact (Economic and Social) – Journey 1

14. 14 The Economic Impact during 3 of those 11 years

15. 15 Paul’s story: What the CCG have done – Commissioning for Value  CCG have used CfV pack, identified Diabetes as a key improvement priority  Worked with AT and neighbouring CCGs to ensure wider system improvement (whilst not allowing this to slow progress for their own population)  Engaged the right people, conducted a deep dive and service review, identified what needed to change, built the case, took the decisions and implemented the change  What does the next Paul’s journey look like now?

16. 16 Paul’s story - Journey 2  NHS Health Check identifies Paul’s condition at the end of year 1 – Case management begins…  Use of specialist clinics for advice on diet and exercise (10x cost of GP advice) and this repeated every 2 years  Care Plan / Medication / Retinopathy Screening brought forward 18 months compared to Journey 1  Self Management – Desmond Programme  Diabetes Patient Support Group set up locally

17. 17 The Impact (Economic and Social) J2

18. 18 Discussion Points  Type two diabetes is a largely preventable disease caused, and controlled, by lifestyle  Better “vertical” integration (along the clinical pathway) and “horizontal” integration (between the parties) could improve outcomes and save substantial costs  Who should take the initiative for the individual and for the population?

19. 19 Granularity – Population to Patient Where to LookHow to Change SDM Care Planning Manage care out of hospital CfV Pack Atlas Programme Budgets Populations Systems What to Change Individuals Deep Dive Path- way Provider

20. 20 CURRENT SERVICE FUTURE SERVICE Fit for Purpose Efficiency and market options Supply and capacity options No/ low benefit Step 1 – define: Step 3 – categorise : Step 2 – define: Redesign, Contract, Procure Contract, Procure, Divest Step 4 – recommend : Maintain Divest Service Review Pathway – Diagnostic steps Fit for Purpose Efficiency and market options Supply and capacity options

21. 21 Respiratory Care in Warrington Health Economy 2010/11 – £1.5M Overspending V. demographic peers Only 2/3s of asthmatics known Worst quintiles – COPD rate of em admns, deaths within 30 days, %age receiving NIV, re-admns 2012/13 – £0.6M UNDER spending V. demographic peers Delivered by focus on variation – problems fixed or improving (e.g. 30% less COPD NEL admissions, MDT, 70+ p.m. triaged away from acute sector) HSJ Commissioner of the Year

22. 22 Where Bradford are now (and where West Cheshire were)…

23. 23 Where West Cheshire are now (and where you could be)…

24. 24 Number of Circulatory indicators in the bottom quintile of the practice cluster Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive comparison of performance. Each coloured bar represents a different set of indicators e.g. dark blue is prevalence. The specific indicators are then shown in the table on slides 21-27 for the 3 practices with the highest total number of indicators in the bottom quintile 1 Galvanising Clinicians – On the right things

25. 25 Change the clinical perspective Dr Jones is a Derby-based respiratory physician. Last year she saw 346 people with COPD and provided evidence based, patient centred care

26. 26 All people with the condition People receiving the specialist service She 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 from the knowledge of her team People receiving the service People who would benefit most from the service

27. 27 Dr Jones is given a day a week for Population Respiratory Health and the local COPD Network and Service helps her to increase population value by:  Working with Public Health to reduce smoking  Network development  Improving the quality of patient information  Professional development of all system staff (e.g. nurse educators)  Production of the Annual Report of the service

28. 28 Work through the phases and Commission for Value Where to LookHow to Change SDM Care Planning Manage care out of hospital CfV Pack Atlas Programme Budgets Populations Systems What to Change Individuals Deep Dive Path- way Provider

29. 29

30. 30 Where can I find out more? The Powerpoint presentation you have seen today, an excel spreadsheet with the underlying data is available on the Right Care website You will also find there links to short online learning videos on the Right Care approach and links to some of the tools and packs mentioned in the presentation Email Feedback or questions to rightcare@nhs.netrightcare@nhs.ne Or Visit and follow the link www.rightcare.nhs.uk/paul_adams

31. 31 For more information – contact the team Professor Matthew Cripps - National Programme Director, NHS Right Care Email: rightcare@nhs.net Dr Peter Brambleby, Independent public health consultant, Email: p.brambleby@btinternet.comp.brambleby@btinternet.com Mr. Anthony Lawton – Right Care Associate Email: Anthony.Lawton@ffmi.co.ukAnthony.Lawton@ffmi.co.uk Jules Gaughan - Right Care Associate Email: juedrop@me.comjuedrop@me.com Mr. Ian McKinnell - NHS Right Care Email: ian.mckinnell@btopenworld.comian.mckinnell@btopenworld.com