Long Term Conditions: Long Term Conditions What’s wrong and what do we need?

©2009 . Private and Confidential

NHS East of England

Long Term ConditionsLong Term Conditions

What’s wrong and what do we need?

Dr Steven Laitner, Co-Chair, LTC Programme Board


A significant challenge

- 2 -

Source: “How cold will it be? Prospects for NHS funding 2001-17”, The Kings Fund, July 2009

Tepid

Cold

Arctic

£millions (2010/11 prices)

1. “ARCTIC” Real funding cuts (First 3 years: -2%, next 3 years, -1%)

2. “COLD” Zero real growth (0% every year)

3. “TEPID” Real increase (First 3 years: 2%, next 3 years, 3%)


•What’s the problem with LTC Care


HCC National

Patient Survey


….and

• 82% of those with an LTC want to do more self care

• 75% would feel confident about self care if they had more guidance/ support

• Half did not have a clear plan

• More than half had not been encouraged to self care

MORI


….and some quotes from our Service User Reference Group

“recognise the “patient” as an expert in themselves

“listen to us”

“don’t only concentrate on the clinical”

“be aware that management of the LTC is only a small part of my life”

“I want to be seen as a whole person”

“support us in seeing the same GP more than once!”

“stop using language and knowledge as a barrier”

“come down to our level”

“speak to me with respect”

“ don’t give too much information in one go”


What’s the problem – care model?

• An overly medical and paternalistic model

• Insufficient personalisation, support for self care or Informed Decision Making

• Variable service quality and customer experience

• Lack of integration:– Generalist and specialist care

– Physical and mental health

– Medical and nursing, therapy

– Medical and social

• Unwarranted Variation in activity

8

Top 30 PCTs(Lowest Rates)

Next 31 PCTs

Next 30 PCTs

Next 31 PCTs

Bottom 30 PCTs (Highest Rates)


Next 31 PCTs

Next 30 PCTs

Next 31 PCTs



Next 31 PCTs

Next 30 PCTs

Next 31 PCTs


Musculoskeletal programme- variation in knee replacement costs

Primary Knee Replacement - AgeSexNeeds standardised cost per 1000 population for PCTs

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151

PCT

AgeSexNeeds standardised cost (£

per 1000 population)

London

Primary knee replacements cost £5,808.

There is a 4-fold variation in expenditure between PCTs(adjusting for age, sex and need).

The coefficient of variation is 21.0%.(This takes into account all PCTs, not just the top and bottom PCTs.)

The potential savings are £39M(if PCTs with rates higher than the median reduced to this level).

Total Inpatient

Expenditure (£M)

Potential Saving using

50th percentile (£M)

Potential Saving as % of

Total Inpatient Expenditure

392 39 10.0%

What’s the problem – system?

• Inexorable demand with an forthcoming unprecedented reduction in resources(we need to do much better with much less)

• Historical inability to manage demand using current levers

• Poor alignment of incentives

• “Micro-contracting” of an incredibly complex business process/ care pathway/ supply chain

• Lack of clinical and financial management and accountability across the pathway


•So what can we do about it?



OUR VISION FOR LTCs

• Personalisation

– Person not Long Term Condition Label

– Holistic Health - Physical, Emotional and Social

– Care according to needs and preferences

– Patient outcomes as well as clinical outcomes and experience

– Personal Health Planning

• Self Care and “co-production”

– Supported Self Care

– Rehabilitation

– Personal Health Planning

• Commissioning of Long Term Conditions

– Co-production at the strategic level

– Whole pathway approach

– User and carer engagement in re-commissioning


so what “new” do we need to buy?

• Demand Mx including Admission Avoidance

• Specialist advice and support to 1’ care

• Referral triage

• Primary care clinical management (QOF++)

• Shared Decision Making

• Personal Health Planning

• Supported Self Care

• Holistic Biopsychosocial Approach

• Integration

• The “Holy Grail” of clinical and financial accountability

Individual ’s story Professional ’s

story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge

and health

beliefs

Emotional Behavioural Social Clinical


story


Goal Setting



story


Goal Setting


Knowledge

and health

beliefs

Knowledge

and health

beliefs

EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical


story


Goal Setting



story


Goal Setting


Knowledge

and health

beliefs

Knowledge

and health

beliefs



story


Goal Setting



story


Goal Setting


Knowledge

and health

beliefs

Knowledge

and health

beliefs


Engaged,

informed patient

HCP committed to

partnership working

Organisational processes

Commissioning- The foundation


story


Goal Setting


Knowledge

and health

beliefs



story


Goal Setting



story


Goal Setting


Knowledge

and health

beliefs

Knowledge

and health

beliefs


The clinic experience

Registration, recall, review, and follow up

Access & communication

Named contact

IT templates

Awareness of approach to self-management

Consultation skills /

competencies

Multi-disciplinary team working

Knowledge of local options

Clinical expertise

Structured education/ Information

Awareness of process & options

Pre-consultation results

Access to own records

Emotional & psychological support

Engaged,

informed patient

HCP committed to

partnership working

Organisational processes

Commissioning- The foundation


story


Goal Setting


Knowledge

and health

beliefs



story


Goal Setting



story


Goal Setting


Knowledge

and health

beliefs

Knowledge

and health

beliefs


The clinic experience

Registration, recall, review, and follow up

Access & communication

Named contact

IT templates

Awareness of approach to self-management

Consultation skills /

competencies

Multi-disciplinary team working

Knowledge of local options

Clinical expertise

Structured education/ Information

Awareness of process & options

Pre-consultation results

Access to own records

Emotional & psychological support

Developing the menu

Linking micro-to macro-

Commissioning care planning

Measurement User involvement

Money / contracts

0% 25% 50% 75%

CA-Prostatectomy

CAOrchiectomy*

coronary bypass*

coronary bypass

hysterectomy

hysterectomy*

mastectomy

back surgery

mastectomy*

bphprostatectomy

bphprostatectomy

Standard Care

D-Aid

.

Decision Aids reduce rates of discretionary surgery

RR=0.76 (0.6, 0.9)O’Connor et al., Cochrane Library, 2009

Standard

care, $2,751

Video

Decision Aid ,

$2,026Video Decision

Aid plus

Coaching, $1,566

$0 $500 $1,000 $1,500 $2,000 $2,500

Kennedy et al. JAMA2002; 288: 2701-2708

HysterectomyHysterectomy

GIVE PEOPLE THE CARE THEY NEED AND NO LESS,

THE CARE THEY WANT AND NO MORE

A Whole Pathway Approach

Where do we buy it from?

The traditional commissioner approach

• The traditional providers and…

• The “add ons”

Traditional model – methods of controlling Demand and delivering savings

My proposed transformational approach

• An integrating “pathway hub approach” with whole pathway (programme budget) clinical AND financial responsibility

Programmed budget modelDemand management

A Pathway Hub or

Whole Pathway Provider/ Prime Vendor and

Subcontractor to:

• Provide, performance manage and subcontract• Deliver Care Closer to Home (an alternative to hospital outpatients)• Identify and meet training needs of primary care • Ensure quality and VFM from 1’ Care• Manage the demand for secondary care services• Improve population and individual health (includes prevention responsibility)

• Ensure provision of self care support, care planning, informed decision making

• Manage the Programme Budget(s) on your behalf

ALIGNING CLINICAL AND FINANCIAL INCENTIVES -CLEAR ACCOUNTABILITY ACROSS THE PATHWAY

Summary - what do we need?

• Support for Personal Health Planning• Support for Self Management/ Self Care• Navigation support• Support for Informed Decision Making• Access to information• Access to support• Empowering services

• Oh….and a integrating provider/ provider group to do this and more…..

There are no short cuts to any

place worth going

Beverly Sills

[email protected]

Health & Medicine

Long Term Conditions: Long Term Conditions What’s wrong and what do we need?