NHS Next Steps Review Initial Briefing Materials on Long Term Conditions

1
NHS Next Steps Review Initial Briefing
Materials on Long Term Conditions
DRAFT
3 October 2007
2
Introduction to this regional briefing

• This briefing is intended to act as an
  introductory overview for the clinical group
• It reviews the current situation in this clinical
  area across the West Midlands, outlines selected
  parts of a case for change, and provides some
  examples
• This briefing is intended as the start of a wider
  process and as a helpful dialogue
• It aims to be fully consistent with the NHS West
  Midlands strategy document Investing for Health
  which also provides useful material in this
  clinical area

Purpose
Fit with national briefing materials

• The Department of Health (DH) has produced a
  separate introductory briefing that covers
• Key national facts and figures on this clinical
  area
• An overview of the evidence base on good practice
  in this area
• National or international case studies of
  successful work
• We have designed this regional briefing to avoid
  overlap with the DH materials, by focusing on
• Presenting the regional situation
• Starting to develop the case for change
• Putting forward some local examples of good
  practice or innovation

• This document points out some significant
  variations across the West Midlands and compares
  the West Midlands with other regions
• Understanding the root causes of regional
  variations can help identify best practices and
  improve outcomes across the health economy
• In a region such as the West Midlands, variations
  in practice or outcomes are typically not caused
  by resource availability
• Understanding what really drives this variation
  is likely to surface a number of improvement
  opportunities that can be taken forward by the
  clinical group

Interpreting regional variation
3
Introduction to this regional briefing (cont.)

• The document therefore contains the following
  parts
• Current situation across all clinical areas The
  challenges facing the West Midlands health
  services as a whole, across all clinical areas
• Current situation in this clinical area The
  starting point for this clinical area
  specifically, covering questions such as access,
  investment, inequalities and outcomes
• Case for change Selected issues with current
  common practice in the West Midlands
• Vision for the future Examples of successful
  work in the West Midlands to date, and some
  questions on the future path of services that
  your group may wish to consider.

Structure of this document
Further development

• NHS West Midlands intends this to be the start of
  a dialogue
• In particular, if you believe that some analyses
  in this document are misleading or incorrect,
  then we would welcome it if you would provide us
  with more appropriate, up-to-date or accurate
  information

4
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation for long term conditions
• Case for change
• Vision for the future

5
Executive summary Long-Term Conditions

• The West Midlands health system faces 7
  challenges outlined in Investing for Health
  widening inequalities, variability in quality and
  safety, services that are difficult to navigate,
  low public confidence, too little prevention, low
  return on investment, and cost pressures
• Within Long-Term Conditions we note that
• Long-term conditions are a significant issue for
  the region
• Their prevalence is linked to economic
  deprivation
• Variations are seen in screening, diagnosis and
  care planning
• Patients need to be involved more in care
  planning
• Long-term conditions have a serious economic
  impact

Current situation
Case for change

• We identify two aspects of the case for change in
  the West Midlands
• Diabetes context, evidence-based practice and
  current issues
• COPD context, evidence-based practice and
  current issues

Vision for the future

• Examples of good practice and innovation exist in
  the region, such as the Diabetes Year of Care
  initiative that aims to raise service standards
  by putting the patient in control, and the use of
  individual health budgets for long term
  conditions that aim to empower patients to
  identify and obtain the best care for their needs
• There are therefore several questions about the
  future direction for the clinical group to
  consider, including
• What are the key issues for you?
• How can detection of LTCs in the population via
  primary care be improved?
• What best practices/innovations have you seen?
  Are there barriers to implementing them?
• What is your vision for the future?

6
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation for long term conditions
• Case for change
• Vision for the future

7
The West Midlands health system faces 7 challenges
Challenge
1
Outcomesand quality
Widening inequalities
Despite improvements in overall health status,
inequalities in health have widened
2
There remains an unjustifiable variability in the
quality and safety of services and individual care
Variability in quality and safety
3
Patientfocus
We do not always help patients to navigate the
system
Difficult to navigate
4
Low public confidence
The public, our customers have little
confidence that their local NHS will get better
5
Too little prevention
We are not achieving enough in prevention
Investmentfocus
6
We spend substantial amounts of resources on
clinical activities where there is little return
on investment in terms of improved health, or
where there are more cost-effective alternatives
Low return on investment
7
Cost
The rate of cost pressures arising from doing
more of the same outstrips any conceivable rate
of increased funding
Cost pressures and opportunity costs
Source Investing for Health
8
Inequalities in health are significant
471
1
Deprivation index
Standardised years of life lost per 10,000
population
200305 pooled
2004 ward-based figures
Warwickshire
Worcestershire
Shropshire
South Staffs
Herfordshire
Solihull
North Staffs
Telford Wrekin
Dudley
West Mids average
Coventry
Walsall
Wolverhampton
Stoke on Trent
Sandwell
S Birminghanm
Heart of Birmingham
Birmingham E N
England average
Standardised YLL rate is the number of years
of life lost divided by the age-standardised
resident population aged under 75 years. The
age-standardised rate is the rate of events that
would occur in a standard population if that
population were to experience the age-specific
rates of the subject population Source National
Centre for Health Outcomes Development
9
and have widened in recent years
1
Gap between highest and lowest life expectancy,
years
84
Female highest
82
3.8 years
80
Female lowest
3.3 years
78
Male highest
76
4.9 years
74
4 years
Male lowest
72
19911993
9294
9395
9496
9597
9698
9799
982000
9901
200002
0103
0204
20032005
Source National Centre for Health Outcomes
Development
10
There remains an unjustifiable variability in the
quality and safety of services and individual care
90
2
STROKE EXAMPLE
Equal to or above national average
Below national average
2006 audit
Patients treated in a stroke unit,
Emergency brain scan within 24 hours of stroke,
Screening for swallowing disorders within 24
hrs of admission,
Trust (Site)
Burton Hospitals
Dudley Group of Hospitals
George Eliot
Good Hope Hospitals
Heart of England
Hereford Hospitals
Mid Staffordshire General Hospitals
Royal Wolverhampton Hospitals
Sandwell and W Birmingham (City Hospital)
Sandwell and W Birmingham (Sandwell District
Hospital)
Shrewsbury Telford Hospital
University Hospital Birmingham
South Warwickshire General Hospitals
N/A
100
South Worcestershire PCT
University Hospital North Staffordshire North
Staffords
UH Coventry and Warwickshire (St Cross Rugby)
UH Coventry and Warwickshire (Walsgrave Hospital)
Walsall Hospitals
Worcestershire Acute Hospitals (Alexandra H,
Redditch)
Worcestershire Acute Hospitals (Worcester Royal
Hospital)
62
66
42
National average
International evidence indicates maximum of 3
hours is preferred
England, Wales and Northern Ireland Source T
he National Sentinel Audit of Stroke 2006,
February 2007
11
We do not always help patients to navigate the
system
129
3
are serious in the West Midlands and result in
high emergency admissions rates
Issues with providing joined-up care for asthma
Standardised emergency hospital admissions for
asthma, 2004. Average admission rate 100

• In England
• 1 in 4 people with asthma are not offered or do
  not have a routine asthma review
• More than three-quarters of all adults and
  children with asthma (82 and 75 respectively)
  do not have written personal asthma action plans
• 12 of people who had experienced an asthma
  attack requiring emergency care do not know what
  to do during an asthma attack, and 16 do not
  know what to do after an attack
• People who do not have a written personal asthma
  action plan are four times more likely to have an
  asthma attack requiring hospital treatment than
  those with a plan

East
South East
South West
London
East Midlands
North East
West Midlands
Yorkshire andHumberside
North West
Source The Asthma Divide, Asthma UK, 2007
12
The public, our customers have little
confidence that their local NHS will get better
32
4
Thinking about the health services in your area,
do you expect them to . . .?
dont know
. . . get much better
. . . get much worse
11
2
. . . get better
29
. . . get worse
. . . stay about the same
Source Ipsos MORI Survey for NHS West Midlands
August and September 2006 3,555 responents
13
We are not achieving enough in prevention
18
5
Smoking cessation success rate
Women smoking during pregnancy
06/07, of people who set a quit date who
successfully stopped smoking
2005/06, of births
Telford And Wrekin
Shropshire County
Birmingham E N
South Birmingham
South Staffordshire
Heart Of Birmingham
Worcestershire
Solihull Care
Coventry
West Mid Avg
Dudley
Herefordshire
North Staffordshire
Warwickshire
Walsall
Stoke On Trent
Wolverhampton City
Sandwell
National average
53
15.9
Source The Information Centre for Health and
Social Care, Healthcare Commission Annual Health
Check
14
We continue to spend substantial amounts of
resources on clinical activities where there is
little return on investment in terms of improved
health, or where there are more cost-effective
alternatives
121
6
Improvement opportunity from bringing
standardised surgery rate for 5 procedures down
to that of lowest quartile
Relative level of surgery
HRG cost, annualised, 000
Actual vs. expected rate
105
Warwicks
109
S Staffs
91
Worcs
118
S Bhm
109
Sandwell
83
Bhm E N
81
Coventry
89
Solihull
69
H of Bhm
Total opportunity for five procedures in 13 PCTs
9.5m
64
Wolverhampton
79
Shropshire
68
Dudley
75
Telford Wrekin
Four PCTs excluded owing data quality or lack
of data supplied Myringotomy, hysterectomy,
lower back surgery, tonsillectomy, and dilation
and curettage. Selected because evidence-based
thresholds for when the surgery is likely to be
effective are sometimes ignored Given the
PCTs population base. 100 expected, under 100
lower than expected, over 100 higher than
expected. Figures are across all five procedures,
and so a PCT with under 100 overall can
nonetheless have savings potential as it is over
100 in one or more procedures. Source NHS
Better Care, Better Value Indicators
15
The rate of cost pressures arising from doing
more of the same outstrips any conceivable rate
of increased funding
9
7
PCT allocations, W Midlands
Annual growth rate, nominal

• Cost of inpatient activity in the region has
  grown at around 10 annually in recent years
• This has been manageable given the significant
  funding increases seen since the release of the
  NHS Plan
• In the future the funding settlement is likely to
  be tighter and so similar rates of activity
  increase will not be sustainable

5
Cost of inpatient activity, W Midlands
Annual growth rate, nominal
10
10
99/0005/06
05/0611/12
Assumes 2.5 real increase above GDP
deflator Assumes continuation of historical
rate of activity growth of 6 p.a. and 4 p.a.
tariff inflation Source DH HES
16
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation for long term conditions
• Case for change
• Vision for the future

17
This section sets the context for long term
conditions in the West Midlands

• Long-term conditions are a significant issue for
  the region

• Their prevalence is linked to economic deprivation

• Variations are seen in screening, diagnosis and
  care planning

• Patients need to be involved more in care planning

• Long-term conditions have a serious economic
  impact

18
Hypertension, asthma, CHD and Diabetes are the 4
most common long term conditions in West Midlands
Prevalence, West Midlands, 2005/06
unadjusted population
12.9
6.1
3.9
3.6
2.4
1.6
1.3
0.7
0.7
0.5
COPD
Hypo-thyroi-dism
Stroke and TIA
Coronary Heart Disease
Cancer
Epilepsy
Left Ventric-ular Dys-function
Diab- etes
Asthma
Hyper- tension
Several sources suggest that QOF
significantly underestimates prevalences, so
actual figures may be significantly higher. For
example Diabetes, British Heart Foundation
analysis (2003) Mental Health, Psychiatric
Morbidity Survey of Adults (2000) CHD
Hypertension, Association of Public Health
Observatories (2003/04) Stroke, Health Survey
for England (1999) Heart Failure, British Heart
Foundation Asthma, Health Survey for England
(2001) Source QOF data 2005/06
19
Long term conditions are a significant cause of
death in the region
2
Mortality per 100,000 European-standardised
population, West Midlands, 2003/05
Cancer
Coronary heart disease
Stroke
COPD
Diabetes
Epilepsy
Hyper-tension
Asthma
Source NCHOD
20
Recorded prevalence of LTCs varies widely across
West Midlands
213
West Midlandsaverage
Prevalence of long term conditions by West
Midlands PCT, 2005/06
Registered long term conditions per 1,000 need
and age adjusted population
374
356
340
297
Wed. W Bromwich
Rowley, Reg. Tip.
Wolverhampton C.
Burntwood, L. T.
Redditch Broms.
S Worcestershire
SW Staffordshire
Oldbury Smthk.
Cannock Chase
S Warwickshire
N Warwickshire
E Staffordshire
Dudley, B. C.
S Birmingham
Dudley South
Herefordshire
Shropshire C.
Newcastle-u-L
Northern Bhm.
Heart of Bhm
Wyre Forest
Coventry
N Stoke
S Stoke
Solihull
Walsall
E Bhm
Rugby
Pre-2006 PCTs. Long term
conditions covered are those measured by QOF
registers Source QOF Data
21
Census data suggests a link between economic
deprivation and the incidence of long term
conditions
48.3
Prevalence of limiting long-term conditions by
socio-economic classification, West Midlands, 2001
of population aged 16 or above with limiting LTC
Higher managerial and professional large
employer/higher managerial
Higher managerial and professionalhigher
professional
Lower managerial and professional
Intermediate occupation
Small employers and own-account workers
Lower supervisory and technical occupations
Semi-routine occupations
Routine occupations
Long-term unemployed
Never worked
Full time student
Not classified
Source Census table S024
22
However, recorded prevalence is not correlated
with economic deprivation, suggesting that LTCs
may be under-recorded in deprived areas
Registered long term conditions by socio-economic
group
LTCs registeredper 1,000 unadjusted population
(2005/06)
400
N. Stoke
390
Staffordshire Moorlands
Newcastle Under Lyme
Wednesbury W. Bromwich
380
Wyre Forest
S. Stoke
Rowley Regis Tipton
370
Herefordshire
Oldbury Smethwick
S. Dudley
Shropshire County
360
Wolverhampton City
N. Warwickshire
350
Solihull
Walsall
E. Staffordshire
340
Cannock Chase
N. Birmingham
Dudley Beacon Castle
S.W. Staffordshire
330
Rugby
Burntwood Lichfield Tamworth
320
E. Birmingham
S. Warwickshire
S. Birmingham
310
Redditch Bromsgrove
Telford Wrekin
300
Coventry
S. Worcestershire
290
280
270
Heart Of Birmingham
0
20
25
30
35
40
working age population in 4 lowest
socio-economic categories (2001 census)
Note The directions East, West, South, North,
East and West are abbreviated as E. W. S. N.
respectively Source NHS Information Center
QOF Data, 2005/06 Census table S024, 2001
23
QOF performance for the care of long term
conditions is inconsistent across West Midlands
QOF scores for West Midlands PCTs, 2005/06
COPD
Stroke
of available points achieved
of available points achieved
100
100
98
96
13
96
8
92
94
88
92
0
0
W. Mids PCTs ranked by score
W. Mids PCTs ranked by score
Cancer
Diabetes
of available points achieved
of available points achieved
100
100
98
98
96
6
10
96
94
92
94
90
0
0
W. Mids PCTs ranked by score
W. Mids PCTs ranked by score
Source NHS Information Centre, QOF Achievement
by Disease by PCT, 2005/06
24
Increased patient involvement in care planning
could improve resource utilisation
Potential to improve resource utilisation

• Research evidence about self management
  programmes such as EPP, indicate that patients
  completing the EPP course experience
  significantly lower hospital admissions
• One conservative estimate of the effect of EPP is
  that expert patients experience, on average, 17
  fewer admissions
• It costs approximately 270 per patient
  completing the Expert Patient Programme
• NHS West Midlands estimates that by targeting
  patients with long term conditions that have been
  admitted to a hospital, PCTs can cover the costs
  of providing or commissioning the Expert Patients
  Programme within 1 year and make cumulative
  savings for each subsequent year.

Background the Expert Patients Programme

• The Expert Patient Programme supports people to
  be able to best manage their own health
• In the second half of 2006/07, more than 1,600
  people in West Midlands completed an EPP
• A three-fold increase is required to hit national
  targets, and the optimum level of provision may
  be higher

Source Investing for Health, NHS West Midlands
25
Long Term Conditions take up significant hospital
resources in the West Midlands
4.3
Prevalence and emergency activity and costs of
LTCs in the West Midlands, 2005/06
Unadjusted Prevalence,
Emergency Admissions, Spells
Emergency Costs, m
1.3
COPD
13,469
15.4
3.6
CHD
20,133
22.8
3.9
Diabetes
5,212
6.0
6.1
Asthma
5,815
4.3
Based on HRGs for Heart Disease, Heart Failure
and Hypertension Includes diabetic
complications Source HES, Reference Costs, The
Information Centre for Health and Social Care
26
Long term conditions increase dependency and
decrease economic well-being
Limitations on independence prevalence as age
adjusted population, England, 2005
Employment rate, LTC sufferers vs. non-LTC
sufferers, England, 2005
No LTC
No LTC

1 LTC
At least 1 LTC
gt1 LTC
Problems working
Problems washing/dressing
Problems with usual activities
Some pain/dis-comfort
Some anxiety/depression
1025
2635
3645
4654
5564
6574
75
Source Health Survey for England (2005), DH
National Clinical Review evidence base
27
In some West Midlands PCTs there are frequent
avoidable emergency admissions
65
Relative level of emergency admissions for W
Midlands PCTs for 19 conditions best treated in
the community, Q4 06/07
Index, England average 100
Sandwell
Wolverhampton
Bhm E N
Heart of Bhm
S Bhm
Worcs.
S Staffs.
Telford Wrekin
Total productivity opportunity across 12 PCTs
32m
Coventry
Dudley
Warwicks.
Shorpshire
Given the PCTs population base. 100
average, under 100 lower emergency admissions
than average, over 100 higher emergency
admissions than average. COPD, angina
(without major procedure), ENT infections,
convulsions and epilepsy, congestive heart
failure, asthma, flu and pneumonia (gt2 months
old), dehydration and gastroenteritis, cellulitis
(without major procedure), diabetes with
complications, pyelonephritis, iron-deficiency
anaemia, perforated/bleeding ulcer, dental
conditions, hypertension, gangrene, pelvic
inflammatory disease, vaccine-preventable
conditions, nutritional deficiencies Note Five
PCTs excluded owing to data quality or lack of
data supplied Source NHS Better Care, Better
Value Indicators
28
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation for long term conditions
• Case for change
• Vision for the future

29
This section addresses 2 disease areas as examples

• Diabetes context, evidence-based practice and
  current issues

• COPD context, evidence-based practice and
  current issues

30
Diabetes is a major health problem, in West
Midlands as nationally, with some studies
suggesting QOF may be under-estimating its
prevalence
3.6
Estimates of prevalence of diabetes, unadjusted
QOF recorded prevalence 2005/06
PBS model estimated prevalence 2001
England
West Midlands
Source QOF Data Yorkshire Humber Public
Health Observatory PBS Model
31
Current evidence-based practice for diabetes
Access to secondary care advice
Management of complications
Prevention
Early detection
High quality disease management

• Weight management
• Physical activity
• Improved diet

• Care plan including annual screening for eye,
  vascular, cardiac and renal disease
• Routine monitoring of HbA1c
• Training and education for patient
• High quality self-care programmes

• Specialist outpatient advice

• Link to vascular and cardiac surgery, renal
  medicine

• Targeted outreach
• Routine screening

Source Clinical evidence review team analysis
32
Current diabetes prevention and management in the
West Midlands is some way from this practice
Access to secondary care advice
Management of complications
Prevention
Early detection
High quality disease management

• Variation in adoption of cost effective
  approaches
• Variation in number and deployment of community
  staff e.g. school nurses, health visitors

• Variation in of diabetics subscribed to care
  programmes
• Variation in adherence of patients to care plans
• Lack of segmented approaches to care
• Lack of routine monitoring

• Variation in access to specialist outpatient
  advice

• Variation in access to specialist services

• Lack of consistent approaches to identifying
  diabetics

Source Clinical evidence review team analysis
33
The West Midlands spends less on diabetes
programmes and treatmentthan the national
average . . .
306
per registered diabetic, 2005/06
Sandwell
Solihull
Worcestershire
South Birmingham
Warwickshire
Shropshire County
Heart of Birmingham
South Staffordshire
Stoke on Trent
Walsall
Wolverhampton City
Telford and Wrekin
North Staffordshire
Dudley
Herefordshire
Birmingham E N
438
401


Note Data not available for Coventry
PCT Source DH Programme budget spend The
Information Centre for Health and Social Care QOF
statistics
34
Interventions vary significantly across the region
of diabetic patients with recommended clinical
and lifestyle checks completed by general
practice (01 January 2005 to 31 March 2006)
Blood pressure
Choles-terol
HbA1C
Micro-albu-minuris
Serum creat-nine
Neuro-pathy
Retinal scree-ning
Peri-pheral pulses
Smo-king
Body mass index
Source The Healthcare Information Centre QOF
Data 2005/06 NHS West Midland analysis
35
Patient engagement in the management of diabetes
could be improved, in West Midlands as nationally
47
Patients who said they agreed a care plan for
their diabetes during the previous 12 months,
West Midlands PCTs ,2006
Almost always
Sometimes, rarely or not at all
Herefordshire
52
South Birmingham
55
Shropshire County
48
Walsall
62
38
Coventry
60
Telford Wrekin
58
Wolverhampton City
62
Heart Of Birmingham
50
Dudley
54
Sandwell
57
43
Birmingham East North
57
North Staffordshire
57
Stoke on Trent
59
Worcestershire
50
Warwickshire
51
Solihull
43
57
West Midlands Average
55
England Average
53
Source Healthcare Commission, Survey of People
with Diabetes
36
Engagement metrics of diabetes care
significantly lag treatment metrics
95
Good practice for disease management for diabetes
Actual performance for diabetes, England, 2006

• Key tests and measurements are carried out every
  year to check health and prevent complications
• These include measures of HbA1c value, urine
  tests, blood pressure, cholesterol, body mass
  index
• They also include systematic screening for
  retinopathy and foot problems
• Annual care planning sessions take place to
  discuss treatment options and goals
• People are given chance to discuss their personal
  goals,
• They agree a care plan
• They have chance to discuss different medications
• There is structured education to empower people
  with the skills, knowledge and expertise to self
  manage effectively
• People participate in and education course

How many people report they are getting this? ()
HbA1c test
Urine test
Blood pressure
Chole-sterol
Feet examined
Discuss different medica-tions
Agree a care plan
Weighed
Attend an edu-cation course
Check for Retino-pathy
Discuss personal goals
Type of care
Source DH National Next Stage Review HCC
Survey of People with Diabetes
37
This section addresses 2 disease areas as examples

• Diabetes context, evidence-based practice and
  current issues

• COPD context, evidence-based practice and
  current issues

38
Current evidence-based practice in the COPD
pathway

• Screening to identify those at risk
• Smoking cessation and public health initiatives/
  campaigns

• Triage call centre and patient database
• Exercise in referral and other healthy living
  care
• Telephone supported self-care
• Pulmonary rehabilitation
• Care manage-ment for severe patients

• Clinics in the community
• Forces on moderate/severe patients

• Intermediate care nurses trained in COPD

• Emergency care gatekeeper
• Reduced LOS via developing links to GPwSIs,
  intermediate care and social care
• Facilitated discharge

• Screening to identify those likely to have COPD
• Mobile clinics to identify patients
• Diagnostic testing with GPwSI specialist nurse

Source Clinical evidence review team analysis
39
Current COPD prevention and treatment is some way
from this practice

• Limited specific screening
• Variable success at smoking cessation programmes

• No single comprehensive database available
• Exercise on referral not always taken up
• Limited provision for self-care
• Limited care management for severe patients

• Mostly offered in acute centres
• Limited clear database to patient members treated

• Often COPD-specific skills

• Patients present to AE and sometimes
  inappropria-tely referred

• Limited specific screening
• Limited but developing mobile clinics
• Testing carried out in both GP surgeries and
  acute centres

Source Clinical evidence review team analysis
40
Tackling of COPD in community care could be
improved, with variability across the region
COPD QOF scores, W. Midlands PCTs, 200506
In the context of QOF, 13 is a significant
variance
of available points achieved
13
Pre October 2006 PCT results Source The
Information Centre for Health and Social Care,
QOF Achievement by Disease by old PCT
41
COPD case finding has yielded positive results
in other areas of the country
25.2
Results
Benefits
Lifeexpectancy,years
Approach
QALYs
Costs,

• 2004 study on value of case finding
• Model was used to systematically compare costs
  and benefits of opportunistically testing
  patients who present at the GP with certain
  characteristics (age over 35, smoker/ex-smoker,
  chronic cough) with current practice
• Total costs, life years gained, and
  quality-adjusted life years (QALYs) gained were
  modelled and compared
• Costs were discounted at 6 and benefits at 1.5
  in line with NICE recommendations

Opportunisticallycase finding
25.25
19.36
1,732
Not opportunisticallycase finding
25.20
19.32
1,696

• Cost per life year gained is 713 and cost of
  QALY gained is 815
• Favourable cost-effectiveness ratio under current
  decision-making conditions
• Opportunistic case finding in primary care is
  therefore a relatively cost-effective strategy
• Note that model is quite sensitive to some
  parameters and the results should be interpreted
  with this in mind

Source Chronic Obstructive Pulmonary Disease
National Clinical Guidelilne on management of
chronic obstructive pulmonary disease in adults
in primary and secondary care, Thorax, 2004
42
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation for long term conditions
• Case for change
• Vision for the future

43
This section looks ahead to the future for the
West Midlands

• Examples of good practice and innovation exist
  for diabetes

• and for long term conditions generally

• There are therefore several questions about the
  future direction for the clinical group to
  consider

44
The POETIC framework, developed in West
Midlands, offers one way of thinking about how to
manage diabetes and other long term conditions
POETIC framework for success factors in long
term healthcare

• Patient Safe, Public Health-Driven

Patient-centred
P O E T I C
Objective-clear
What is it that we desire to achieve and why
Evidence-based
Audit-informed, research will be desirable
Team orientated
multidisciplinary, well-trained, validated
Integrated
Primary, secondary care, schools, community,
councils
Cost-effective
cost efficient, but clinically governed
Source Dr Vinod Patel, Warwick Medical
School/George Eliot Hospital NHS Trust
45
One approach to diabetes is to tackle it
alongside other linked conditions
Joint alphabet approach to the treatment of
diabetes and other conditions
25 of patients with stroke or CHD conditions
also have diabetes, suggesting need for a joint
approach
Source Dr Vinod Patel, Warwick Medical
School/George Eliot Hospital NHS Trust
46
Diabetes Year of Care initiative aims to drive
service improvement by putting the patient in
control
Overview of initiative

• Part of a national initiative West Midlands will
  create early adopters in each PCT with seat on
  national steering group for learning exchange
• Primary care professionals will work with patient
  groups to create the idea of entitlements the
  care a diabetes patient can expect to receive
  over a year
• Healthcare workers will assist patients in
  knowing more about their own condition and
  demanding high quality care

Objectives

• Create concept of entitlement among informed
  patients, who will then drive service improvement
  by demanding appropriate tests and treatments
• Reduce variability in GP services received by
  diabetic patients, thereby driving up the quality
  of care received by this patient group

Source NHS West Midlands commissioning staff
47
Risk stratification techniques may help case
managers reduce hospital care loads by better
targeting interventions
Outcomes
Currently, case management often misses those
patients for whom it would have the greatest
impact
Risk stratification process

• Greater understanding case managers can better
  understand the profiles of their patient
  populations and the location and identity of
  heavy service users among the patient group
• More focused intervention GPs and case managers
  can develop targeted, clinically evidence-based
  interventions to help individuals better manage
  their conditions and reduce their need for
  secondary care

• Details of all patients who have had contact with
  secondary care in last 12 months are processed
• Each patient is risk-scored the score is the
  number of times more likely the patient is to
  consume healthcare resources than the average
  West Midlands patient
• The patient population is stratified to identify
  highest risk segments
• Detailed care histories are available for
  individual high-risk patients

Systematic deployment and use of
risk-stratification techniques across the region
could increase case management productivity
Source NHS West Midlands United Healthcare
RISC analyses team analysis
48
The complexity of case management and other
interventions required depends on a patients
level of risk, as identified through
stratification
Intervention strategies required for different
patient risk strata
Highest risk
3
Complex case management
Professional care
2
Case management
1
Self care support and management
Self care
0
Wellness
Lowest risk
Source NHS West Midlands analysis
49
The Birmingham OwnHealth project delivers
promising outcomes by proactively managing the
care of patients with LTCs
Example outcomes,
Overview
in action or maintenance stage at baseline

• Telephone-based case management service run by
  nurse care managers
• Covers diabetes, COPD, heart failure and CVD
• Currently operating across 3 PCTs and serving
  around 1300 patients (July 2007)
• Operates in several languages
• Focus on
• Proactivity outbound calls to patients at agreed
  time
• Patient responsibility patients set own goals
• Motivation, coaching and support of patients

in action or maintenance stage at follow-up
Physical activity
Diet
Stop smoking
Heart failure symptoms
Angina pectoris
Hypo-glycaemic symptoms
Hyper-glycaemic symptoms
Source OwnHealth presentation materials,
National Commissioning Conference
50
Patient satisfaction with Birmingham OwnHealth is
high
I think you get good advice, which is the main
thing. You are not on your own when you have a
care manager. You can always ring up and ask a
question if you are worried about something and
usually you get a good answer
All this sort of stuff that she gives you is
really educational . . . My doctor is brilliant
but I feel that I am in safe hands with care
manager. It is a bit hard to explain really for
a man, but she makes my day
I did find it quite reassuring to talk to
someone, not on a face-to-face basis, with whom I
could share my feelings, what I thought I was
doing right and what I knew I was doing wrong and
to have that fed back to me, one way or another,
which I have been perfectly happy with
I feel well in myself and it motivates me to
stick to the diet that I have. I was 14 stone,
going on 15 I am down to 10 now. care manager
has motivated me into doing something. She has
not asked me to lose weight because she has never
seen me, but I have lost it
Source OwnHealth presentation materials,
National Commissioning Conference
51
Individual health budgets for long term
conditions aim to empower patients to identify
and obtain the best care for their needs
Objectives

• Focus on patients with high utilisation of
  emergency and secondary care services
• Reduce overall healthcare resource utilisation by
  high risk patient groups
• Improve legibility of services for patients with
  long term conditions
• Enable maximum flexibility so that patients can
  personalise services around their own
  preferences, lifestyles and conditions
• Promote greater integration between health and
  social cares cervices received
• Promote patient responsibility for their own
  healthcare by putting them in control of the
  services they receive
• Will support those patients who are currently
  least able to exercise choice to do so

Source NHS West Midlands commissioning staff
52
Questions for the clinical group to consider

• Which interventions achieve the best value for
  the resources (time, skill, expertise, funding)
  invested?
• How can detection of LTCs in the population via
  primary care be improved?
• What best practices/innovations have you seen?
  Are there barriers to implementing them?
• What is your vision for the future?