International efforts to improve quality, reduce costs and increase transparency

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• International efforts to improve quality, reduce
  costs and increase transparency
• On the theme of shift in the National Health
  Service of England
• Helen Bevan
• Bipartisan Congressional Health Policy Conference

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How did we spend our healthcare resources last
year?
Social care 12bn Primary care physicians and
other primary care (including drugs) 15bn Commu
nity care 10bn Mental health 7bn Elective and
ambulatory (outpatient) 12bn Non-elective and
critical care 14bn
Social care 12bn
Primary care 15bn
Total expenditure 72bn (138bn)
Acute care 45bn
Accident and emergency, Out of hours, emergency
transport 3bn
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How did we spend our resources last year?
Social care 12bn Primary care physicians and
other primary care (including drugs) 15bn Commu
nity care 10bn Mental health 7bn Elective and
ambulatory (outpatient) 12bn Non-elective and
critical care 14bn
25
Expenditure 2005/06 Total 72bn (138bn)
75
Accident and emergency, Out of hours, emergency
transport 3bn
4
How will this change in future?
Social care 12bn Primary care physicians and
other primary care (including drugs) 15bn Commu
nity care 10bn Mental health 7bn Elective and
ambulatory (outpatient) 12bn Non-elective and
critical care 14bn
25
30
Expenditure 2005/06 Total 72bn (138bn)
75
70
Accident and emergency, Out of hours, emergency
transport 3bn
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The 2006 White Paper represents an ambitious new
direction

• better prevention services with earlier
  intervention
• a greater proportion of care outside of
  hospitals and in the home
• more support in the community for people with
  long term needs
• more choice and a louder voice for service users
• tackling health inequalities and ensuring access
  to high quality care for all
• integration between health and social care

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Shifting location, process and provider of care

• focus on prevention and early intervention
• patient-driven care and self-care
• care in local community settings
• assume care will be provided by a professional
  with the right skills
• high quality, cost effective care for all

• focus on treatment
• professionally driven care
• care in specialist hospital settings
• assume care will be provided by a doctor
• variation in access, clinical quality, resource
  utilisation

from
to
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Quality and Outcome Framework reward and
incentive programme for General Practitioners

• Established in 2004 as a core component of the
  new GP Contract
• around 30 of a GPs compensation package
• voluntary
• 8,500 practices, covering 53 million patients
• at level of practice, not individual GP
• via Quality Management and Analysis System

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Quality and Outcome Framework reward and
incentive programme for General Practitioners

• Covers 4 domains
• Clinical 76 indicators in 11 areas coronary
  heart disease left ventricular dysfunction
  stroke and transient ischaemic attack
  hypertension diabetes pulmonary disease
  epilepsy hypothyroidism cancer mental health
  asthma. Worth up to 550 points
• Organisational 56 indicators in 5 areas records
  and information patient communication education
  and training medicines management clinical and
  practice management. Worth up to 184 points
• Patient experience 4 indicators in 2 areas
  patient survey and length of time with the
  doctor. Worth up to 100 points
• Additional services 10 indicators in 4 areas
  cervical screening, child health surveillance
  maternity services contraceptive services. Worth
  up to 36 points

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Quality and Outcome Framework examples of
points availability in clinical domain

• Disease registers maintaining a high quality
  disease register for each disease category (2-6
  points)
• Asthma percentage of patients aged 8 and over
  diagnosed as having asthma with measures of
  variability or reversibility (6 points)
• Depression in those patients with a new
  diagnosis of depression in the previous year, the
  percentage who have had an assessment of severity
  (appropriate to primary care) at the outset of
  treatment (25 points)
• Mental health percentage of patients with
  schizophrenia, bipolar affective disorder and
  other psychoses with a review recorded in the
  preceding 15 months. In the review, there should
  be evidence that the patient has been offered
  routine health promotion and prevention advice
  appropriate to their age, gender and health
  status (23 points)
• Stroke percentage of patients who have had a
  stroke or TIA in whom the last blood pressure
  reading (in the last 15 months) is 150/90 or less
  (5 points)
• World class clinical database

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Quality and Outcome Framework results from the
first 2 years
2005/6
2004/5
Average points per practice
No. of practices scoring the maximum 1,050 points
Average score in the clinical domain (of 550 available)
958.7 (91.3 of available total)
1,010.5 (96.2)
222 (2.6 of total)
813 (9.7)
507.7 (92.3)
534.2 (97)
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GP compensation

• average salary from NHS lt200,000
• significantly higher than average NHS salary for
  hospital specialist
• GPs have had 40 increase in compensation in 2
  years

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Case study onesupporting people with long term
conditions in the county of Cornwall

• People with long term conditions who are at high
  risk are proactively supported in the community
  by nurses with advanced skills who
• work as part of the primary healthcare team
• refer patients directly to specialist doctors in
  hospitals
• order diagnostic investigations
• prescribe medicines and treatments
• As a result
• 50 reduction in hospital admissions for this
  group
• growth in emergency admissions down from 9 to 1
  (-3 in over 75s)
• 72 reduction in no. of visits this group made to
  their primary care physicians
• 61 reduction in home visits
• 42 reduction in contacts made with the emergency
  primary care (out of hours) service
• higher patient satisfaction, more joined up
  care, better quality, lower costs

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Case study twoEast Midlands Ambulance Service
avoidable admissions project

• Aim
• to reduce unnecessary hospital admissions amongst
  patients who dial 999 but who do not have a
  life-threatening condition
• Action
• core ambulance crews who answer 999 calls were
  replaced with paramedics with advanced skills
  (emergency care practitioners - ECPs)
• As a result
• 60-70 reduction in the proportion of patients
  taken to hospital and subsequently admitted
• a largely elderly group of patients avoid the
  trauma and knock-on consequences of hospital
  admission
• no increase in risk no decrease in patient
  satisfaction and significant cost saving from
  hospital admissions avoided
• In addition
• scheme set up with British Red Cross Society to
  enable ECPs to call in trained volunteers to
  watch patients in their homes overnight until
  they see the GP the next day

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Quality and outcomes framework

• champions prevention and quality
• based on evidence
• creates good practice across the system
• high compliance
• low variation
• quality of local and national database basis
  for decision making
• moving towards longer term health and well-being
  outcomes the bar is rising
• foundation for shift to primary care and other
  policy directions
• enables role redesign and other new ways of
  working

• -
• underestimate of baseline performance
• rise in GP compensation
• administrative workload
• GPs taking a higher proportion of practice
  income as personal income
• question some indicators
• not stretching enough
• not high impact
• need to move to more outcome focused measures
• focuses on only a minority of patients