Great innovations of the first and second health care revolution

• MRI and CT scanning• Statins • Antibiotics• Coronary artery bypass

graft surgery• Hip and knee

replacement• Chemotherapy• Radiotherapy• Randomised controlled

trials• Systematic reviews

Gower Street - Doll & Hill

Broad Street - John Snow

The First The Second

- BUT all health services face five major problems:

• Patient harm

• Unwarranted variation in quality and outcome

• Failure to maximise value

• Inequalities

• Failure to prevent

AND new, additional challenges are developing

• Rising expectations

• Increasing need

• Climate change and carbon constraints

• Financial constraints

Value = Outcomes / Costs

Outcome = Good – Bad (Outcome= Effectiveness – Harm)

Costs = MoneyCosts = Carbon + Opportunity Lost

Lower value activities are those which:  1.Have clear evidence that they are ineffective or that they do more harm than good.

2.Have no evidence of effectiveness but are not being delivered in the context of research that would allow evidence to judge effectiveness to be gathered.

3.Have evidence of effectiveness but are being offered to patients whose characteristics are different from the characteristics of the patients in the research studies which produced the evidence of effectiveness.

4.Treat a patient who has not been given unbiased information in a way that they can understand the probability of both benefit and harm of accepting the offer of treatment.

5.Use resources which would produce more value, namely a better balance of benefit to harm, if invested in some other service

Use resources which would produce more value, a better balance of benefit to harm, if invested in some other service.

This may be an investment in:

• another type of intervention for this group of patients eg, switching resources from oxygen therapy to triple drug therapy for people with COPD• a service for another group of patients within the same programme budget eg, switching resources from cataract surgery to fund increased costs for AMD• another programme budget eg, switching resources from the gastrointestinal and liver programme budget, by reducing upper GI endoscopy, to the musculoskeletal budget to fund more hip replacements.

NB: these resources are being released by disinvestment from interventions with evidence of effectiveness so there will be an impact on the group of patients but the decision is made on the principle that greater value will result by the change in investment.

The law of diminishing returns

BVHP The better value health care programme

Benefits

Investment of resources

Harmful effects increase in direct proportion to the resources invested

BVHP The better value health care programme

Harmfulside effectsof care

Investment of resources

After a certain level of investment the health gain may start to decline;

the point of optimality

Benefits

Investment of resources

Harms

Benefits - harm

Higher value

Higher value

Lower value

Reorganise, educate

Higher value

Higher value

Lower value

Reorganise, educate

Destabilise / Atlas

Constrain/programme budgets

No decision about me without me

Population-based accountable integrated care systems

Programme budgets

Population-focused clinicians

Knowledgeable commissioners

Shared decision-making support service

Clinical commissioning insights on major health systems prepared by one cluster for Do Once And Share

NHS Atlases of Variation (2.0 in November +5 specialty atlases)

Annual Programme Budget Review (December)

Health investment packs – spend and outcome data for every PCT/cluster

RIGHTCARE PRODUCTS & SERVICE THE NHS POST REFORM

NHS Atlas 1.0

Published

Nov

2010

Oct2011

Organ donation and

transplantation

Child Health Atlas – in collaboration

with ChiMat

Diabetes themed

Atlas

Portal Launch:- Keynote article(s)

- case-studies- variation bibliog.

2nd Comprehensive NHS Atlas

published – National event.

Feb2012Jan

2012

Cancer-themed Atlas

Marc

h2012

Right Care NHS Atlas – provisional vision line

Apri

l2012

Forward strategy for

NHS Atlas

Kidney CareAtlas

This vision line outlines the proposed publication programme for Right Care Atlases during 2011 and beyond Atlases in dotted callouts are still under consideration and all publication dates are subject to further change arising from on-going discussions and subject to ministerial office approvals

Diagnostics Atlas

Dec2011

Nov2011

DH MinisterialSign-off

Sept

2011

Liver Disease

Atlas

2012/13programme

launched

14/09/2011

www.rightcare.nhs.uk/atlas

CANCER

RESPIRATORY

GASTRO

CANCER

RESPIRATORY

GASTRO

MENTALHEALTH

CANCER

RESPIRATORY

GASTRO

MENTALHEALTH

Medicallyunexplainedphysicalsymptoms

Homeless people

Children

Older people with fouror more diagnoses

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic Obstructive Pulmonary Disease)

Asthma

Triple drug therapy

O2 rehabilitation

A SYSTEM is a set of activities with a common set of objectives ( also known as a service).

A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation).

A PATHWAY is the route patients usually follow through the network.

This is an example of a national service set up as a system

HIERARCHY

NETWORK

AVERAGESPEND

AVERAGEOUTCOME

LOWERSPEND,BETTEROUTCOME

LOWERSPENDWORSEOUTCOME

HIGHERSPEND,BETTEROUTCOME

HIGHERSPEND,WORSEOUTCOME

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic Obstructive Pulmonary Disease)

Asthma

Triple drug therapy

O2 rehabilitation

Innovation to increase value and improve quality

High value innovation

Innovation & disinvestment to increase value and improve quality-

from PBMA to PPPB

Dr Jones is a respiratory physician in the Brighton Hospital Trust and last year she saw 346 people with COPD and to provide evidence-based, patient-centred care, and to improve effectiveness, productivity and safety

Dr Jones estimated that there are 1000 people with COPD in East Sussex and a population-based audit showed that there were 100 people who were not referred who would benefit; she needs to practise

population medicine

Dr Jones, the co-ordinator of the East Sussex COPD Network and Service has responsibility, authority and resources (one day a week and support) for

• network development• localisation of the Map of Medicine• quality of patient information• professional development of generalists, and pharmacists • production of the annual report of the service

She is keen to improve her performance from being 27th out of the 106 COPD services, and of greater importance, 6th out of the 23 services in the prosperous counties.

Information Knowledge technology

Citizens

The Drivers of the Third Industrial Revolution (Manuel Castells)

www.bvhc.co.uk

Neither markets nor bureaucracies can solve the challenges of complexity

BVHC