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Transcript of 1 NOEL J STAUNTON (BSc, MRPharmS, MBA, Dip H.Econ) Pharmaceutical Consultant-3i consultancy ltd Work...
1
NOEL J STAUNTON (BSc, MRPharmS, MBA, Dip H.Econ)
Pharmaceutical Consultant-3i consultancy ltd
Work with Pharma companies (Pfizer, GSK, BI, Novartis, Flynn, Shire, Galderma, Stiefel, Solvay, Takeda, Lundbeck etc, etc)
Mob 07 980 148 711. E mail [email protected]
2
TODAY
NHS reorganisation –Why?
PBR
PBC
WCC
3
TODAY
Darzi Polyclinics
Pharmacy White Paper
PCO levers
In July 2002 the WHO asked the UN Security Council:
“What, in your honest opinion, can we do to solve the problem of the shortage of food in the rest of the world?”
Remember, people interpret things
differently.
Didn’t work because:
East Europeans didn’t understand the word “honest”
Chinese didn’t understand – “opinion”
Middle Easterners didn’t understand – “solve”
South Americans didn’t understand – “problem”
Western Europeans didn’t understand – “shortage”
Africans didn’t understand – “food”
Americans didn’t understand – “rest of the world”
6
NHS REORGANISATION - WHY?
We’re spending more £s per head on health than EU15 and EU27 countries but our outcomes are poor
0 300 600 900 1,200 1,500 1,800 2,100 2,400 2,700 3,000 3,300 3,600
Romania
Bulgaria
Latvia (2004)
Turkey
Lithuania (2004)
Estonia (2004)
Mexico
Poland
Slovak Republic
Hungary (2004)
Czech Republic
Korea, Republic of
Cyprus (2004)
Malta (2004)
Slovenia (2004)
Portugal
Spain
New Zealand
Greece
EU27
Italy
Finland
Japan (2004)
Australia (2004)
EU15
UK
OECD
Netherlands (2004)
Canada
Sweden
Germany
Belgium
Ireland
Austria
France
Denmark
Iceland
Switzerland
Norway
Luxembourg (2004)
USA
Total1 annual health care expenditure per capita (£ cash)
Notes: 1 Public and private spending. 2005 figures for Belgium, Cyprus, Denmark, Estonia, Japan, Latvia, Lithuania, Malta, Slovak Republic and Slovenia are WHO provisional estimates. Figures are dependent on exchange rates between national currencies and £ sterling over time. Figures for OECD, EU27 and EU15 are weighted averages.Sources: OECD Health Database (OECD). World Development Indicators (World Bank). World Health Report: Core Health Indicators (WHO). World Health Organisation National Health Accounts Series (WHO). For sources of UK data refer to Table 2.1.
Figure 2.6 Total1 annual health care expenditure per capita in OECD and EU countries, circa 2005
0 2 4 6 8 10 12 14 16 18 20
Iceland
Sweden
Luxembourg
Japan
Finland
Norway
Czech Republic
Portugal
France
Belgium
Greece
EU15
Germany
Ireland
Slovenia (2004)
Spain
Austria
Switzerland
Denmark (2004)
Italy
Netherlands
Australia
New Zealand
UK
Canada (2004)
Korea, Republic of (2002)
Malta (2004)
EU27
OECD
Estonia (2004)
Hungary
Poland
USA (2004)
Slovak Republic
Lithuania (2004)
Latvia (2004)
Bulgaria (2004)
Romania (2004)
Notes: 1 Deaths under 1 year per 1,000 live births. See Table 1.20 for rates for all available OECD/EU countries. EU15 as constituted before 1 May 2004. EU27 as constituted on 1st January 2007.Sources: OHE calculations based on data from WHO Mortality Database (WHO). OECD Health Database.
Figure 1.11 Infant mortality rates1 in selected OECD and EU countries, circa 2005
Infant mortality rate1
64 66 68 70 72 74 76 78 80 82 84
Estonia
Turkey
Romania
Latvia
Bulgaria
Lithuania
Hungary
Slovak Republic
Poland
Mexico
Czech Republic
Slovenia
Portugal
USA
Denmark
Korea, Republic of
Luxembourg
Ireland
Cyprus
Finland
Belgium
Germany
Malta
UK
Greece
Austria
Netherlands
New Zealand
Norway
Italy
Canada
France
Spain
Sweden
Australia
Switzerland
Iceland
Japan
Source: World Population Prospects (United Nations).
Figure 1.7 Projected life expectancy at birth in OECD and EU countries, 2005 - 2010
Life expectancy (years)
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
Korea, Republic of (2002)
Japan (2003)
Luxembourg
Mexico (2002)
Greece (2003)
Spain (2003)
Sweden (2002)
Finland
Malta
Portugal (2003)
Poland (2003)
Iceland (2003)
Norway (2003)
Austria
Australia (2002)
Switzerland (2002)
Slovak Republic (2002)
Canada (2002)
Italy (2002)
Czech Republic
Estonia (2003)
Germany
France (2002)
Lithuania
Slovenia (2003)
UK (2005)
Latvia
Ireland (2002)
Netherlands
New Zealand (2000)
Hungary (2003)
Denmark (2001)
Note: Year is 2004 unless stated otherwise.Sources: OHE calculations based on WHO Mortality Database (WHO). Mortality Statistics Series DH2 (ONS). Vital Events Reference Tables (General Register Office of Scotland). Demographic Statistics (Northern Ireland Statistics and Research Agency).
Figure 1.16 Age standardised mortality rates from breast cancer, women aged 15 - 74, in selected OECD and EU countries, circa 2004
Rate per 100,000 population
0 50 100 150 200 250 300 350
Japan (2003)
Korea, Republic of (2002)
France (2002)
Netherlands
Switzerland (2002)
Portugal (2003)
Italy (2002)
Spain (2003)
Luxembourg
Norway (2003)
Australia (2002)
Austria
Iceland (2003)
Denmark (2001)
Canada (2002)
Germany
Slovenia (2003)
Sweden (2002)
UK (2005)
Greece (2003)
Mexico (2002)
Malta
New Zealand (2000)
Finland
Ireland (2002)
Poland (2003)
Czech Republic
Slovak Republic (2002)
Hungary (2003)
Lithuania
Estonia (2003)
Latvia
Females
Males
Note: Year is 2004 unless stated otherwise.Sources: OHE calculations based on WHO Mortality Database (WHO). Mortality Statistics Series DH2 (ONS). Vital Events Reference Tables (General Register Office of Scotland). Demographic Statistics (Northern Ireland Statistics and Research Agency).
Figure 1.13 Age standardised mortality rates from coronary heart disease, men and women aged 15 - 74, in selected OECD and EU countries, circa 2004
Rate per 100,000 population
0% 10% 20% 30% 40% 50% 60% 70%
Portugal
Korea, Republic of
Spain
USA
Czech Republic
Slovak Republic
Canada
Mexico
Hungary (2004)
New Zealand
Poland
Denmark
Sweden
Germany
Finland
Netherlands (2002)
Luxembourg (2004)
Australia (2004)
UK
Japan (2004)
Austria
Norway
France
Italy
Switzerland
Iceland
Hospital expenditure as a percentage of total health spending
Notes: Year is 2005 unless stated otherwise. Figures at end of bars relate to hospital expenditure per capita in £ (money of the day). Cross-country comparison should be carried out with caution as figures may be based on different definitions.Sources: OECD Health Database. UK figure see Table 3.1 and Table 2.2.
1,6607
1,448
664
913
1,324
729
655
1,254
603
561
694
80
93
128
932
299
838
Figure 3.3 Hospital expenditure as a percentage of total health spending and hospital expenditure per capita (£) in selected OECD countries, circa 2005
309
712
624
131
386
617
129
73
536
13
MOST (ALL?) NHS CHANGES REVOLVE AROUND SPENDING MORE IN PRIMARY CARE AND LESS IN SECONDARY CARE
PBR
PBC
World Class Commissioning
GP contract, Community Pharmacy contract, Consultants contract
Nurse and Pharmacist Prescribing
Managing long term conditions
Etc, Etc, Etc
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PBR
Old system - block contracts PAY FOR WHOLE POPULATION Don’t know how much hospital care costs Can’t disinvest from secondary care
New system - PBR PAY FOR EACH INDIVIDUAL PATIENT National tariff CAN DISINVEST FROM HOSPITALS
15
PBR
England only (but Celtic nations eventually)
Copy of US system which DOES reduce hospital stay (Ref HSJ,
9th Dec 04, P 16)
International phenomenon DRGs first in the USA -Medicare
France uses US DRGs
Italy uses modified version of US DRG system
Germany & Netherlands from 2003
England, Australia, Norway, Austria, Finland, Sweden, Japan and Canada have own case mix tools
16
A 55 year old man with a history of heart disease is admitted to coronary care with an MI. His condition is complicated by heart failure. He is discharged after 32 days.
PBR - example acute MI
17
Patient is discharged from hospital.
Hospital finance clerk reads patient’s notes and types into her computer:
Primary diagnosis – MI Secondary diagnosis -CHF
PBR software spews out a code – HRG E11
PBR - example acute MI
18
HRG E11 - non-elective spell = £4,787
2 extra days @ £183 =£366
Total charged to PCT =£5,153
HRG code
HRG name
Elective spell tariff (£)
Elective long stay trimpoint (days)
Non-elective spell tariff (£)
Non-elective long stay trimpoint (days)
Per day long stay payment (for days exceeding trimpoint)
Short stay (less than 2 days) emergency tariff (£)
E11
Acute Myocardial Infarction w cc 5,006 43 4,787 30 183 957
E12
Acute Myocardial Infarction w/o cc 2,908 19 3,017 14 191 603
PBR - example acute MI
19
The tariff covers EVERYTHING that happens to the patient
whilst in hospital (drugs, tests etc)
Overseas PBR has stimulated primary care prescribing
(in order to prevent expensive hospital tariffs)
Overseas PBR has threatened secondary care
prescribing (the hospital earns the same amount regardless
of which drug they use) UNLESS the drug reduces length of
stay
Birth of real pharmaco economics in UK?
PBRPBR
20
Fund holding DID change how many patients
went into hospital (unlike HAs, PCTs, and other
NHS changes) (Ref Health Foundation, Oct 04)
PBC born in England only (April ’05) and voluntary
Resuscitated in April ’06 through the GMS contract
PBC
21
Practices meant to keep at least 70% of any freed up resources
This wasn’t happening so BMA said don’t do PBC UNLESS you get a written agreement (HSJ 19th April 07, P8).
Resources freed up may be spent on: Equipment; Training, clinical and non-clinical staff; Premises development with specific PCT board approval;
Freed up resources can be shared across a wider group of practices
Practice Based Commissioning: achieving universal coverage Jan 06
PBC efficiency gains
22
PBC Currently – results aren’t great
Audit Commission said: “We’ve not yet seen any real evidence of it (PBC)
leading to the redesign and transformation of services that was hoped”.
They blame PCTs and the way they have set PBC budgets. (Ref HSJ 22 Nov ’07, P 7).
However PBC is here for medium term at least NHS to use private firms to assist PC clusters with
business cases (Ref HSJ 24 July 08, P 6)
23
World Class Commissioning
“Adding life to years and years to life”.
Commissioning Assurance Handbook, dated 4 June 2008. PCTs will be assessed against three elements – Outcomes, Competencies and Governance. PCTs need to complete a self assessment and submit materials by end October 2008.
PCTs to be ranked from 1 to 5 (5 = a WCC)
24
DARZI-Polyclinics
Each PCT in England must have a new Polyclinic
Also over 100 new GP practices in “under-doctored” PCTs (mainly NE and NW England)
Contracts will be awarded Dec ‘08
Real reason for doing this is to introduce some fat into the fire of change
Many private companies bidding including Virgin, United Healthcare, BUPA. Virgin have had expressions of interest from 300 GP practices, Ref HSJ 22 May 08, P 11 but have now PULLED out of opening GP surgeries (Ref GP 26th Sep 08)
25
DARZI - Polyclinics
Set-up costs met by DOH - £250-800m.
Winners will develop new services funded by start-up monies in competition with existing practices
Some existing practices may go bust
Practices will increasingly work in groups with shared approaches to medicines management
Practices won by United Health, Care UK, Virgin, will restrict access, employ GPs and look to widespread formularies and prescribing policies
Pharmacy White Paper
(Green paper, White Paper, Bill, Legislation)
White paper proposes that pharmacies will:
prescribe certain common medicines, be first port of call for minor ailments, saving every GP the equivalent of around one hour per day;
provide support for people with long-term conditions;
be able to screen for vascular disease and certain STDs, such as Chlamydia;
work much more closely with hospitals to provide seamless care;
play a bigger role in vaccination.
26
Pharmacy White Paper
Let’s not forget:
Pharmacies currently only doing 85 MURs each (*allowed to do 400) (Ref PJ 2 Aug 08, P 121)
Lots of previous false dawns for pharmacy
PWSI announced 2 years ago but only 2 (yes 2) in England
27
Some things are obvious
PCO LEVERS
PCOs are proven to influence prescribing National audit office survey of 2,000 GPs in ’07 Atorvastatin + Losartan in decline
Prescribing incentive scheme is main lever
PCOs reserve powerful levers for top priorities (normally big cost savings)
PCO LEVERS
Prescribing incentive schemes 5* lever, only for big savings (e.g. statins, sartans,
antidepressants etc)
Practice support pharmacists 5* lever, only for big savings
ScriptSwitch 3* lever, smaller cost savings and quality issues
Monthly Rx newsletters/Guidelines etc 2* lever, reinforce others
Guidelines 1* lever, let someone else waste time on these
31
NOEL J STAUNTON (BSc, MRPharmS, MBA, Dip H.Econ)
Pharmaceutical Consultant-3i consultancy ltd
Work with Pharma companies (Pfizer, GSK, BI, Novartis, Flynn, Shire, Galderma, Stiefel, Solvay, Takeda, Lundbeck etc, etc)
Mob 07 980 148 711. E mail [email protected]