www.england.nhs.uk

23rd March 201610.30am – 3.30pm

WELCOME!

LtC Year of Care CommissioningEIS and LTC Community of

Practice Workshop

www.england.nhs.uk

• National context• Integrated intelligence – Kent• Use of the linked data - Leeds• Health 1000 – BHR• LTC animations

Introductions and outline of today:

www.england.nhs.uk

• To understand national context and thinking around LTC care

for the future

• To hear and learn from LTC YoC Commissioning Programme

EIS around key achievements as at end national programme

• To develop local thinking for 1617 and beyond

• To network and share knowledge

• To contribute to the development of the LTC framework

animations card game

Learning Outcomes:

www.england.nhs.uk

National Update

Julie Renfrew

www.england.nhs.uk

• 4 year national programme 2012 to 2016

• Lots of learning shared

• NOT the end of the work

• Close of the proof of concept stage - transition now

to mainstreaming.

• EIS plans / work in 15/16 to embed YOC

Commissioning outputs into operational processes

Long Term Conditions Year of Care Commissioning Programme

www.england.nhs.uk

LTC Framework

Commitment to Carers

Frailty

Health AgeingGuide

Fire Service as an asset

Care Homes Quick Guides

Care & Support Planning

Navigating Health& Social Care

Self Care

Ambitions for End of Life Care

Our Declaration

Delivery Models

Planning for Change:• Capitated Budget• Contracting• Simulation Modelling

Patient and Service Selection

Planning for Change:Workforce

Whole Population Analysis;Understanding your population

LTC Dashboard LTC Toolkit

www.england.nhs.uk

Long term conditions resources

Simulation modelUnbundling recovery simulation model

www.england.nhs.uk

7

Using behavioural change to open

minds

o Make a declaration at www.engage.england.nhs.uk/survey/ltc-declaration

o Tell your teams about our worko Encourage them to make a declarationo Ask them to feed back thoughts and

ideaso Use our hashtag – #A4PCC – when

you see work that is relevant to person-centred care for people with LTCs

o Let us know of any events, activities or social media opportunities that we can join forces with you

#A4PCC – Action for Person-Centred Care

Person with long term

condition

www.england.nhs.uk

National Context and Perspective for 2016/17

Jacquie WhiteNHSE

www.england.nhs.uk

LTC care for the future: Person Centred Co-ordinated CareJacquie White

Deputy Director - Long Term Conditions, Older People and End of Life Care Clinical Policy & Strategy TeamNHS England

23rd March 2016

www.england.nhs.uk

Opening thought

The good physician treats the disease; the great physician treats the patient who has the disease.

William Osler - 1800s

11

www.england.nhs.uk

What’s the diagnosis?

www.england.nhs.uk 13

1mPeople with frailty

10mPeople have two

or more LTCs

0.5mAt end of life

16mPeople have one

LTC

Long term conditions: some facts

www.england.nhs.uk 14

0.01%average no. hours

per year spent with health

professional 33%70%health budget

spent on LTCs

3.2%of people with LTCs

have a care plan

Long term conditions: some facts

of GP consultations are with people with multi

LTCs

www.england.nhs.uk 15

50 50

96 4

50% of total emergency beds days for over 75s

4% over 65s in care home with 14% total emergency admissions for over 65s

2570 25% of hospital beds occupied by someone dying

Three-fold increase in cost of health care with frailty

Long term conditions: some facts

www.england.nhs.uk

Long term conditions: some facts

16

1 in 9

Nearly 1 in 2(46%)

said they had fallen ill but just had to continue caring

£1bn in Carer’s Allowance goes unclaimed each year

said the person they cared for had emergency admission or social services while the carer recovered from illness

www.england.nhs.uk

People living longer but not always well

The larger the number of co-morbidities a patient has, the lower their quality of life

Increasing evidence on over-treatment and harm

Social isolation/loneliness a risk factor for mortality in over 75s and should be supported as a co-morbidity

And…

01/05/2023

www.england.nhs.uk

Wellbeing is about more than just medically managing a condition

It’s about thriving not just survivingIt’s an ethical, social and financial issueShared decision-making is key We need to take support people to self-

care, feel in control No one knows more about their

condition than the patient

Navigating health and care: Living independently with long term conditions, an ethnographic evaluation • http://

www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/navigating-health-and-care.aspx

18

Why does it matter to people with LTCs?

www.england.nhs.uk

• More activated patients have 8% lower costs in the base year and 21% lower costs in the following year than less activated patients

• Health coaching can yield a 63% cost saving from reduced clinical time, giving a potential annual saving of £12,438 per FTE from a training cost of £400

• Coaching and care co-ordination has shown to reduce emergency admissions by 24%

• Social prescribing can reduce emergency admissions by 11%• Timely physiotherapy for people with MSK conditions can save £1.50 for every

£1 invested• Community-based neurological care models could save the NHS £369,286 per

patient over 10 years• Improved medication adherence for instance in 6000 adults in the UK with Cystic

Fibrosis, could save more than £100 million over a 5-year timescale• Proactive case finding, frailty assessment, care planning and targeted

intervention could prevent between 20% and 30% of hospital admissions in over 85’s

• Areas that have implemented EPaCCs* see an increase in home deaths and annual savings of £35,910 per 200,000 population

*Electronic Palliative Care Co-ordination system19

Benefits to all

www.england.nhs.uk

The “treatment”

www.england.nhs.uk

Person centred coordinated care“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”

Goal:

Improve quality of life and experience of end of life care for people with Long Term Conditions and their carers through:

21

www.england.nhs.uk

Framing delivery….LTC Framework:

Empowered patient and carersProfessional collaborationBest Practice (clinical and organisational)Commissioning

Delivering Person Centred Co-ordinated Care Cf: ‘Roadmap for Strengthening people-centred health systems in the WHO European Region: A Framework for Action towards Coordinated/Integrated Health Services Delivery (CIHSD)’ (WHO 2013)

www.england.nhs.uk

The Framework

23

Organisational & Clinical Processes

Informed and engaged patients and carers

Health & Care Professionals committed to

partnership working

Commissioning

• Information and technology

• Case finding & risk stratification

• Guidelines, evidence and national audits

• Self Management• Patient activation• Health literacy• Group and Peer

Support• Care Planning• Carer support• 3rd sector support• Community

mobilisation

• Integration of services

• Multi Disciplinary Teams

• Health coaching• Clinical activation• Workforce

development• Care Co-ordination

• Place based approach to needs assessment and planning

• Joint Commissioning • Joint funding (BCF,

shared risk and reward)

• Metrics and Evaluation

• Service User and Public Involvement

Key factors needed to deliver Person Centred Coordinated Care and that are being supported nationally:

www.england.nhs.uk

The “review”

24

www.england.nhs.uk

The LTC Year of Care journeyNational

initiatives (pre 2012

)

Health &

Social Care Act

(2012)

National

Collaboration for integrated care

(2013)

Person

centred co-

ordinated care: LTC

framework (2013

)

Five year forwa

rd view 5YFV (201

4)

Post

election (2015)

Integration

pilots, Community

Matrons, Self management, Techno

logy, PHB, LTC Year

of Care

Commissioni

ng Programme

“Duty”, New

organisations, roles and

responsibilitie

s – Local, Nation

al

National

support –

Narrative,

definition,

Better care fund,

Integration

pioneers

Permissive

framework for

local implementatio

n – House

of Care

Clarity of

vision, prioriti

es, new

national

programmes: “new

models of

care”, “integrated

personal

commissionin

g”

LTCs embedded in

all programmes, Self-care

priority, STPs

25

LTC Year

of Care: Development year and site

selection

LTC Year

of Care:

1st year – experimentation to define scope

LTC Year

of Care:

2nd year –techni

cal phase (data and

analysis)

LTC Year

of Care:

2nd year –techni

cal phase (data and

analysis

LTC Year

of Care:

3rd year – development

of curren

cies and new

delivery

models

LTC Year

of Care:

4th year – implement

currencies,

testing deliver

y models and

capitated

budgets.

www.england.nhs.uk 26

Celebrating success

www.england.nhs.uk

Sharing the LTC YoC learning

27

1. Handbook and case studies:• Leadership and engagement• Co-production• Whole population diagnostic• Patient & Service Selection• Delivery Models• Defining and managing a budget• Contracting and performance monitoring

www.england.nhs.uk 28

2. Communication and promotion:• Nationally & Internationally• Presentations, articles, social media

3. Supporting other programmes/initiatives:• STPs, Vanguards, IPCs, Maternity review etc

4. EIS roles:• Local sharing and input into wider plans• 6 – 12 months f/u• What else?

www.england.nhs.uk

Continuing to implement and push the boundaries

29

www.england.nhs.uk

And finally - the world we operate in…

30

I can't change the direction of the wind, but I can adjust my sails to

always reach my destination.

Jimmy Dean

www.england.nhs.uk

@jaqwhite1#A4PCC

jacquie.white@nhs.net

www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/

31

Thank you

www.england.nhs.uk

Working in partnership across Kent developing integrated intelligence

Kent LTC YOC Commissioning EIS

Year of Care Early Implementer Workshop23rd March 2016

Kent Long Term Conditions Year of Care Commissioning Programme

Content

1. Public Health leading the informatics dimension using their statutory powers – Abraham George

2. The Kent approach to linking data, and identifying YOC patients– Pete Gough

3. The programme structure – for post Year of Care – Abraham George

4. Data Quality Improvement – Tom Bourne

5. Using the linked dataset for Matched Cohort studies – e.g. Home Safety Visits – Abraham George, James Finch (Kent Fire and Rescue)

 

1. Using Public Health Powers

Abraham George, Consultant in Public Health

Context - Local Profile of Kent

• >1.5 million population www.kpho.org.uk • Health and care service planning at multiple levels • Public Health Intelligence works closely with local data

warehouse team that collates and link data from >100 health and care providers

• Kent LTC YOC programme – Year 4 out of 4• 1 of 5 national early implementer sites• Part of national Integration initiatives eg. Pioneer, Vanguard,

Integrated Personal Commissioning etc.• Kent whole population dataset analyses examining impact of

multi-morbidity on health and care service activity and costs.

Public Health Statutory Powers• Health and Social Care Act 2012 - Councils have a statutory responsibility for improving the

health of their citizens and for providing local public health services • Includes a duty to take appropriate steps to improve the public health of people in our area -

include carrying out research, providing information, advice and facilities for the prevention and treatment of illness and providing incentives to encourage the adoption of healthy lifestyles. We also seek to minimise health risks to individuals arising from poor accommodation, environment or other factors.

• Public Health has a statutory right to access and use your confidential information, but only does so when absolutely necessary e.g.

– Organising the National Child Measurement Programme;– Organising the NHS Health Check Programme;– Organising and supporting the 0-5 health service and school nursing services;

• Statistics and intelligence are gathered about health and social care in order to meet our statutory duties to produce:

– Director of Public Health’s Annual Report;– Joint Strategic Needs Assessment; (Care Act 2014)– Health and Wellbeing Strategy;

• We have a statutory responsibility to assess risks to public health arising from inequalities in health care provision, poor quality or inappropriate housing, lifestyles, education and employment, communicable diseases, chemicals, poisons, radiation and environmental health hazards.

• Public Health are also supporting CCG’s with regard to Section 3 NHS Act 2006 Under section 3(1), a CCG must arrange for the provision of certain specified health services to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility.  

Why public health?

• Statutory powers• Located in council• Central position covering all CCG areas• Informatics expertise• Health intelligence expertise• JSNA

Legal ways to link data

Four choices for sharing confidential data about groups and populations:

• Consent (will generally need to be explicit rather than implied)

• HSCIC power • Support under s251 Regulations• Anonymised/pseudonymised data

39

Pseudonymisation Options

Option 1: Pseudonymisation at Source (no re-identification);Option 2: Pseudonymisation at Source (variation using Public and Private Key);Option 3: Pseudonymisation on Landing;Option 4: Full Consent;Option 5: Section 251 application to the CAG;Option 6: Department of Health issued directions to HSCIC (and therefore DSCROs);Option 7: A mix of the above (e.g. Southend-on-Sea).

Key Challenges1. Information Governance

– Current approach to data sharing has been difficult – different expert opinions on how to share / link data

2. Data quality and accessibility– Good support from provider organisations– Quality / completeness of data variables across

different organisations

3. Commissioner buy-in

Key Successes 1. Establishment of partnerships 2. Range of analytical projects to support commissioners

respond to national direction on payment systems3. Enhanced data quality discussions with providers

(prompted by analysis of linked dataset)4. Generation of research and development opportunities

with academia (PSSRU & Farr institute) 5. Raising awareness of informatics within local authority 6. Exploring new applications of linked datasets (e.g.

systems modelling)

2. The Kent approach to linking data, and identifying YOC patients

Pete Gough, HISbi manager

Defining MethodologyIdentify Year of Care Patient Cohort

Risk Strat Band 1 or 2 (top 5% of popn)Rising Risk score –

Rapid – 3 consecutive rises (15 points overall)Gradual – 4 rises in 6 months

Age 18 or over2 or more of QOF LTCs (from GP data)Remain in for minimum 6 monthsFlagged as B,C,D,E depending on number of LTCs

Defining MethodologyHow to create main dataset

Key is to link data at a patient levelNeed common identifier – NHS NumberAlso need to keep data pseudonymousTHIS WAS A PROBLEM!!!!A REAL PROBLEMTook 6 months to solve

Defining MethodologySolution:

Need method for organisations to flow data into dataset pseudonymised but flag as YoCSQL Hashing Tool – via SQL Server directly or via excel add inTwo numbers never exist in same place – pseudonymisation happens in transit

Defining MethodologyNow have a way of linking all datasets by patient without knowing who they were or being able to link to any other dataset

There was much rejoicing

3. Programme structure for post–Year of Care

Abraham George, Consultant in Public Health

Implementing Integrated Payments

LinkedDataset

HISbiProviders

Change Management, Engagement, Governance

Programme Management

Data Quality

PH

InformaticsAnalysis

PH

Model of Care

ImplementPayment

Arrangements

Contracts

Design ofPayment System

Flow of data into the Kent Integrated DatasetGP practice Mental

healthOut of hours

Acute hospital

HospiceAdult social care

Ambulance service

KENT INTEGRATED DATASET

Kent County Council Public Health and HISBI data warehouse

Community health

Public health

KID minimum dataset: data on activity, cost, service/treatment received, staffing, commissioning and providing organisation, patient diagnosis, demographics and location.

Datasets linked on a common patient identifier (NHS number) and pseudonymised

Arrangements are in progress to link to data covering other services, including: Health and social care services: Children’s social care, child and adolescent mental health, improving access to psychological therapies, and non-SUS-reported acute care. Non-health and social care services: District council, HM Prisons, Fire and Rescue, Probation, and Education.

C

KENT INTEGRATED DATASET

Ongoing data quality improvement efforts, to ensure data is of sufficient quality to support new payment systems and decisions on service reconfiguration

1. CAPITATED BUDGETS 2. SYSTEM MODELLING 3. EVALUATION

1. Select Cohort/ population

2. Select services

3. Set the price

4. Financial risk mitigation5. Payment cash flows6. Gain/loss agreements7. Quality/outcome measures

1. Generating evidence-based assumptions to support systems modelling

2. Quality assuring and refining existing models

Activity

Finance

Staffing Estates

Quality and safety

Contract model

1. Evaluation of commissioned services.

2. Attempts to identify the economy, efficiency and effectiveness of individual services.

3. Assessing the relative benefit of services compared to one another.

Utility of the Kent Integrated Dataset

4. Data Quality Improvement

Tom Bourne, Senior Analyst

C

KENT INTEGRATED DATASET

Ongoing data quality improvement efforts, to ensure data is of sufficient quality to support new payment systems and decisions on service reconfiguration

1. CAPITATED BUDGETS 2. SYSTEM MODELLING 3. EVALUATION

1. Select Cohort/ population

2. Select services

3. Set the price

4. Financial risk mitigation5. Payment cash flows6. Gain/loss agreements7. Quality/outcome measures

1. Generating evidence-based assumptions to support systems modelling

2. Quality assuring and refining existing models

Activity

Finance

Staffing Estates

Quality and safety

Contract model

1. Evaluation of commissioned services.

2. Attempts to identify the economy, efficiency and effectiveness of individual services.

3. Assessing the relative benefit of services compared to one another.

Utility of the Kent Integrated Dataset

Why invest resource in data quality?

• The Kent Integrated Dataset (the KID) will serve at least 3 important purposes:

1. To generate budgets for integrated care services

2. To evaluate complex care models (and interventions)

3. To generate assumptions to support systems modelling

• Whether service providers, commissioners, and finance managers will accept the KID’s evidence will depend on the assurances we can give on data quality.

• Or, put more positively, data quality can give service providers the confidence to change services or payment systems for the benefit of patients

Context

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Q, Do we have sufficient cost and activity data to support the development of new payment systems?

Data reconciliation templates

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Q, Is the quality of our data stable over time?

Data quality dashboard1. This first version of the dashboard concentrates on the completeness and longitudinal stability of the key data

fields and aims to introduce an element of competition around compliance by providers and CCGs.

2. We are now discussing ‘fatal quality thresholds’. On stability, this could be set at 5%, meaning that if in one month we received a dataset with only 94% of the number of records received from a data provider in the previous month, then this would be flagged for further discussion.

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Q, Do we have sufficient data to support new payment models?

PSSRU work- regression model to identify drivers of average total cost

Multi-morbidity

Age

Sex

Risk score(& previous use)

Controlling for practice led variation

Average Total Cost (ATC)

PredictorsExplaining up to a third of the

variation in ATC

Q, Can we use these drivers to segment the population into cohorts to build tariffs?

£1,014 across all population

£1,708 across just service users

PSSRU work - quantify likely uncertainty/tolerance

£1,500- 1SD- £200

+ 1SD + £200

Q, Will average costs produced from the dataset be sound predictors of future prices to support risk sharing decisions?

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Q, What have we learnt to date?

GP practices: need to focus efforts on West of the county (and better understand any bias introduced by ‘patchy’ coverage)

14 of 19 flowing

15 of 17 flowing

18 of 21 flowing

19 of 29 flowing

34 of 34 flowing

20 of 61 flowing

8 of 14 flowing

Also need better assurance over the quality of GP read coding, which we are using to define LTCs

High cost

drugs

GP prescri

bing data

Maternity

(non-deliver

y)

Pathology

Sexual health

For some we have been able to develop a plan to bring in

Some we are unlikely to ever get

For some datasets, the impact is large, and the ‘fix’ complicated, so we will need to develop temporary mitigation strategies and communicate approximate nature

There are several healthcare activities, accounting for significant chunks of expenditure, on which we are not yet capturing data

However, we are reasonably confident we can ‘account’ for this expenditure (known unknown) and must now prioritise sourcing this data and bringing it into our dataset.

Data quality efforts

Recording and prioritising

gaps

1. Formal data reconciliation exercise

with East Kent Federation of CCGs

2. Data quality clauses in CCG commissioning

contracts (working with CSU)

3. Informal data quality discussions with providers via Kent Wide Finance and

Informatics Group (supported by data quality

dashboard)

4. Working with University of Kent to establish

whether the cost and activity data we hold is of

sufficient quality to support new payment models5. Compiling a

comprehensive data dictionary

Data quality improvement plan

Data quality improvement planQuality dimension Research ready? (1-10)Accuracy 5

Timeliness and punctuality 10

Accessibility and clarity 2

Comparability: geographic 6Comparability: other units of healthcare 7

Comparability: over time 7Coherence Yet to be scoredRelevance 6Additional: External comparison Yet to be scored

Additional: Uniqueness 7Additional: Engagement of data providers 9

Additional: Engagemenf of data users 5 (and rising)

5. Matched Cohort Studies

Gerrard Abi-Aad and James Finch

Matched cohort analysis of Kent Fire and Rescue Home Safety Visit Data

Gerrard Abi-Aad, Head of Health Intelligence, Kent County Council

Version: 01Last updated: March 2016

71

Background

Increased interest in exploring the ‘hidden’ benefits of public services – fiscal constraints coupled with a recognition of the need for improved cross sectoral joint action. Kent Integrated Dataset – enhanced opportunity to evaluate ‘hidden impacts’ through data linkage techniques and advanced analytics

72

Identification of the final ‘Intervention’ cohort

KFRS – HSV data

Kent Patient Master Index (March 2015)

Individuals requesting and receiving a HSV(30,601, 01 April 2012 to 31 March 2015)

Initial NHS number

matching

11,377 / 30,089 (37.8%)

2nd stage matching to identify householders

Final intervention cohort HSV (requesters

+ ‘presumed’ occupants) 27,021* (15,644 +

11,377)*165 patients were removed due to further data quality

issues resulting in a final cohort of 26,856

73

Identification of the final ‘Control’ cohort

Presentation title, Month Year

Age

Index of Multiple Deprivation (LSOA)

Gender

A&E attendance date (01 April 2012 to 31 March 2015

SUS – A&E (Kent residents only)

(>500,000 cases)

74

Findings_1Of the 26,856 KFRS subjects identified, 7,478 (28%) were found to have attended A&E during the period 01 April 2012 to 30 September 2015. Of these, 4859 (65%) attended once only whereas 2,619 (35%) attended on two or more occasions. In total the 7,478 KFRS subjects ‘generated’ a total of 12,178 A&E attendances. The subject to attendance ratio for this group was 1.63 attendances per person on average.

Presentation title, Month Year

75

Findings_2The 7,478 subjects included in the analysis were case matched to 9,588 (128.2%) ‘control’ subjects in the A&E attendance dataset. Of these, 8,874 (93%) attended once only whereas 714 (7.4%) attended on two or more occasions. In total the 9,588 control subjects ‘generated’ a total of 10,443 A&E attendances. The subject to attendance ratio for this group was 1.1.

Presentation title, Month Year

76

Findings_3

Non parametric tests were used to assess whether or not the proportional distribution in A&E attendances differed between the control and the intervention groups. A two-way analysis of variance by ranks revealed no significant differences between both groups (p=.180).

Presentation title, Month Year

77

ConclusionsThe apparent lack of association between HSV and reduction in A&E utilisation is not necessarily indicative of absence of impact.Requirement for a more nuanced case control matching framework required but perhaps not possible? (A&E attendance for effects of inhalation?)Absence of a dynamic PMI may have introduced systematic bias (difficult to determine the scope of any potential bias)Perhaps most significantly, the high initial miss-match rate (62.2%) may have introduced further unhelpful bias which impeded a more accurate case control selection process. It has not been possible to assess the underlying reasons for the high miss-match rate?

Presentation title, Month Year

78

Kent Public Health Observatory

79

Thank you!

Presentation title, Month Year

Gerrard.abi-aad@kent.gov.uk

Http://www.kpho.org.uk/

www.england.nhs.uk

Working in partnership across Kent developing integrated intelligence

Questions and discussion

www.england.nhs.uk

Developing integrated data to support service redsign

Leeds LTC YOC Commissioning EIS

Developing integrated data to support service redesign

decision making

Alison Phiri - Business Intelligence ManagerMohini Chauhan - YoC Commissioning Manager

• Developing the data setWhat?

• Review of current Information Assets

• Gap analysis

• Developed Leeds Data Model

• Tailored Leeds Data Model for specific purposes.

What?

Leeds Integrated Health & Social

Care Data Model

Datasets linked on a common patient identifier

GP Practice Data Notional costs assigned

Community Dataset Notional costs assigned

Mental Health Data Cost per unit assigned

Inpatient Data

Adult Social Care Data No costs assigned

Outpatient Data

A&E Data

Year of Care Combined Dataset

ACG Grouper

Linked data processed through

the ACG Grouper to create risk scores

Input Dataset

Used for production of

capitated budgets

Output Dataset

Used for cohort

identification

To be defined

Dataset for shadow

monitoring

Key:

• How did we use the dataset?

So what?

• Cohort identification – pivot table hell!

• Created a tool that enabled us to get the best out of the data

• Introduction to data packs

• Data packs were developed to create an impact and so they could be easily distributed to stakeholders across the system.

• Inspiration taken from commissioning for value data packs.

• A visual and engaging way of presenting data.

• The data packs do not provide the answers to which cohorts should be selected. Their purpose is to generate discussion and to support stakeholders to make a more informed decision around which cohorts they would like to focus on.

Now What?

CASE MANAGEMENT

DISEASE MANAGEMENT

SUPPORTED SELF CARE

POPULATION WIDE PREVENTION

Which populations do we want to target?

Reducing unplanned admissions?

Reducing total costs?

Health outcomes/potential years of life lost (PYLL)?

Multimorbidity?

Age?

Risk of high healthcare utilisation?

Focus on now or the future?

Frailty?

Prevalence of CHD, COPD and Diabetes is higher than the rest of the city Around 40% of the NHS

Leeds South and East CCG population has one or more

LTC

Emergency readmissions are significantly higher than the national averageThe biggest cause of years of life lost is due to cardiovascular disease cancer and respiratory disease

More people have mental health problems than in the rest of the city, above the national average

Health related

quality of life for people

with LTC’s is

significantly lower than the national average

25% of the CCG population have an existing

health problem, which is above the England average

More people are living with 2 or 3 LTC’s, compared to the rest of the city By 18/19 PYLL

to be improved by 26.6%

Please note: the data on this slide was taken from a number of sources including; public health profiles, the LSE CCG 2 year plan, NHS England commissioning for value packs and the NHS England long term condition dashboard.

NHS Leeds South and East CCG

Whole population dataset

Analysis of Leeds city wide data involved testing the following methodologies to understand utilisation of healthcare services, over a two year period:

a. Patients who had three or more A&E attendancesb. All patients aged 85 and over c. All patients with a Frailty Index of seven or more d. All patients with 4 or more long-term conditions e. All patients in the top 2% by risk of unplanned hospitalisation in

the next 12 months (based on the Kings Fund’s Combined Predictive Model algorithm).

The analysis demonstrated an increased use of healthcare services over the subsequent two years when moving from (a) to (e) and points towards a multimorbidity model.

18-34 35-44 45-54 55-64 65-74 75-84 85+0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Number of LTC’s, by age, for people with at least one LTC*

13+

12

11

10

9

87

6

5

4

3

2

1

Age category

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

GP

Community

Mental Health

Outpatients

A&E

Inpatients

£0 £5,000,000 £10,000,000 £15,000,000 £20,000,000 £25,000,000 £30,000,000 £35,000,000 £40,000,000 £45,000,000 £50,000,000

£12,297,218

£11,947,166

£6,591,526

£12,381,539

£2,439,706

£43,220,633

Total costs of services, for people with at least one LTC*

Total costs (£)

Serv

ice

area 14%

13%

7%

14%3%

49%

% total costs of services

GP

Community

Mental Health

Outpatients

A&E

Inpatients

*NHS Leeds North CCG

1 2 3 4 5 6 7 8 9 10 11 12 13+ -

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Total costs of services, by number of LTC’s, for people with at least one LTC*

Inpatient

A&E

Outpatient

Mental Health

Community

GP

Number of LTC/s

Tota

l cos

ts (£

)

*NHS Leeds South and East CCG

1 2 3 4 5 6 7 8 9 10 11 12 13+ -

2,000.00

4,000.00

6,000.00

8,000.00

10,000.00

12,000.00

14,000.00 Average costs of services, by number of LTC’s, for people with at least one LTC*

Inpatient

A&E

Outpatient

Mental Health

Community

GP

Number of LTC/s

Aver

age

cost

s (£

)

*NHS Leeds South and East CCG

Patterns of multimorbidity*

*NHS Leeds West CCG

Ischemic heart diseaseCOPD

Depression(+any other conditions)

1028 people affected of which 47%

are male

Average costs per person, over a one year period £5,399

8.6 average number of LTC’s per person

Total costs, over a one year period £5,550,474

GP costs £439,814

Inpatient costs £3,277,790

A&E costs£199,067

Outpatient costs £438,993

Mental Health costs£155,436

Community costs£1,039,082

*NHS Leeds South and East CCG

18-34 35-44 45-54 55-64 65-69 70-74 75-79 80-84 85+0

50

100

150

200

250

0

10

65

205

153 152

182

150

111

Age split of patients who have IHD, COPD and depression (+any other conditions)*

Age category

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

50

100

150

200

250

0 0 1

11

36

119

171

203

153

121112

51

37

103

Numbers of multiple LTC’s for patients with IHD, COPD and depression (+any

other conditions)*

Number of long term conditions

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

NHS Leeds South and East CCG

Beeston Chapeltown Kippax Middleton Seacroft0

5000

10000

15000

20000

25000

12472

22856

14955

21171

14757

Neighbourhood teams

Num

ber o

f pat

ient

s

Neighbourhood team breakdown, for patients with at least one LTC*

*NHS Leeds South and East CCG

Leed

s C

ity M

edic

al P

ract

ice

City

Vie

w M

edic

al P

ract

ice

Oak

ley

Med

ical

Pra

ctic

eB

eest

on V

illag

e S

urge

ryS

hafto

n La

ne S

urge

ryC

ottin

gley

Com

mun

ity C

entre

Sha

ftesb

ury

Med

ical

Cen

treLa

ybou

rn &

Par

tner

s Th

e M

edic

al P

ract

ice

Bel

lbro

oke

Sur

gery

Eas

t Par

k M

edic

al C

entre

Gar

den

Sur

gery

Linc

oln

Gre

en M

edic

al P

ract

ice

The

Pra

ctic

e at

Har

ehill

s C

orne

rR

ound

hay

Roa

d S

urge

ryTh

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urge

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ork

Stre

etTh

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ichm

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Med

ical

Cen

treS

hake

spea

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omm

unity

Pra

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eA

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Con

way

Med

ical

Cen

treG

arfo

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edic

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Gib

son

Lane

Pra

ctic

eN

ova

Sco

tiaK

ippa

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all

Moo

rfiel

d H

ouse

Rad

shan

Med

ical

Cen

treS

will

ingt

on C

linic

Ling

wel

l Cro

ft S

urge

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urge

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urge

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ross

Sur

gery

The

Arth

ingt

on M

edic

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entre

Whi

tfiel

d P

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Mid

dlet

on P

ark

Sur

gery

Hun

slet

Hea

lth C

entre

Col

ton

Mill

Med

ical

Cen

treW

indm

ill H

ealth

Cen

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anst

on S

urge

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ark

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The

Fam

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urge

ry

Beeston Chapeltown Kippax Middleton Seacroft

0

1000

2000

3000

4000

5000

6000

7000

GP breakdown, by neighbourhood team, for patients with at least one LTC

Neighbourhood team

Num

ber o

f pat

ient

s

*NHS Leeds South and East CCG

102

Coronary heart disease (n= 1801)

Hypertension (n=8267)

Heart failure (n= 1122)

Stroke/ TIA (n= 1009)

Diabetes (n= 2314)

COPD (n= 1283)

Depression (n=8646)

Dementia (n= 399)

1632

1001

789

1766

791

2702

326

533

1001

204

361

277

404

120

279

789

204

242

160

391

143

520

1766

361

242

236

746

86

329

791

277

160

236

510

64

591

2702

404

391

746

510

194

138

326

120

143

86

64

194

1632

533

279

520

329

591

138

Coronary heart disease

Hypertension

Heart failure

Stroke/ TIA

Diabetes

COPD

Depression

Dementia

Multimorbidity analysis at NT level

COPDHypertention

Lipid Metabolism Disorders

Cardiac Arrhythmia

Ischemic Heart Disease

Heart Failure

Peripheral Vascular Disease

Renal Failure

Cerebrovascular Disease

Osteoporosis

Rheumatoid ArthritisEpilepsy

Parkinsons

Multiple Sclerosis

Hypothroidism

Chronic Pancreatitis

Chronic Liver Disease

Cancer

Depression

Bipolar Disorder

Schizophrenia

Dementia and Delirium

-

5,000

10,000

Prevalence of other conditions for pa-tients who have Diabetes (n=10654)*

*NHS Leeds North CCG

I visited my GP 35 times, in the past year

My name is Bob. I suffer from COPD, IHD,

rheumatoid arthritis, high blood pressure, high cholesterol and

depression

The total cost for my healthcare, over the

year, was around £9500

I was admitted to hospital 8 times, which

cost £6000

I was seen by a number of health professionals

and visited the outpatient clinic 19 times

I am between 45-54 years old

Having a care plan will help me feel more

supported to manage my condition

I want to feel more empowered to

manage my condition

Where can I find out about self help courses for people who have long-term conditions?

I want to find out more about my condition. Where are the

best places to do this?

Are there any lifestyle changes I should make to

help my health?

What do our service users say?How do I meet other people

who have the same condition as me? Is there a

local or national support group?I feel I cannot manage my

condition due to lack of information and support

How can I make my condition easier on my family and

friends?

Developing integrated data to support service redesign decision making

Questions and discussion

Health 1000:A local complex care organisation

BHR LTC YOC Commissioning EIS

My services selected by Me

• Introduction

• Technology developed to facilitate “YoC research and Health 1000 provision”

• YoC Research & Cohorts

• Implementation of a Person Centred Provider organisation

• Current Situation – Health 1000 Limited.

Establishing a Complex Care Organisation in East London

Presenter : Rob MeakerDate : 23rd March 2016

Background on the pilot site area in East London

Introduction

East Of England

LAS Station

Central London

Cluster 1

Cluster 2

Cluster 3

Cluster 4

Cluster5

Cluster4

Cluster6

Cluste

r3

Cluster2

Cluster 1

Cluster 1

Cluster 2

Cluster 3

Cluster 4

Cluster 6

Walk In Centre

Cluster 5

Hospital

Geography of the boroughs and key health infrastructure

Borough Population 770,000

Emerging GP federations

Redbridge federation

Havering federation

Barking & Dagenham federation

Introduction

Alignment between YoC and the vision for health and social care in BHR

Introduction

2008 – Polysystems & Person Centred Care

2009 – Risk Stratification

2010 – Integrated data

2011 – LTC management, & The Year of Care

2012 – Integrated Case Management

2013 – Rapid Response & Community Treatment Teams

2014– Complex Primary Care Practice establishment

2015– became operational.

Timeline for person centred care & complex care organsiation

Introduction

Operational January 2015, Core Staff Recruited, Patients No increasing

Ben and Eileen have been married for 59 years. They have four children, nine grandchildren and eighteen great-grandchildren and they also spent fifteen years fostering teenagers. Now, their focus is on enjoying life and their family.Eileen was diagnosed with osteoporosis in 1986, and has had resulting problems with her knees and joints. She overcame breast cancer and she also had a heart attack in 2012. Her husband, Ben, was diagnosed with prostate cancer last year and has a collapsed vertebrae in his back. They had been registered at their previous GP practice for 40 years when they received the call from Health 1000. Staff at the new practice explained that there would be specialists on hand, that they would be able to get an appointment whenever was convenient for them and that they could be looked after in their own home if need be. At first, they weren’t sure if they were doing the right thing by moving practice, but the support they’ve received since joining Health 1000 has left them confident that they’ve made the right decision. For Eileen, the biggest difference is that someone is always on the other end of the phone to help. When calling the practice, she can get straight through to their key worker who is already aware of all their problems and the medication they take. She said: “They’re always informative and eager to help. It feels like they know you personally and they’re interested in your welfare. It makes you feel more confident. We haven’t been with Health 1000 very long, but we’ve seen a big improvement.” The emotional support that they receive from Health 1000 is as important as the physical care. A while ago, Eileen was worried about her husband’s health. She called the practice and spoke to their doctor, who offered to come out to their home and give him a check-up that same day. She said: “Just offering to get someone to come and see you makes you feel so much better. You might not need it, but you know it’s there. They can make you feel better in yourself just by being there, and you know that they’re taking a real interest. That’s the most important thing.”

Patient case study - Health 1000

Ben and Eileen Eaton

Introduction

Before joining Health 1000, Maurice had been registered with the same GP practice in Barking his entire life. Maurice keeps busy and doesn’t like to take up too much of his doctor’s time, but he has a number of health problems and his GP suggested that he join Health 1000, as doctors there would be able to treat him in a way that would work better for him. Asked for his views on how he’s been treated since joining Health 1000, Maurice said: “I find I’m getting more attention here than at my old practice. Before I was just a number, but here I feel like they really listen to me. It gives me confidence.”Maurice finds it easier to get an appointment to see his doctor: “At my old practice, I might have had to wait two weeks to see my doctor. But pain doesn’t wait a fortnight! You want to get treatment for it there and then. Now I know I can call up in the morning, come down to Health 1000 and see someone.”He also knows that if the doctor has any concerns or if he needs an X-ray, they can send him on to the relevant department straight away, and it’s quicker and easier for him to collect his prescriptions.For Maurice, one of the best things about Health 1000 is the people that work there: “So far I’m impressed. They listen. Without a doubt I would recommend the practice to other people.”

Patient case study - Health 1000

Maurice Wilson

Introduction

The graphic below captures the experience of two patients using Health 1000

Play Video 540

Patient Story Part 1

https://youtu.be/x5ThfJ3dvxU

The Year of Care Pilot

Data Analysis and Cohort selection

Data Analysis and cohort selection

Infrastructure for effective data analysis has been a challenge

Hospital Data

GPData

Infrastructure is key

•Link data•Commission a data platform

Platform should provide

•Risk stratification•Case Management•Activity level data•Costed datasets•Fast user defined analysis•Not SQL•Automated reporting•Snova technology•ITK standard interfaces

 

Community data

Social Care data

Cohort selection

Data Analysis

Case Management

3949 individuals

Care ManagementSupported self care

40,248 individuals

Self CarePrevention and wellbeing promotion

162,163 individuals

RELATIVE RISK 2-20%Emergency admits = 7129 A&E visits = 26,756Total Cost= £47 million

RELATIVE RISK 0-1%Emergency admits = 3931A&E visits = 7158Total Cost = £16 million

RELATIVE RISK 21-100%Emergency admits = 1512 A&E visits = 23,586Total Cost= £22 million

Case ManagementImproving outcomes for patients with complex health and social care needs

Care ManagementIncreasing the ‘value of care’ provided to patients with long term conditions

Self CareEmpowering patients, carers & families to make informed decisions about their care treatment & providing choice in primary care to meet these needs

BHR

Kirklee

s

Lambeth

Leeds

North St

affs

South Es

sex0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Average cost of care for complex patients 1 % risk

Average cost per patientAverage

BHR

Kirklee

s

Lambeth

Leeds

North St

affs

South Es

sex

West Ham

ps0

2,0004,0006,0008,000

10,00012,00014,00016,00018,000

Average cost of care for patients 10 %

Average cost per patientAverage

BHR Total

Kirklee

s Total

Lambeth

Total

Leeds T

otal

North St

affs T

otal

South Es

sex To

tal

West Ham

ps0

5000

10000

15000

20000

25000

30000

Combined average for patient care

Average cost per patientAverage

Data Analysis

ICM increased community spend during YOC pilot

Data Analysis

Moved towards – comorbidities based on Scottish multimorbidity report 2008

Data Analysis

DiabetesDementiaStroke

COPD

HypertensionCVDHeart Failure Depression

Patient cohort for the service 5 or more long term conditions.2000 patients eligible across BHRCCGs and aim to recruit 1000

Patient cohortRow Labels Cohort Hypertension CHD Diabetes Stroke Depression COPD Heart Failure DementiaLTC 5+ 100 99 96 80 70 80 69 75 36Scottish modified LTC 4+ 1924 1816 1559 1421 863 793 783 679 303Grand Total 2024 1915 1655 1501 933 873 852 754 339

The selected cohort criteria, excludes CHC patients

The number of patients in the complex care cohort by the annual number of primary care contacts - 2013/14 data only, Barking & Dagenham CCG cohort only

This illustrates a relatively normal distribution of patients receiving primary care contacts around the mean of 51 contacts per year , but still there was one patient with 186 contacts in 2013/14 . The relatively normal distribution of numbers around the mean is represented by a skewness value of close to 1

Activity Cost (£thousand)

2012/13 2013/14 2014/15 2012/13 2013/14 2014/15

Primary Care Contact85,311 91,416 91,288 3,839 4,114 4,108

Pharmacy272,793 271,471 274,340 4,804 4,781 4,831

Acute care A&E2,341 2,342 1,936 277 291 244

Outpatient11,523 11,077 11,320 1,219 1,502 1,546

Daycase1,130 925 572 858 740 439

Elective162 131 128 579 392 353

NEL short-stay443 435 336 497 461 336

NEL long-stay959 985 768 3,174 3,178 2,538

Community care Face-to-Face12,052 20,654 24,936 2,210 3,814 4,396

Telephone1,032 1,859 2,244 55 96 109

Total17,511 19,368 18,899

Total annual number of events and total annual cost for all patients in the complex care cohort - all CCGs

Activity and cost for the cohort

Variation in activity between patients

The averages in the previous slide hide a great deal of variation. Thus if we take one example, patient's in the complex care cohorts on average visit A&E once a year but over 50% of patients did not visit A&E at all during 2013/14, and one patient visited 41 times .

Perhaps the most striking feature of the data is that large percentages of patient in the complex care cohorts didn't require acute inpatient care at all in 2013/14.

The trend in adjusted cost for all patient in the complex care cohort by service type

• Costs have more than doubled in 7 years

• 0ver 50% of costs are primary care

• Acute care accounts for 29% of cost and reducing

• £10k average cost per patient but escalates dramatically in last year of life

The costs have increased for these patients over the 7 years, presumably as more of the patients in the cohorts need services and/or patients in the cohorts need greater volumes of services

The greatest cost increases over the period for patients in the cohorts were primary care and community care. In percentage terms, the cost of acute care has decreased over the period.

The Implementation of a Complex Care organisation

Implementation

Legal & governance issues , Clinical design, Financial model, location and Patient recruitment

• Establishing the financial arrangements for the service as set up, then BAU and capitated budget moving forward

• CQC registration• Insurances wider provision of services• GPs and the Provider list and having a non GP as the clinical lead• CCG membership • Receiving records from practices- system challenges• Legal requirements for the Limited Company,• The APMS contract• Recruiting clinical teams for a time limited project and people leaving• GPs and the Provider list and having a non GP as the clinical lead

Challenges setting up the organisation

• Early Implementer site for YOC

• Advanced data sets from primary care, acute community and social care

• PMCF Bid to include testing of capitated budget being developed to one provider in early 2014

• PMCF Bid to include testing of capitated budget being developed to one provider in early 2014

• PMCF bid approved may 2014

May 2014

• Started work on project

May 2014

June-September 2014

• academic development of the service model and staffing requirements with UCLP

• Set up of the legal entity to operate the service

• Source premises• Source clinical leadership

October-January 2014

• Commence recruitment of staff

• Training • Premises set up• Legal entity formed• APMS discussions started• Engagement with practices • January 16th APMS

contract signed• January 19th first patient

registered

Complex Care organisation timeline

Governance

Community Trust

Private Provider

Voluntary Sector

GP Federation

Acute Trust

ROLE WTE at start up

Start up Cover provided WTE by month 3

MD and Geriatrician (50:50 role)

1.0 20 hours direct patient care plus 17.5 hours management plus on call support as required

1.0

HCS Key workers 5.0 73.5 hours per week 8am to 18.30pm Monday to Sunday. This is a dual function role covering reception and health care support and requires two members of staff to be on duty during 08.00 to 18.30pm Monday to Friday

6.0

GPs 3.0 52 hours per week 08am to 18.30pm Monday to Friday plusOn call for 5 hours per week Monday to Friday 6.30 to 8pm and 24 hours on Saturday and Sunday from 8am to 8pmA total of 81 hours per week

3.0

Practice Manager 1.0 37.5 hours per week as required to cover 7 days per week on rota

0.5

Nurse 1.0 37.5 hours per week during 8am to 6.30pm 0OT 0.5 18.5 hours per week during 8am to 6.30pm 3.0Physiotherapist 0.5 18.5 hours per week during 8am to 6.30pm 2.0Pharmacist 0.5 18 hours per week Monday to Friday as required 1Community Nurse 0.0 Not applicable 4.0

Mental health Nurse 0 Not applicable 0.5

Social Worker 1.0 Seconded from Local Authority

Complex Care organisation staffing model

Operation process for the clinical model

Key Features of the clinical model

• GP lead model of chronic disease management with proactive case management of medical and social care

• Tele-monitoring• Patient and carer education and enhanced self-management• Promotion of independence and personal responsibility• Shared care record with agreed care plan• Quality improvement embedded in culture• Key worker skills and competencies developed

Age UK care navigator pilot

Financial modelling

31/01/2015 28/02/2015 31/03/2015 30/04/201531/05/201

530/06/201

5 31/07/201531/08/201

5 30/09/201531/10/201

5

2 12 55 175 295 415 535 655 775 895

Costs Clinical Staff B £53,131 £53,131 £53,131 £53,131 £54,417 £65,585 £65,585 £76,754 £83,495 £87,923 Operational £17,634 £17,684 £17,899 £18,499 £19,099 £19,699 £20,299 £20,899 £21,499 £22,099 Per Patient Per Month Pharmacy £67 £133 £799 £3,663 £11,654 £19,645 £27,637 £35,628 £43,619 £51,610 £59,602Acute £174 £349 £2,093 £9,592 £30,519 £51,446 £72,373 £93,300 £114,227 £135,154 £156,081Community £175 £350 £2,098 £9,616 £30,596 £51,576 £72,556 £93,536 £114,516 £135,496 £156,476Social Care £83 £167 £1,000 £4,583 £14,583 £24,583 £34,583 £44,583 £54,583 £64,583 £74,583Out of Hours £34 £68 £405 £1,856 £5,906 £9,956 £14,006 £18,056 £22,106 £26,156 £30,206 £70,765 £70,815 £71,030 £71,630 £73,516 £85,284 £85,884 £97,653 £104,995 £110,022

Total Costs £71,831 £77,210 £100,340 £164,888 £230,722 £306,439 £370,987 £446,704 £517,994 £586,969Revenue Year of Care Payment £707 £1,414 £8,486 £38,892 £123,747 £208,602 £293,457 £378,312 £463,167 £548,022 £632,877APMS Revenue £80

Total Revenue £1,414 £8,486 £38,892 £123,747 £208,602 £293,457 £378,312 £463,167 £548,022 £632,877

Revenue > Cost???? YES YES YES YES

Total Spend Jan to Apr £433,846Total Available £900,000Total Remaining £466,154Total Spend to Breakeven £230,430

IN BUDGET

Total Additional Funding Requirement -£235,724

Point of transition where operating costs are lower than revenue and the organisation breaks even

Financial modellingApr-15 May-15 Jun-15 Jul-15 Aug-15

Description ParametersStaff Costs B Total Costs £164,888 £230,722 £306,439 £370,987 £446,704

Sensitivity Total Revenue Original £124,914 £210,569 £296,224 £381,879 £467,5341 Flex Capitated Revenue Increase by 25% Total Increased Revenue £156,142 £263,211 £370,280 £477,349 £584,417

Decrease by -25% Total Decreased Revenue £93,685 £157,927 £222,168 £286,409 £350,650Apr-15 May-15 Jun-15 Jul-15 Aug-15

DescriptionSensitivity Total Costs (Staff Costs UCLP) £182,320 £250,007 £326,858 £416,858 £482,692

2 Choose Staff Costs Total Costs (Staff Costs Health 1000) £164,888 £230,722 £306,439 £370,987 £446,704Total Revenue £124,914 £210,569 £296,224 £381,879 £467,534

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15£100,000

£300,000

£500,000

£700,000

£900,000

£1,100,000

Total Costs Total Revenue Original Total Increased Revenue Total Decreased Revenue

Tota

l Mon

thly

Cos

ts/R

even

ues (

£)

Effect of changing Capitated Revenue Payment Only

StaffNEW PATIENT (mins - once off) MD Geriatrician GP Nurse Therapist Social Worker Key Worker Source - see Health 1000 Staff email (hidden tab)

could either be any of five individuals doing this work so one fifth of total time assigned to each.

Initial Visit 14 14 14 14 14 70Assessment 24 28 24 24 24 72 various options of mix of staff undertaking workAdmin 60Care Planning 10 40 10 10 10 10TOTAL TIME A NEW PATIENT 48 82 48 48 48 212 minutes EXISTING PATIENT (mins per month) MD Geriatrician GP Nurse Therapist Social Worker Key Worker check 4 reviewsReviews 5.83 5.83 5.83 5.83 0.00 23.33 quarterly review of 70 mins by one professional 560 560Reactive 11.88 11.88 11.88 60 mins per day for 50 patients by 1 of 3 professionals TOTAL TIME EXISTING PATIENT 5.83 17.71 17.71 17.71 0.00 23.33

WTE 40 hours per week for 48 weeks

1920

WTE NEW 0.0004 0.0007 0.0004 0.0004 0.0004 0.0018 WTE 160 hours per month 160

WTE EXISTING 0.001 0.002 0.002 0.002 0.000 0.002minutes in hour 60

WITH UTILISATION MD Geriatrician GP Nurse Therapist Social Worker Key Worker UtilisationWTE NEW 0.0005 0.0008 0.0005 0.0005 0.0005 0.0022 85%WTE EXISTING 0.0007 0.0022 0.0022 0.0022 0.0000 0.0029

check for 1000 patients1000 0.71 2.17 2.17 2.17 0.00 2.86

Financial modelling – Staffing model calculations option B

Patient number VS Staff Costs

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

£0£20,000£40,000£60,000£80,000

£100,000£120,000£140,000£160,000

0

200

400

600

800

1000

1200

Staff UCLP Staff Health 1000 Patient Numbers

Staff

Cos

t

Patie

nt N

umbe

rs

1-Jan-15 1-Feb-15 1-Mar-15 1-Apr-15 1-May-15 1-Jun-15 1-Jul-15 1-Aug-15 1-Sep-15 1-Oct-15 1-Nov-15 1-Dec-150

200

400

600

800

1000

1200

Num

ber o

f reg

ister

ed p

atien

ts

Patient recruitment

Play Video 540

Patient Story Part 2

Outcomes per £ Spent

COM

SPREM

S

PROMS

Evaluation – Independent evaluation by the Nuffield Trust

BHRQuestions and Discussion

May 2013

• Early Implementer site for YOC

• Advanced data sets from primary care, acute community and social care

• PMCF Bid to include testing of capitated budget being developed to one provider in early 2014

• PMCF Bid to include testing of capitated budget being developed to one provider in early 2014

• PMCF bid approved may 2014

May 2014

• Started work on ACO roll out

May 2014

June-September 2014

• academic development of the service model and staffing requirements with UCLP

• Set up of the legal entity to operate the service

• Source premises• Source clinical leadership

October-January 2014

• Commence recruitment of staff

• Training • Premises set up• Legal entity formed• APMS discussions started• Engagement with practices • January 16th APMS

contract signed• January 19th first patient

registered

Year of Care Timeline

Outline governance structure

Direct reporting linesInformation flow

Programme Management BoardChair (independent)

NEDs (providers, CCGs, Programme Clinical Lead)

Executive Lead (MD)Other Executive (COO)

Complex Primary Care Practice

NHS EnglandCCGs

Local AuthoritiesContractual

Clinical Staffing(via providers)

Support ServicesHR

Finance IT

Other

Owners

(‘members’)

Regulators etcCQC

MonitorNHSLA

TDA

2

Differences in hospital service use between cases and controls (see table 5, page 25)

-10

0

10

20

30

40 Extra service use among the control group

n = 146 n = 126 n = 146n = 151

Estimated cost differences in acute sector based on projected changes in hospital activity.

-£100

-£50

£0

£50

£100

£150

£200

£250

Outpatients A&E Elective inpatientvisit

Emergencyinpatient visitCo

st d

iffer

ence

per

per

son

-m

onth

Low High Projected

The impact of the number of patients recruited to the service and plausible scenarios for which costs balance.

£0

£25,000

£50,000

£75,000

£100,000

£125,000

£150,000

£175,000

£200,000

£225,000

£250,000

0 100 200 300 400 500 600 700

Health1000 Total running cost Lower bound Upper bound Projected Health1000 staff cost

Upper bound costdifferences

Lower bound cost differences

Operational cost

Total running cost (including staff costs) of delivering service at Health1000practice

Projected costdifference estimates

Staff cost

+

Implications of relaxing eligibility criteria

Lower service use => Recruitment of more patients to achieve acceptable statistical powere.g. with a 15% reduction

It will affect the balance between fewer costs saved per patient and lower cost of providing primary care services via Health 1000

Numbers needed to achieve 80% power

Recruited under existing criteria

300

Existing criteria

600

Opening up to three conditions

800

A&E atten

dances

Outpatient visit

s

Electi

ve admissions

Emerg

ency admiss

ions

Primary

care co

ntacts

-60%

-50%

-40%

-30%

-20%

-10%

0%

% difference in use over 2014

Health service use for people with three conditions compared with those currently eligible for Health 1000

The Next Steps

Implementing The Learning From Health 1000 across the Wider

Health and Social Care Economy

Per capita costing

Health 1000: A local complex care organisation

Questions and discussion

www.england.nhs.uk

LTC Framework postcards game

Susie Peachey

www.england.nhs.uk

• Helping us to test and develop it

• Each group should have:• Picture of the LTC Framework • Set of 30 cards

• Aim is to match the illustrations to a section of the Framework

• THERE IS NO DEFINITIVE CORRECT ANSWER• It is the discussions that are as important as the

final result

The LTC framework postcard game

www.england.nhs.uk

Summary of the day and key messages

Bev Matthews

www.england.nhs.uk

23rd March 2016

CLOSE

LtC Year of Care CommissioningEIS and LTC Community of Practice

Workshop