Influence of QIPP on the commissioning of medicines

Professor David Colin-ThoméIndependent Health Care Consultant

Former GP and former National Clinical Director for Primary Care, Department of Health , England

david@dctconsultingltd.co.ukwww.dctconsultingltd.co.uk

Commissioners

• – not providers – should decide what they want to be provided. • They need to take into account what can be provided, and for

that purpose will have to consult clinicians both from potential providers and elsewhere, and to be willing to receive proposals, but in the end it is the commissioner whose decision must prevail. (Francis Inquiry 2)

• And Jeremy Hunt set out his agenda. His four priorities were improving dementia care; improving survival rates for killer diseases; investing in technology; and making sure that care was just as important as treatment

The King’s Fund Transforming our health care system (2011)

Top Ten priorities for commissioners 1. Active support for self-management2. Primary prevention3. Secondary prevention4. Managing ambulatory care sensitive conditions5. Improving the management of patients with mental and physical needs6. Care co-ordination through integrated health and social care teams7. Improving primary care management of end-of-life care8. Effective medicines management9. Managing elective activity-referral quality10. Managing emergency activity – urgent care

Better Health, Better ValueMuir Gray

 •Although the clinical advances of the last fifty years have led to dramatic improvements in health there are still five outstanding problems in every health service: •patient harm, waste, unwarranted variation in outcome, inequity, and failure to prevent the preventable. •Furthermore, every service also has to face the four new challenges – rising demand and increasing need which have to be met within both financial and carbon resource constraints.•With five types of commissioning, Clinical Commissioning Groups, Specialist commissioning, public health commissioning, local authority commissioning and the commissioning of primary care-general practice, pharmacy services, dentistry and optical.

Whither the role of pharmacy?

• Medicines advice and optimisation of course• Contribute to clinical commissioning• But NHS commissioning is all about value in provision• So providers need to contribute to commissioning• How to influence ‘ right care’ and compassion particularly in

hospital• Community Pharmacy as a resource to its community• Collaboration and competition with list based general practice• All providers need to have a population responsibility• Long term conditions care is the health and healthcare issue• Care of the frail elderly a national disgrace

Long Term conditions

• Prevention• Early diagnosis• Self care• Bio-clinical interventions in primary and secondary care• Re-ablement and rehabilitation• End of Life care• Meeting of two experts-care planning and a ‘Year of Care’• Social Care

QIPP

• The NHS is tasked find 4% productivity growth per year over the next four years – the “Nicholson challenge”.

• The Department of Health has stated that it expects 40% of this to come from reduced hospital activity tariffs and the same from improvements in workforce deployments.

• The NHS is on track in 2011/12 to meet QIPP objectives. Currently this is weighted towards central actions, including pay and administrative cost reductions and local efficiency programmes.

• For future years, delivering the additional efficiency savings and quality improvements will require the NHS to focus on delivering transformational change through clinical service redesign.

DH QIPP Right Care

• Right Care is a programme designed to increase the value from the resources allocated to healthcare and directly address variations in spend, activity and outcomes in three ways:

• improved clinical involvement in commissioning • stronger patient involvement through shared decision making • supporting commissioners with knowledge, information and

coaching to consider the legitimacy of variation and thus whether the level of variation needs addressing

• unwarranted variation, defined as “Variation in the utilization of health care services that cannot be explained by variation in patient or patient preferences”.

Commissioning has been too bureaucratic, focused on contracts and too complicated

• I was a commissioner for 36 years. I used to call it a referral• In the NHS, commissioners must be about ensuring good provision of care for

their patients• It is the unique attributes of the GP system that has lent itself well to being the

central plank of post 1990 English NHS reform.• Much of what is done in hospital (and expensively) can be done out of hospital • And once out of hospital the hospital’s resources must follow• Out of hospital does not always entail more clinical work for GPs-OP FU and

LTC care• It is about good relationships underpinned by contracts not defined by the

contract• Need good information/Business Intelligence to make best value decisions• And we have;• Poor clinical outcomes and the present NHS continues to under perform• Outdated and outmoded organisation of care• Clinical interventions of low value

Patient Decision Aids:

• International evidence suggests a 20 per cent reduction in ‘discretionary surgery’ when Patient Decision Aids are used (Cochrane Collaboration review).

• Research from the Ottawa Hospital Research Institute also states that patients who don’t have decision support:

• Are 59 times more likely to change their mind• Are 23 times more likely to delay their decision• Are five times more likely to regret their decision• Blame their practitioner for bad outcomes 19% more often

Variations in healthcare

• Variations in healthcare exist for many legitimate reasons. Populations and individuals have distinct needs, and some of the variation observed is a reflection of the responsiveness of the service to meeting particular needs.

• However, the degree of variation demonstrated for instance in the Right Care Atlas of Variation cannot be explained solely on that basis.

• Unwarranted variations are driven not by the needs of the patient but by the limitations of the healthcare system and the healthcare professionals within it.

The primary objective for Right Care is to maximise value

• the value that the patient derives from their own care and treatment

• the value the whole population derives from the investment in their healthcare

To successfully increase value for both patient and population, health service reform must integrate both in an single model; separately, they become opposing imperatives

Francis Inquiry 2 The System!

• As identified during the first inquiry, the Trust was an organisation that lacked insight and awareness of the reality of the care being provided to patients. It was generally defensive in its reaction to criticism and lacked openness with patients, the public and external agencies.

• The responsibilities and accountabilities of external agencies were not well defined, often resulting in “regulatory gaps” or failure to follow up warning signs.

• Organisations operated in silos, without consideration about the wider implications of their role, even guarding their territories on occasion.

• This situation was exacerbated by a lack of effective communication across the healthcare system in sharing information and concerns. Organisations relied on others to keep them informed rather than actively seeking and sharing intelligence.

• At the heart of the failure was a lack of openness, transparency and candour in the information emanating from the Trust and over-reliance on that information by others.

• This was not helped by the constant reorganisation of NHS structures, often leading to a loss of corporate memory and misunderstandings about an organisation’s functions and responsibilities. Information flow was generally poor.

In the future

• A “cure” or “vaccine” for certain cancers. • An increase in the number of lifestyle drugs available • Devices that have the capacity to replace or integrate

with human tissue • Biosensors that allow continuous monitoring of a

patient • Pharmacogenetics support more effective treatments • In the longer term stem cells provide capacity to

replace or repair organs