Scn cvd-network-meeting-jan-2015

Improving health outcomes across England by providing improvement and change expertise

SCN CVD Network Meeting

Friday 16 January 2015

Chair Huon Gray

National Clinical Director Cardiac

October 2014

Contents (40 pages)

October 2014

NHS Improving Quality

Hilary Walker

Head of Living Longer Lives

Friday 16th January 2015

Summary (1)

• Local leadership & ‘structured partnership’

Summary (1)


• Single leadership group

Summary (1)


• Single leadership group

• Stable mandate + Mental Health (Parity of Esteem) prioritised

• Emphasis on workforce (LETBs and HEE)

• Prevention (National Prevention Board chaired by PHE)1. CCG & LG levels of ambition

2. National action (alcohol, fast food, tobacco and others)

3. National diabetes prevention programme

• NHS programmes to help people stay in work (including healthier NHS workforce)

Summary (2)

• Empowering patients (digital health records, access to GP records,

personal budgets, learning disabilities, choice, Public & Patient Involvement)

• Engaging communities (volunteering, charities, NHSE to reflect diversity)

• New models of care (national New Models of Care Board)– Multi-specialty community providers (MCPs)

– Integrated primary & acute care systems (PACS)

– Viable smaller hospitals

– Enhanced care in Care Homes

– Expressions of early interest by end January 2015

– Health & Care Garden City (Ebbsfleet and Bicester)

– Innovative technologies & working (AHSN & others partnering), CtE

– Emphasis on Urgent & Emergency, Maternity, Specialised, Cancer

– New National Cancer Strategy

Summary (3)

• New deal for primary care (workforce & infrastructure)

• Strong clinical leadership

• Improving quality & outcomes (National Quality Board)

• National Information Board – Transparency, paperless NHS

– Electronic prescriptions

– Discharge summaries, e-referrals

– Interoperable digital records

• Patient safety– Sepsis and AKI as priorities (CQUINs)

– Antibiotic resistance (CCG quality premium)

– Implement at least 5 of the 10 clinical standards for 7 day services

– Diagnostics, pathology & functional genomics

Summary (4)

• Increasing productivity & efficiency– Narrowing the gap between least and most efficient

– Technology

– Better staff retention

• NHS finances– 10% reduction in NHSE & CCG admin costs

– Accurate demand & capacity plans by providers and commissioners

– Tariffs (inflation +3.0%, tariff cost uplift +1.93%, provider efficiency expectation -3.8% so net decrease in tariff of 1.9%)• Marginal rate above baseline = 50% of tariff

• Up to 2.5% of provider income to come from national CQUINs– Existing (Dementia & Delirium, physical health in SMI)

– New (AKI, Sepsis, Urgent & Emergency care)

Improvement Programmes

Domain 1: Living Longer LivesHilary Walker

Domain 2: Long Term ConditionsJane Whittome

Domain 3: 7day ServicesAnn Driver

Domain 4: Experience of CareJane Whittome

Domain 5: Patient SafetyFiona Thow

Living Longer Lives

• Cardiovascular Disease

• Engaging Primary Care

• Raising Awareness

NHS Health Check

• NHS IQ have facilitated the spread of innovative approaches to engaging ‘seldom seen, seldom heard’ groups through our case study and webinar series.

• The work identifies examples of innovative practice, develops and publishes corresponding case studies and then holds webinars to support other Local Authorities in applying the learning to their own local situation

• This approach will be showcased as a Poster at this year’s International Clinical Microsystems Festival in Sweden (24th-26th Feb 2015)

• NHS IQ have worked with Public Health England to develop a self-assessment tool aligned to graded levels of support to aid Local Authorities in implementing the NHS Health Check Programme in their area.

GRASP update

• 2,723 practices have uploaded GRASP-AF data

• 101 practices have uploaded GRASP-COPD data

• 59 practices have uploaded GRASP-HF data

• 157 CCGs have uploaded data on at least one of the GRASP tools in at least one practice

GRASP roll out strategy

• A move to the promotion of audited care rather than a particular audit tool

• We are gathering intelligence on alternative audit tools in use

• We would like to identify those CCGs where no audit tools are in use and promote the use of GRASP in these CCGs

• If you have any information on the use of alternatives, or plans to use GRASP in your SCN or CCG then please contact Ian Robson or your regional LLL team contact

Date of next meeting

Friday 17th April in London

Focus on rehabilitation

Thank you

Any questions?

[email protected]

@hilarywalkerNHS

mailto:[email protected]

The Commissioning Landscape And Cardiovascular Disease Services

Personal Perspectives

Mark Scott

City and Hackney CCG

23

Summary Of Presentation

• Current Commissioning Landscape

• Developments In City And Hackney

– One Clinical Commissioning Group

– Impact On Commissioning Cardiovascular Diseases

• Discussion Points

– Implications For Strategic Clinical Networks

24

My Background

25

• Initially In Acute Trusts And Clinical Network– Moved to commissioning

• Worked for London CCGs– North West London and North East London

– Currently City and Hackney CCG

– Programme Director Integrated And Urgent Care

• Many English CCGs– Personal perspectives from one CCG

New Commissioning Landscape

• NHS England

- National

- Regional (Strategic Clinical Networks)

- Local

• Clinical Commissioning Groups

– Commissioning Support

• Public Health

26

Clinical GP-Led Commissioning

27

1991 to 1997

1994 to1997

2005 to 2011

2011 to present

GP Fundholding

Total Purchasing

Pilot

Practice based commissioning

CCGs and GP Commissioning

28

2011/12 Changes To The System

Current Structures In Health

• GP Commissioning

• Commissioning support market

• Central commissioning primary care

• Central commissioning specialist services

29

Health And Local Authority Issues

• Public Health

– moved to local authorities

• Better Care Fund

– Small proportion of services jointly commissioned through BCF

30

City And Hackney CCG

Where Is At Now?

31

Clinical Commissioning Started 2007

32

2005 to 2011

2011 to present

Practice Based Commissioning

CCGs and GP Commissioning

Practice Based Commissioning Focus on pathways

33

• Focus on pathways

• Linking secondary care and primary care

• GP Education

• Benchmarking performance data

• Demand management

East London Integrated Care

Success in improving quality and reducing costs

Historical Performance For CVD Outcomes Prior To PBC

• One of worst performing areas for CVD outcomes

• Poorly performing on intermediate outcomes– Blood pressure control

– Glycaemic control

– Cholesterol

• High premature mortality and high referral rates

34

City And Hackney Vs Other CCGs

• Rank Achievement For All 211 CCGs

• 50 Long Term Conditions QOF Indicators– City and Hackney – Top for 10 indicators– In the top 10 for 12 indicators– In top quartile for 14 indicators

• Low Referral Rates– 2.3% reduction in referral rates (09/10 - 10/11)– Challenge benchmarking CVD since changes in local

clinical networks

35

Quality And Outcomes Framework Data For 2013/14

36

Long Term Conditions Locally Enhanced ServiceImplemented March 2013

Percent Patients Treated Increased Patient Numbers

1

10

100

1000

BP ≤ 150/90 Cholesterol ≤ 5

CHD annualreview

Ad

dit

ion

al P

atie

nts

37

0%

30%

60%

90%

65+ pulserhythm

recorded

Cholesterol<5

BP <150/90

Pe

rce

nt

Pat

ien

ts

2013 2014

Variations In GP Practice PerformanceComparing Measuring Cholesterol and BP

38

0

10

20

30

40

50

0 10 20 30 40 50

Ch

ole

ste

rol M

eas

ure

s

BP Measures

GP Practices successful in one indication are successful in all

Increased Role Of Private Sector?

39

• Tendering contracts

– CVD contracts frequently re-commissioned

– Circle, Serco, Virgin situation

• Local experience

– Focus on collaboration and integration

Current Key Organizational Issues

40

• Primary Care Co-commissioning

– Conflicts of interest

• Commissioning Of More Specialized Services

– Capacity within CCGs

– Organizational memory

– Collaboration across CCGs

– Links with acute clinicians and clinical networks

41

Fine, Problem Or Bigger Problem

CCG 2

CCG 1

Finances Impacting Performance

42

• A&E Performance

• Delayed transfer of care

• Cancer waiting times

• 18 week waiting times

• Cardiovascular specific waiting times

Key Factors And Quality Gap

43

1. Funding

2. Reconfiguration and service change

3. Integrated health and social care economy

These three factors key to creating culture of clinically-led quality improvement

A&E Performance and Emergency Activity

44

Overall Performance

1. 2013: 96.0%

2. 2014: 95.8%

Activity Reductions comparing Q1 and

Q2 14/15 with 13/14 periods

A&E Activity Reductions

1. Activity Down: 4.9%

2. Costs Down: 8.5%

Emergency admission Reductions

1. Activity Down: 5.4%

2. Costs Down: 0.93%

Percent Seen Within 4 Hours

Target

07/03/13

15/06/13

23/09/13

01/01/14

11/04/14

20/07/14

28/10/14

91% 93% 95% 97% 99%

Beyond May 2015

45

Five Year Forward View

New Models of Care

• Multi-specialty community providers

• Integrated primary and acute care systems

What could this mean for the role of commissioners and quality improvement?

46

Example from New Zealand

Alliance ContractingNew Zealand Example

• Moved From Competition To Collaboration

– Networks and partnerships as guiding principles for health care delivery

• Removes Health Care Institutional Divides

– Sector-led governance arrangements

– Facilitate ‘whole of system’ approaches to care design and delivery

• Promoted clinical governance and leadership

47

Alliance Membership

Leadership And Chair• Independent chair

• Leadership skill based– Health professional and

managerial

• Capacity to:– lead/influence/understand

perspectives of professional colleagues

• General Practice, nursing, hospital specialty

Members • DHB and PHO CEOs and

managers

• GPs, specialists, nurses, allied professionals

• Ambulance and aged care residential services

• Måori/Pacific leaders

• Patients/community representatives

48

49

Alliance Southleadership

team

Comparison Of Contracts

Traditional Contract Alliance Contract

50

Healthcare Alliances

• Shared goals/objectives

• Clinically led– Whole of system approach

• Decisions based on:– Best for patient

– Best for system

• Pooled budgets

• Allocation of services

• High degree of trust– Competition undermines

alliances

• Joint accountability for results

• Innovation and flexibility– Promotes transformational

change

– Replaces business as usual amongst providers

51

One Hackney Alliance

HOMERTON ELFT CHUHSE CHUSE+LBH

PROVIDERTAVISTOCK

& PORTMANVOLUNTARY

SECTOR

One Hackney Challenge

•Providers set up services, with payment linked to outcome targets they set and agree with commissioners

•An £800k performance fund which will be paid to the One Hackney provider community if agreed metrics are achieved by 31 March 2015

•A further £800k performance fund linked to achievement of metrics during 2015/16

One Hackney Performance Metrics – Payment Basis

l

METRIC MEASURE/PAYMENT BASELINE TARGETMarch 2015

TARGETSeptember 2015

TARGETMarch 2016

1 Increase effectiveness of reablement/rehabilitation

12 month period to target month.Payment based on % achieved.

Payment baseline 90.4% (12 month period)

90.5% still at home 91 days after discharge 1 additional patient still at home90.5% - 100% paid

90.7% still at home 91 days after discharge8 additional patients still at home90.6% - 50% paid90.7% - 100% paid

91.2% still at home 91 days after discharge13 additional patients still at home90.9% - 50% paid91.2% - 100% paid

2 Increase proportion of people dying outside hospital

43% deaths outside hospital(2010-2012)(461 deaths outside hospital out of 1082 total deaths [EOLC Profiles])

Payment baseline 43% (12 month period)

43% deaths outside hospital (464 deaths outside hospital out of 1085 total deaths)

3 more deaths outside hospital43% - 100% paid

44% deaths outside hospital (480 deaths

outside hospital out of 1088 total deaths)

19 more deaths outside hospital43% - 50% paid44% - 100% paid

46% deaths outside hospital (503 deaths

outside hospital out of 1091 total deaths)

42 more deaths outside hospital45% - 50% paid46% - 100% paid

3 Emergency admissions forover 75s to reduce to the London average(all emergency admissions excl maternity, sickle dental and MH)

38 admissions per 1,000 population over 75 per month (Apr 2011 – Jan 2014)335 admissions per month [HES] for 8855 population [ONS 2013]

Payment baseline 335Performance to be based on 12 month average

Reduce admissions by 5 per month to 330 admissions

335 - 50% paid330 – 100% paid


Payment scale:335 (no payment) –320 (100% paid)


Payment scale:335 (no payment) –305 (100% paid)

One Hackney Performance Metrics – Payment Basis

l

METRIC MEASURE/PAYMENT BASELINE TARGETMarch 2015

TARGETSeptember 2015

TARGETMarch 2016

4 Emergency admissions all ages to remain lower than London average(all emergency admissions excl maternity, sickle dental and MH)

6.1 admissions per 1,000 population per month (Apr 2011 – Jan 2014)1735 admissions per month [HES] for 282,000 population [ONS 2013]

Payment baseline – London average

No increase in admission rate compared with London totalBelow London 12 month average – 100% paid

No increase in admission rate compared with London totalBelow London 12 month average –100% paid

No increase in admission rate compared with London totalBelow London 12 month average – 100% paid

5 Reduce emergency bed days 3000 bed days per month for over 75s(Apr 2012 – March 2013)

Payment baseline 3000 bed days per month for over 75sPerformance based on 12 month average

Reduce bed days by 15 to 2,985 per month in over 75s

3000 - 50% paid2985 – 100% paid

Reduce bed days by 75 to 2,925 per month in over 75sPayment scale:3000 (no payment) –2925 (100% paid)

Reduce bed days by 150 to 2,850 per month in over 75sPayment scale:3000 (no payment) –2850 (100% paid)

6 Reduce excess bed day costs £220k per month (Apr 2012 – March 2013)

Payment baseline £220k per monthPerformance based on 12 month average

Reduction of £5k per month to £215k

£220k - 50% paid£215k – 100% paid

Reduction of £20k per month to £200kPayment scale:220k (no payment) –£200k (100% paid)

Reduction of £40k per month to £180kPayment scale:220k (no payment) –£180k (100% paid)

7 Reduce % of admissions readmitted within 30 days

19% of admissions readmitted within 30 days (Apr 2012 – November 2013)Payment baseline 19% (rounded)Performance based on 12 month period

19%

19% or below - 100% paid

17%

Payment scale:19% (no payment) –17% (100% paid)

15%

Payment scale:19% (no payment) –15% (100% paid)

NB. One Hackney informed that baseline values being verified for more recent performance to ensure that targets still relevant.

Conclusions

• Clinical commissioning effective in City and Hackney – improving quality/reducing costs

• Step-change in improvements in cardiovascular outcomes

• Current trends reducing A&E attendances and emergency admissions

• Alliance approach key to quality improvement for integrated services

• Collaboration or competition - key dividing line

56


Lessons from Ants for Networkers

Muir Gray CBE

Better Value Healthcare

The future is not like the Isle of Man, a destination awaiting our arrival, it is like the Forth Bridge, something we have to imagine, design, plan and construct

We have had two healthcare revolutions, with

amazing impact

• Antibiotics• MRI • CT• Ultrasound• Stents• Hip and knee replacement• Chemotherapy• Radiotherapy• Randomised controlled

trials• Systematic reviews• Richard Doll in Gower street

The First The Second

However, all health services, everywhere, still face 5 major problems one of which is unwarranted variation which reveals the other four

• FAILURE TO PREVENT DISEASE &DISABILITY eg stroke and vascular dementia from AF

• WASTE OF RESOURCES through low value activity • HARM, from overuse even when quality is high• INEQUITY, from underuse by groups in high need

And new, additional, challenges are developing

• RISING EXPECTATIONS• INCREASING NEED• FINANCIAL CONSTRAINTS• CLIMATE CHANGE Variation in utilization of health

care services that cannot be explained by variation in patient illness or patient preferences.Jack Wennberg

After 67 years we cannot answer key questions such as

1.Is the service for people with seizures & epilepsy in Manchester of higher value than the service in Liverpool?2. Who is responsible for service for all the women with pelvic pain in Birmingham3.How many liver disease service s are there in England and how many should there be?4.Which service for people at the end of life in London provides the best value?5. Is the service for people with seizures & epilepsy in asthma of higher than the service in Somerset ?

If we could manage AF as well as they do in Bradford there would be 5000

less strokes a year” 1.Is the service for people with atrial fibrillation in Manchester better than the service in Liverpool?3.How many atrial fibrillation services are there in England and how many should there be?4.Which service for frail elderly people wih atrial fibrillation in the London provides the best value?1.Is the service for people with atrial fibrillation in Nottingham better than the service in Sheffield ?5.Which service for people with atrial fibrillation improved most in the last year ?

The Healthcare Archipelago

GENERAL MENTAL PRACTICE HEALTH

COMMUNITY HOSPITALSERVICES SERVICES

PUBLICHEALTHSERVICES

JURISDICTIONS INSTITUTIONS

PROFESSIONS

REGULATORS AND INSPECTORS

Complexity is the dynamic state between order and chaos Kieran Sweeney, Complexity in Primary care

Chaos…..….Complexity……...Order Services for homeless people

Screening for cervical caImmunisation

Services for people With physical and mental Co-morbidity

People with atrial fibrillationPeople with hip pain

People who are elderly and frail

People with pelvic painPeople with dizziness

People with multiple morbiditiywho are alert and online

More of the same is not the answer , not even better quality, safer, greener

cheaper of the same

we need to design, plan and build a new paradigm

The Aim is triple value & greater equity

• Allocative, determined by how the assets are distributed to different sub groups in the population

– Between programme

– Between system

– Within system

• Technical, determined by how well resources are used for all the people in need in the population

• Personalised value, determined by how well the decisions relate to the values of each individual

CVD

Respiratory

Gastro-intestinal

MentalHealth

Between ProgrammeMarginal Analysis and reallocation is a commissioner responsibility with public involvement

CVD

Respiratory

Gastro-intestinal

Between ProgrammeMarginal Analysis and reallocation is a commissioner responsibility with public involvement

CVD

Respiratory

Gastro-intestinal

MentalHealth

Many people have more than one problem ; GP’s are skilled in managing complexity

CVD

Respiratory

Gastro-instestinal

RhythmFailure

Coronary

Within Programme,Between SystemMarginal analysis is a clinician responsibility

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic

Obstructive Pulmonary

Disease)

Asthma

Triple DrugTherapy

Rehabilitation

O2

Stop Smoking Imaging

2. Carry out Within SystemMarginal Analysis

Technical Value (Efficiency) = Outcomes / Costs

Outcome= Benefit (EBM +Quality) – Harm (Safety )Costs (Money + time + Carbon)

Added value from doing things right (quality improvement)

Higher Value

HigherValue

High Value

Lower Value

Lower Value

THE INSTITUTIONAL APPROACH

Hellish Decisions in Healthcare

After a certain level of investment, health gain

may start to decline Benefits

Investment of resources

Harms

Benefits - harm

Point of optimality

1. Reduce lower or negative value activities

4 Increase High Value Innovation by

Disinvestment from Lower Value Interventions and ensure that any

innovation without strong evidence of high value is introduced using the IDEAL

method to ensure evaluation

ESR

Population healthcare focuses primarily on populations defined by a common need which may be a symptom such as breathlessness, a

condition such as arthritis or a common characteristic such as frailty in old age, not on institutions , or specialties or technologies. Its aim is to maximise value and equity for those populations and the individuals within them

It will be delivered not only by commissioners but also by clinicians practising population

medicine

BetterValueHealthcare

PrimarySecondaryAcuteCommunityManagerOutpatientHubandSpoke

Introduce new language A SYSTEM is a set of activities with a common set of objectives and outcomes; and an annual report. Systems can focus on symptoms, conditions or subgroups of the population

(delivered as a service the configuration of which may vary from one population to another )

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

A PROGRAMME is a set of systems with ha common knowledge base and a common budget

STEWARDSHIP to hold something in trust for another

Ban old language

The Healthcare Archipelago

GENERAL MENTAL PRACTICE HEALTH

COMMUNITY HOSPITALSERVICES SERVICES

PUBLICHEALTHSERVICES

SELF CARE

INFORMAL CARE

GENERALIST

SPECIALIST

SUPER SPECIALIST

This is an example of a national service set upas a system


Hierarchy Network

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

Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit from the knowledge of her team

Dr Jones is given 1 day a week for Population Respiratory Health and the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources for

Working with Public Health to reduce smoking Network developmentQuality of patient informationProfessional 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

Three levels of command

STRATEGIC

OPERATIONAL

TACTICAL

Single national

specification

1XX networks,

1,000,000 consultations

and self care

YEAR 1 1. prepare system specification through knowledge harvestingYEAR 2 2.Recruit the first cohort of population based services

3.Support the preparation of the first annual reports of the First Cohort Services

4.Facilitate sharing and learning, involving patient organisationsYEAR 3 5.Recruit the Second Cohort of populations

6.Support the preparation of the annual reports of the First and Second Cohort services

7.Facilitate sharing, learning & improvement involving patient organisationsYEAR 4 8.Recruit the third and final Cohort of populationsYEAR5 9.Support the preparation of the National Annual Report

10.Facilitate sharing and learning, involving patient organisations

We are now in the thirdhealthcare revolution

• Antibiotics• MRI • CT• Ultrasound• Stents• Hip and knee

replacement• Chemotherapy• Radiotherapy• RCTs• Systematic

reviews

The First The Second the Third

Citizens

Knowledge SmartPhone

NHS Confed/ AoMRCAoMRC

Future Focused Finance

Dalton Oldham

RCGP Kings Fund

Five Year Forward View + Personalised Care 2020


Map of Medicine - COPD

Work like an ant colony; Neither markets

nor bureaucracies can solve the challenges

of complexity


Map of Medicine - COPD

Work like an ant colony ; Proverbs 6;6

go to the ant, O sluggaard

study her ways and learn wisdom ,

for though she has no chief,

no officer or ruler

,she secures herfoo in the summer,

she gathers her provisions in the harvest


Huon Gray

CVD Update

16 January 2015

BHF Heart Stats (2012) http://www.bhf.org.uk/publications/view-publication.aspx?ps=1002097

CVD Mortality in England (all <75 yrs)

Source: www.statistics.gov.uk/ statbase/Product.asp?vlnk=6725

Causes of Death (England, <75 yrs)

(Source: ‘Living Well for Longer’ [ONS data], 2013)

Global Burden of Disease Study. Lancet 2013;381:997-1020

DALYs Attributable to top 20 (of 67) Risk Factors (UK)

CVD Risk: Future trend Obesity

England – Impact of Rising Trend in Obesity - Predicted Increase in Cardiovascular Disease Prevalence over & above Impact of Ageing

Diabetes Coronary Heart Disease Hypertension Stroke

2010 2% 1% 1% 1%

2020 15% 8% 5% 5%

2030 38% 20% 13% 11%

2040 68% 33% 23% 18%

2050 98% 44% 34% 23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre

dic

ted

% In

crea

se in

Dis

eas

e P

reva

len

ce

2010

2020

2030

2040

2050

Source: National Heart Forum. A Prediction of Obesity Trends for Adults & their Associated Diseases (NHF. February 2010)

CVD Risk: Ageing Population

England – Population Projections (Principal) –% Growth to 2012, 2017 & 2022

1% 1%2%

7%

3%

6%

2%

5%

2%

6%

20%

10%

22%

6%

10%

4%

7%

21%

31%

44%

10%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0-19 20-44 45-64 65-74 75-84 85 plus All Ages

Proj

ecte

d %

Incr

ease

in P

opul

atio

n

2010-2012 % Increase



Source: ONS Population Projections. 2010-Based

65-74 to growBy 20% 2010-2017

85 plus to growBy 44% 2010-2022

Long Term Conditions: Heart Failure Prevalence

Men Women Men Women Men Women Men Women Men Women

0-44 45-54 55-64 65-74 75 plus

England 0.0% 0.0% 0.2% 0.1% 0.9% 0.4% 3.1% 1.6% 13.7% 12.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Pre

vale

nce

of H

ea

rt F

ailu

re (

%)

England – Heart Failure – Prevalence (%) by Age & Sex - 2009General Practice Research Database 2010

Source: General Practice Research Database 2010, reported in British Heart FoundationCoronary Heart Disease Statistics . 2010 Edition

Long Term Conditions: Heart Failure - Future Prevalence

2012 2017 2022

45 Plus

Women 371,156 398,461 453,129

Men 344,728 387,815 450,342

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Est

ima

ted

Pre

vale

nt

Ca

ses

of H

ea

rt F

ailu

re

Women

Men

England – Heart Failure – Prevalence Cases – Projected Numbers to 2022 – Based on General Practice Research Database 2010

Source: General Practice Research Database 2010, reported in British Heart Foundation Coronary Heart Disease Statistics . 2010 EditionHeart Failure rates by Age/Sex applied to ONS Population Projections.

Up 10%Over 2012

Up 26%Over 2012715,884

786,276

903,470

CVDOS Recommended Actions (10)

• Seeing CVD as one condition (‘family of diseases’)

• Integration of services

• Risk factors, NHS Health Check

• Case finding in 10 care

• Better management in, and support for, 10 Care

• Inherited cardiac conditions (incl. FH)

• Improve survival from OHCA (CPR, AEDs, First Responders,

Education, Registry)

• Raising awareness

• 24 x 7 CV Services

• Care planning (phys & psych support, self care, EOL care)

• Information (CVIN, Service Level Markers, Clinical Audit)

• Researchhttps://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy

Stroke Update

Tony Rudd

16th January 2015

Areas for presentation

• Acute organisational audit

• Clinical audit data

• CCG audit

• Telemedicine commissioning guidance

• Stroke service toolkit

• Single level markers

Stroke News

• Publication of SSNAP organisational audit and June – Sept clinical data

• MR CLEAN trial of intra-arterial treatments

• MHRA review of alteplase

SSNAP organisational dataThrombolysis Provision

Source: SSNAP Organisational Audit, October 2014

1%

1%

0%

0%

8%

8%

83%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No provision at all

No onsite service and less than 24/7 service providedincluding local arrangements

Less than 24/7 service provided overall including localarrangements

Less than 24/7 service provided on-site, with no localarrangements

No on-site service but a 24/7 service provided involving localarrangements

Less than 24/7 service provided on-site but a 24/7 serviceprovided overall involving local arrangements

24/7 service provided on-site

SSNAP organisational data Decision making for thrombolysis – Normal

HoursNational My Site

Consultant physician in person 99% Yes/No

Consultant physician via telemedicine 8% Yes/No

Consultant physician via telephone 17% Yes/No

Registrar 11% Yes/No

Lower grade doctor 2% Yes/No

Stroke nurse band 8 0% Yes/No




Consultant as most senior 99% Yes/ No

Decision making for thrombolysis – Out of Hours

National My Site

Consultant physician in person 50% Yes/No

Consultant physician via telemedicine 61% Yes/No

Consultant physician via telephone 32% Yes/No

Registrar 10% Yes/No

Lower grade doctor 0% Yes/No





Consultant as most senior 94% Yes/ No

SSNAP organisational data Interventional Neuroradiology results

*on site or by referral to another site

Interventional Neuroradiology All sites (167) My Site

% of sites currently using intra-arterial treatment (e.g. thrombectomy) to treat patients with acute stroke*

54%

SSNAP organisational data Nursing levels

Registered nurses usually on duty at 10am

National – total stroke units

My Site

Median per 10 beds Per 10 beds

Weekdays 1.9

Saturdays 1.8

Sundays/Bank Holidays 1.8

Registered nurses usually on duty at 10pm

National – total stroke units

My Site

Median per 10 beds Per 10 beds

Weekdays 1.3

Saturdays 1.3

Sundays/Bank Holidays 1.3

SSNAP organisational data 6 or 7 day therapy working

34% of sites have 6 or 7 day working for at least two of: physiotherapy, occupational therapy, and speech and language therapy.

Source: SSNAP Organisational Audit, October 2014

35%

44%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Occupational therapy Physiotherapy Speech and Language therapy

SSNAP organisational data Prevention of venous thromboembolism

First line treatment for preventing venous

thromboembolism

National My site

Short or long compression stockings 1% (1)

Intermittent pneumatic compression device 42% (77)

Low molecular weight heparin 35% (64)

None of the above 22% (41)

London and East Midlands

East of England and West Midlands

North West

North of England/Yorkshire/Humber

South East Coast

South West/Thames Valley/Wessex

But don’t get too depressed......

Wales and N Ireland

Clinical AuditThrombolysis: Changes over time

D3 LevelNumber of teams achieving each level

Oct – Dec 2013 Jan – Mar 2014 Apr – Jun 2014 Jul – Sep 2014

A 10 teams (6%) 12 teams (8%) 9 teams (6%) 18 teams (12%)

B 20 teams (13%) 26 teams (16%) 31 teams (20%) 26 teams (17%)

C 35 teams (22%) 39 teams (25%) 40 teams (25%) 33 teams (22%)

D 49 teams (31%) 42 teams (27%) 42 teams (27%) 44 teams (29%)

E 46 teams (29%) 39 teams (25%) 35 teams (22%) 31 teams (20%)

Clinical AuditSpeech and Language therpay: Changes over

time

D7

Level

Number of teams achieving each level

Oct – Dec 2013 Jan-Mar 2014 Apr – Jun 2014 Jul – Sep 2014

A 5 teams (3%) 1 teams (1%) 11 teams (5%) 21 teams (10%)

B 16 teams (9%) 15 teams (8%) 19 teams (9%) 26 teams (13%)

C 34 teams (19%) 35 teams (18%) 48 teams (24%) 40 teams (20%)

D 19 teams (10%) 26 teams (13%) 24 teams (12%) 22 teams (11%)

E 109 teams (60%) 120 teams (61% 101 teams (50%) 93 teams (46%)

CCG audit

• >99% participation of CCGs in England– Services Commissioned

• Stroke specific services and generic• Who they are commissioning• Location of services

– CCG organisation• Clinical lead• Do they require participation in SSNAP• Any joint commissioning• Consortium commissioning

• Provisional reports for validation Jan, Final report February and public report march

• Start provider data collection March

Key Elements of a stroke service+ Includes stroke performance standards, repatriation pathways,

workforce guidelines, competency framework, education & training and telemedicine

Commissioning Assurance Framework+ Includes agreement templates such as collaborative working,

confidentiality and conflict of interest

Assessing Need + Includes Health Impact and equality impact assessments, as well as

cost benefit analysis

Programme Governance+ Includes pre-consultation and high level projects plans, engagement

template and Terms of Reference

Option Appraisal Process• Includes factors to consider for rural and urban areas

Stroke Reconfiguration Toolkit Contents

Travel and Activity Modelling – How to guide for the data modelling

+ Health datasets which can be used:

+ how to source these

+ how to use these

+ linking datasets to understand patient pathways

+ Understanding and forecasting changes

+ Modelling drive time & activity volumes

Toolkit Contents Continued

Financial Modelling

+ Template providing financial analysis & costing for stroke service reconfiguration

+ Includes provider and commissioner finance templates, with guidance around use

+ Detail around payment-by-results framework and best practice

+ Overall process map to guide project delivery

Toolkit Contents Continued

Via Stroke SCN per area+ Propose initial contact with Clinical and Managerial Leads to discuss

toolkit

+ Then host local workshops with SCNs and their contacts

Via CCGs+ Target Identified CCGs with Stroke as a priority in their area plans

+ Teleconference or local meetings

+ Add to Learning Environment

Proposed Dissemination

Action Date

Final Draft completion January 2015

BSCS Communications department to complete document layout and compilation

Mid - February 2015

Contact clinical and managerial; leads per SCN area to introduce toolkit and host meetings/workshops

January – March 2015

Contact CCGS to introduce toolkit – avoiding duplication February – March 2015

Upload document to Learning Environment February – March2015

Complete Dissemination March 2015

Planned Timescales

TelemedicineTelemedicine National My Site

Use of Telemedicine 70% Yes/No

If YES:

• Remote viewing for brain imaging is used 97% Yes/No/NA

• Video enabled clinical assessment is used 71% Yes/No/NA

• Telemedicine rota in operation with other hospitals 60% Yes/No/NA

Types of patients assessed by telemedicine National My Site

Only patients potentially eligible for thrombolysis 68%

Some patients (regardless of eligibility for thrombolysis)

21%

All patients (who require assessment during times when telemedicine is in use)

10%

Telemedicine Commissioning guide to be sent to all SCNs

National Action Plan commitment

“Overarching clinical indicators - For ten new clinical areas (including cancer, children’s services, mental health and stroke), data will be made available to tell the public how well services are performing and meeting their needs; the first of these will be available by summer 2014 with more available over the following 12 months. Once it is available, we will be able to use the care.datainformation service outlined above to support the development of this information.”

Service Level Markers: What is being asked?

Phase 1a

• Cancer

• Stroke

• cardiac

What areas have been considered?

Phase 1b

• Learning disabilities

• Mental Health

• Children

Phase 2

• Diabetes ?

• Maternity ?

• Respiratory ?

• Kidney ?

• Liver

• Other ?

Stroke Service Level Marker

• Using SSNAP performance

• Team centred data not patient level

• Adjusted for data quality and ascertainment

• Aim to deliver by March 2015

• Likely to be highly publicised

NCD Update(Renal)

Richard Fluck

Date: 15th January 2015

Think Kidneyswww.thinkkidneys.nhs.uk

System levers

• Forward view: into action 2015/16NHS England is proposing to introduce new national CQUIN indicators to tackle sepsis and acute kidney injury; and a new quality premium indicator to tackle resistance to antibiotics.

04/02/2015

Safety collaboratives: AHSN/SCNSign up for safetyHealth Foundation

‘AKI warning score’

Patient management

system

Alert Response

Local systems

Message

Master patient index

Other data systems

AKI Registry

RegionalNational

Research

QI

Measurement

Engaged,

informed

individuals

& carers

Commissioning

Organisational

& clinical processes

Person-

centred,

coordinated

care

Health & care

professionals

committed to

partnership

working

Plan

Study

Do

Act

CKD Identify patient-reported

outcomes measures

(PROMs)

Baseline data and

analysis

Multiprofessional

steering committee

Interventions to

increase PAM

Advice from

stakeholder groups

Joint work with

voluntary sector

organisations

Advice from

stakeholders

Test at CCG level

PROMs and patient/

carer stories influence

CCGBoards

Commissioning tools

and resources for

CCGs

Opportunities for

innovative

commissioning

Test and measure

PAM

PROM reporting

Use of RPV

Improved quality

reduces demand for

urgent and

unplanned care

Five Year Forward View: Patient Participation

‘Valuing Individuals – Transforming Participation in CKD’An Introduction for interested CCGs

The NHS Five Year Forward View sets out how the health service needs to change,arguing for a more engaged relationship with patients.

The UK Renal Registry working with NHS England, the NCD for renal and the renalpatient community have recently held a series of teleconference calls with CCGswho’ve expressed an interest in getting involved in this work.

Please find the questions the programme will answer through this process:• Routine collection of patient measures across a ‘joined up’ pathway of

care – PAM (Patient Activation Measure) and PROM (Patient ReportedOutcome Measure) is possible.

• Increasing patient activation in CKD is associated with better clinical and person centred outcomes. (Linking PAM to PROM)

• Person centred interventions can be put in place to increase patient activation.

Co-Design event for this programme will be held on the 3rd February 2015 in Birmingham

Please also find the criteria each CCG needs to meet to be involved:

• Broad commitment to the programme vision - increasing patient activation and support for self management

• Has or expects to have Renal Unit/satellite unit engagement – (units will need to commit to using the PAM other tools and relevant interventions) The UKRR may be able to help with engagement

• Has a long term commitment to move this work forward beyond the 2 years of the programme/aligns with other strategic priorities.

• When responding, it would be helpful to indicate what you as a CCG hope to achieve from this work. We can then build this aspect into the measurement work stream and evaluation.

There is significant support and expertise available via the programme and work streams: Measurement, Intervention and Commissioning. For further information please contact: Sue Shaw - [email protected]@renal.registry.nhs.uk or [email protected]




• Convene group to discuss and lead implementation of CG182– NCD Renal

– NCD Pathology

– Clinical Lead, CG 182

– Primary care GP

– CKD expert

– Patient

– Pathology expert

Five Year Forward View CKD: Prevention

11. NHS England has recommended to the Prescribed Services Advisory Group that the following services currently commissioned by NHS England should in future be commissioned by CCGs:

renal dialysis (excluding encapsulating sclerosing peritonitis surgery)

surgery for morbid obesity

Level 1Centralised – full national control of budgets and contracting

• e.g. highly specialised services that are low incidence and high cost

Level 2NHS England + CCG co-commissioning

• e.g. neonatal intensive care; many specialised surgeries

Level 3CCGs collaborating, potentially employing a ‘lead commissioner’

• e.g. renal dialysis

Level 4Full local commissioning

• e.g. chemotherapy

Commissioning of Renal Dialysis is changingConsultation finished – decision awaited

A new CRG structure is required for this model

Level 2

Level 3

Possible role for a new ‘Renal Disease CRG’ assurance Advise on renal dialysis at a national level via:

Exemplar service specifications

National service specifications that will have:• Core elements common across

CCGs to ensure that services

are of high quality in all regions

• Other elements optional to allow

CCGs freedom to do alterations

to meet the local population

needs

The CRG will add valuable specialist input to the local expertise of the CCG consortia:

• CRG to provide strategic planning advice to CCGs

Coordination and liaison with other bodiesQuality improvement

By Utilising data collection and reporting:

• Define quality indicators that can be used to monitor provider performance

• Collect national data on these indicators for comparison

• Publish public “State of the Nation” reports at national, regional and CCG level

• Inform and advice CCG consortia regarding low performing providers

Via financial levers and service improvement

Renal Dialysis is only one part of the renal pathway.• ESRF has many causes and

treatments

• Different parts of the pathway are

commissioned in different levels

• Extremely important to

collaborate with Renal

Transplantation CRG and NHS

Blood and Transplant

• Many bodies have an

interest/responsibility for parts of

the pathway

• Coordination is necessary to

ensure best possible outcomes

The Renal Disease

CRG would be able

to coordinate all

relevant bodies on

renal disease

National Diabetes Prevention Programme

Joanna Clarke, Medical Directorate,NHS England

16 January 2015

“We also need to make different investment decisions - for example, it makes little sense that the NHS is now spending more on bariatric surgery for obesity than on a national roll-out of intensive lifestyle intervention programmes that were first shown to cut obesity and prevent diabetes over a decade ago. Our ambition is to change this over the next five years so that we become the first country to implement at scale a national evidence-based diabetes prevention programme modelled on proven UK and international models, and linked where appropriate to the new Health Check. NHS England and Public Health England will establish a preventative services programme that will then expand evidence-based action to other conditions.”

Five Year Forward View

“We are today inviting those local areas that have made greatest strides in developing preventative diabetes programmes to register their interest at [email protected] by the end of January 2015 in joining with us as partners to co-design a new national programme led by Public Health England, NHS England and Diabetes UK. By March 2015 we will publish our agreed approach, and a nationwide implementation plan from 2016/17 onwards. A national Prevention Board, chaired by PHE and bringing together NHS, local government and other stakeholders will oversee delivery of these commitments.”

FYFV into action

• That those who are at high risk of developing diabetes are referred onto intensive lifestyle management programmes which will support them to lose weight, improve their diet, and be more physically active, and so, in line with the evidence base, reduce their risk of developing Type 2 diabetes.

• That these referrals could be made by GPs, via a personalised care and support plan, through the NHS Health Check programme, or through other routes (e.g. Diabetes UK risk assessments, or through assessments in the workplace).

• That these programmes are supported by marketing campaigns on obesity and Type 2 diabetes prevention, commissioned by Public Health England and local authorities.

Proposition

• The burden of obesity and Type 2 diabetes on the NHS is growing. The FYFV clearly makes the case for shifting the NHS’ focus from treating obesity to reducing it and preventing the development of Type 2 diabetes.

• It is now well established that Type 2 diabetes can be prevented or delayed in high-risk adults. At least 5 major randomised controlled trials, conducted in China, Finland, USA, Japan and India, have documented 30-60% reductions in Type 2 diabetes incidence in adults at high risk of developing diabetes through intensive lifestyle change programme interventions.

• The clinical case for is therefore well established, but has not been trialled at scale in England.

Rationale

• More people at high risk of developing diabetes will receive lifestyle interventions to support them to lower their risk; and

• The incidence of Type 2 diabetes will reduce over the longer term; and

• The incidence of heart, stroke, kidney, eye and foot problems (and mortality) related to diabetes will reduce over the longer term.

Key success measures:• [5-7%] weight reduction in participants of the programme• Risk reduction in participants of the programme• Reduction in the incidence of Type 2 diabetes and associated

diseases (heart attacks, strokes, etc)

Benefits

• Review the national and international evidence on diabetes prevention.

• Seek to identify existing good practice service delivery models, including previous roll out of similar national programmes, and assess approaches to targeting and tailoring of programmes to both increase effectiveness and ensure that take-up does not widen inequalities.

• Work up two or three prototypes for local delivery of referral systems and intensive lifestyle management programmes, based on the evidence and NICE guidance on clinical pathways, with ‘real world translation’, collaboratively with local commissioners, clinicians, and patients. These would be implementation prototypes rather than testing proof of concept (which has been established in international RCTs). These prototypes would conform to core criteria to be defined centrally, to ensure consistency with the clinical evidence base.

Approach (1)

• Develop information systems (including on GP systems) to record those at high risk and track referrals to intensive lifestyle management programmes (including those referred through the NHS Health Check programme), in the context of the prototype development work. GP support for the programme is key, and we will need to work with the GP community to ensure they are bought into the programme from the beginning.

• Establish a robust evaluation framework for the delivery prototypes, to be embedded from the start, to measure local incidence of Type 2 diabetes, and whether it is positively affected by the presence of a diabetes prevention service. This would be based around an operational research approach to evaluation.

• Assess benefits of linking evaluation metrics to payment mechanisms.

Approach (2)

• Test prototypes for local delivery, with a view to a phased roll-out in a staged approach across the country.

• Develop national health marketing strategies on Type 2 diabetes and obesity prevention to support and encourage local delivery of programmes.

• Develop a cohort of local clinical champions and support the development of local collaboratives/communities of interest to enable dissemination of learning and to coordinate local efforts.

Approach (3)

• International evidence review initiated

• First Prevention Programme Board Jan 20th

• Meetings of interested commissioners / providers and stakeholders in February to kickstart thinking on delivery models?

• First cohort of people going through the programme in 2015/16?

Timing

• Prevention Programme Board to sign off high-level approach

• Workstreams initiated in next few weeks

• By end of March, publish agreed approach

Next steps

Partnership working is delivering a regional FH service for the North East and North Cumbria - How might this provide a template for similar initiatives?

Dr Séamus O’Neill , Chief Executive, AHSN

Alison Featherstone, CVD Network Manager

Clinical Network & AHSN

164

North East, North Cumbria, and the Hambleton & Richmondshire districts of

North Yorks

Greater Manchester, Lancashire and south

Cumbria

Cheshire & Mersey

West Midlands

East Midlands

South West

Thames Valley

East of England

Wessex

Yorkshire & The Humber

South East Coast

London

Scale of our problem

• 3.1 million people

• 5,000 people living with FH mutations

• Only 15% known

• Perhaps 50 preventable cardiac deaths per year

– Small numbers per CCG

North East FH Service and History

• Adult specialist lipid clinics well established in 6 Trusts - Durham, Gateshead, Hartlepool, Newcastle, Northumbria, Sunderland

• Adult FH patients also seen in outpatients in Carlisle, Middlesbrough

• Paediatric Lipid clinics in 2 Trusts contributing to RCP Paediatric FH Register

• Regional expertise in FH Diagnosis and Cascade Testing - National Pilot ‘05 – ‘08

• Regional Genetic Service agree to continue support for FH mutation testing

• Specialist Lipid Clinics Network created ‘08 - NICE CG71 compliant FH pathway agreed

• NECVN Lipid Specialists Advisory Group (LSAG) established 2009

• NECVN proposal to implement NICE CG71 rejected by commissioners ‘09, ‘10

• FATS Primary Care Guidelines for Identification of FH (Agreed but not fully implemented)

• NECVN Standards for identification of FH in Acute Cardiology patients (launched ‘09)

FH: can we deliver the new NICE Quality Standard?

Hilton Newcastle Gateshead HotelBottle Bank, Gateshead,

Newcastle upon Tyne NE8 2AR

Northern Lipid Forumin association with

FH Services in the North East – Gap Analysis

• No centralised disease register for Adult FH probands and families in North East

• No Specialist nurses in Adult or Paediatric FH Clinics

• No regional infrastructure for FH Family cascade testing available to support Clinics

• No access to DNA mutation testing for new FH probands

• No clinical management database software (e.g. PASS) available to FH Clinics

• Adult specialist lipid clinics capacity shortfall, particularly in the south of the Region

• Paediatric Lipid clinics not available in south of the Region

• FATS/NECVN Primary Care FH Guidelines not fully implemented in south of Region

• No access to LDL Apheresis

FH: can we deliver the new NICE Quality Standard?

Plan1. Discussions with CCG2. Discussions with AHSN3. Continue bid to BHF4. Regional Approach

Northern Lipid Forumin association with

Northern CCG Forum

• GP Champion

• 13 CCGs– One of the SCN CCG’s is not part of the forum

• Long history of collaboration across the area– E.g. Clinical Innovation Teams

• Selling Idea To The CCGs– Prevention

– Innovation

– Implementing best practice

– Finance – collectively shares the investment

AHSN remit

• Adoption and dissemination of best practice at scale and pace

• Regional integration of a fragmented system

• Forum for collaboration across provider, commissioner academic and commercial organisations

• Working in partnership

AHSN pump-priming

• Project call December 2013

• Strategic priorities included integrated care

• Proposal submitted as partnership between CCGs, Newgene Ltd and Newcastle Hospitals

• £120k awarded (the maximum available)

• Supporting a local SME; partnership with SCN; addressing CCG priority; delivering a quantifiable return on investment

Resource• British Heart Foundation (approx. £160k)

– Nursing team for running regional FH cascade testing service

• AHSN (£120k)– Next generation chip and sequence genetics

• AstraZeneca (in-kind)– PASS software licence

• Northern Forum CCGs– Year 1 £134,122 Year 2 £294,277 Year 3

£368,520

• SCN (in-kind)– Admin support– Access to clinical networks

Current Status

• Steering Group

• Interviewed and recruited to nursing posts

– But still have vacancy interviews 27th Jan

• Regional MDT is in place – virtual

– Currently managed by SCN until admin in place

• Numbers tested have been small

– Nurses not in place

• Developing education for primary care

The Challenges

• Keeping the coalition together

• Dealing with bureaucracy – appointments of BHF-funded nurses

• Rolling out across other regions

– Any volunteers?

The partners

http://chsintranet/wp-content/uploads/2012/04/CHS-lozenge-logo-colour4.png

http://chsintranet/wp-content/uploads/2012/04/CHS-lozenge-logo-colour4.png

Contact Details

Any queries to:

Rachel TomlinNetwork Delivery Lead

Northern England Strategic Clinical Networks

NHS England

Tel no: 01138 251629 Mobile: 07980729760Email: [email protected]


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