The last forty years in healthcare have been terrific

Sir Muir Gray

Keynote presentation at NIHR CLAHRC East Midlands launch event, 14 February 2014, Loughborough

Progress in the last 40 years has been amazing but all health services, everywhere, still face 5 major problems one of which is unwarranted variation which reveals the other four

• HARM, from overuse even when quality is high• INEQUITY, from underuse by groups in high need • WASTE OF RESOURCES through low value activity • FAILURE TO PREVENT DISEASE &DISABILITY

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

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.

Cancer

Respiratory

Gastro-intestinal

Between Programme Marginal Analysis and reallocation is a Board responsibility with public involvement ; the aim is optimal allocation ie you cannot get more value by shifting a single £

Allocative value

Cancer

Respiratory

Gastro-intestinal

MentalHealth

Between Programme Marginal Analysis and reallocation is a commissioner responsibility with public involvement

Cancers

Respiratory

Gastro-intestinal

MentalHealth

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

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic Obstructive Pulmonary Disease)

Asthma

Within Programme,Between SystemMarginal analysis is a clinician responsibility

Cancer

Respiratory

Gastro-intestinal

MentalHealthSpecialist

Commissioning

Technical Value = Outcomes / Costs

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

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic Obstructive Pulmonary Disease)

Asthma

Triple DrugTherapy

Rehabilitation

O2

Smoking cessation

Within SystemMarginal Analysis is a clinical stewardship responsibility with patient involvement

The law of diminishing returns

Benefits

Investment of resources

Harmful effects increase in direct proportion to the resources invested

Harmful orSide effectsOf care

Investment of resources

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

Benefits

Investment of resources

Harms

Benefits - harm

Evidence,Derived from the study of groups of patients

The values this patientplaces on benefits & harms of the options and on risk taking

The clinical condition of this patient; other diagnoses, risk factors and their genetic profile and in particular their problem, what bothers them psychologically and socially

Choice Decision

Personalised and Stratified Medicine

As the rate of intervention in the population increases, the balance of benefit and harm also changes for the individual

patient

Necessary appropriate inappropriate futileHigh value Low value Negative Value

BENEFIT

HARM

BetterValueHealthcare

• Is epilepsy care in Leicestershire better than epilepsy care in Derbyshire?

• Who is responsible for the service for people with bipolar disorder in Lincolnshire?

• Did the service for people who are breathless in Rutland improve last year?

• Is the service for frail elderly people getting better in Nottinghamshire, is it better than in Northants, and who is responsible for it?

• How many asthma services should there be in the East Midlands and is that different from the number of services for inflammatory bowel disease or rheumatoid arthritis ?

NHS or nHS?

The Care Archipelago

GENERAL MENTAL PRACTICE HEALTH

COMMUNITYHEALTH HOSPITALSERVICES SERVICES

SOCIALSERVICES

The Commissioning Archipelago

GP/ Pharmacists/optometrists

Public Health

Specialistcommissioning

211 CCG’s 152Local Authorities

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 for those populations and the individuals within them

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

Ban old language

General practiceCommunity

services

Hospital care Mental healthcare

Self-care

Informal care from family and voluntary help

Generalist

Specialist

From archipelago to system People receive care that is co-ordinated around their needs

and supports them to live the lives they want to lead

Social care

SuperSpecialist

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

BetterValueHealthcare

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

BetterValueHealthcare

“Culture…the shared tacit assumptions of a group that it has learned in coping with external threats and dealing with internal relationships.”Schein, E.H (1999) The Corporate Culture Survival Guide

“Leadership …and a company’s culture are inextricably interwined.”Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System

Two national public health projects

• The stroke and vascular dementia (SVD) prevention project – improving health through population and personalised care for people with atrial fibrillation – 25th march

The Falls and Fragility Fracture (FFF) prevention project – improving health through population and personalised based systems for people at risk of falls and fragility fractures -27th March

New Knowledge

• An understanding of all issues related to value, including the ethical issues such as accountability for reasonableness; and the work of Amartya Sen and Norman Daniels

• Understanding allocative efficiency and relevant writings, such as the workings of Thomas Rice

• Systems and network development with familiarity with other work of people such as Manuel Castells.

• Concepts of population accountability for clinical services including the work of Thomas Friedman.

New skills

• Understanding and Increasing Value• Designing and building Systems of Care• Creating the Right Healthcare Culture• Delivering Population-based Medicine.• Designing and delivering Patient Centred and

Personalised Care

BetterValueHealthcare

Map of Medicine - COPD

Work like an ant colony; Neither markets nor bureaucracies can solve the challenges of complexity