Tim Briggs

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IMPROVING CLINICAL QUALITY, THE BACKBONE OF THE CARTER REPORT AND THE MODEL HOSPITAL Getting it Right First Time (GIRFT) Open Forum Events 26 th May 2016 Professor Tim Briggs Consultant Orthopaedic Surgeon RNOHT National Director Clinical Quality and Efficiency NHS Past President of the BOA GETTING IT RIGHT FIRST TIME Improving the Quality of Orthopaedic Care within the National Health Service in England

Transcript of Tim Briggs

Page 1: Tim Briggs

IMPROVING CLINICAL QUALITY, THE BACKBONE OF THE CARTER REPORT AND THE MODEL

HOSPITAL

Getting it Right First Time (GIRFT)Open Forum Events

26th May 2016

Professor Tim Briggs

Consultant Orthopaedic Surgeon RNOHT

National Director Clinical Quality and Efficiency NHS

Past President of the BOA

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Background: The NHS in UK – “The Perfect Storm”

• Growing population – 60M in 2010 now 64M in 2014

• Ageing population – By 2030 33% >60 yrs. 15.3M >65yrs by 2031• Population living longer and expecting to remain active

• Increasing BMI – by 2050 60% men / 50% women will be obese.

• >65% patients admitted are 75 yrs age or greater

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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12th NJR Annual Report - 2015

• Hip Revisions:• 2009 2014 – 7,478 8,925

• 19.4% increase• 2004 2014 – 2,698 8,925

• 231% increase• Knee Revisions:• 2009 2014 – 4,780 5,873

• 22.9% increase• 2004 2014 – 1,221 5,873

• 381% increase

THR/TKR47,000 in 2004181,000 in 2013

>200,000 in 2014

Each increasing by over 7% annually

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Background: Recent News NHS settlement

• The NHS settlement for 2016-2017 has given the provider sector some breathing space but also challenges.

• £3.8billion additional funding from the Treasury, and the 1.06% inflation uplift together with only a 2% tariff efficiency factor ( most providers were expecting 3.8%)

• In real terms 1% per annum real terms increase funding next 5 years

• Currently NHS 8.6% GDP By 2020 – NHS will run on 7% of GDP

• The provider sector will need to critically look at itself: IMPROVE QUALITY, VARIATION, EVIDENCE BASE

• TRANSFORMATION to maintain long term sustainability. requiring efficiency planning, and some centralisation of services across all sectors of provider provision

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

UK Govt debt £1.5 96 TrillionBorrowing £1Bn every 4 daysInterest £1Bn per weekAusterity: NHS savings £22Bn

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In reality…The NHS will be underfunded by Billions

Procedures of low clinical value

Dr. Foster Annual Report

The pressure is on GPs NOT to refer increasing numbers of patients for Orthopaedic careNew Devon CCG deficit of £14.5 Million last yearNew criteria “Urgent and Necessary measures”Aim: Balance the books

* Requiring patients with a BMI over 35 to lose 5% of their weight or to get under BMI 35 before planned surgery* Requiring patients to stop smoking for at least eight weeks

before planned surgery* Suspension of some types of shoulder surgery

This will dominate the health agendaCCGs don’t know what they are buying

We need to find another wayClinically led!!

CCGs under significant financial pressure

Demand Management – RationingDe-commission services

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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London• Annual Health Budget £16 Billion

• £1 Billion into primary care

• £2 Billion into Mental Health

• £13 Billion spent in HOSPITALS (Providers)

• In London 23 Trusts carrying out 13% of total orthopaedic and spinal elective activity in England

• Provision of Care is 80% of the cost ie Secondary care providers

• We as Clinicians need to make the changes to our practice

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Provision of Care is the Key

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GIRFT Objectives

• Supporting the following in elective orthopaedic care:• Improved patient experience • Re-empowering clinicians• Improved patient safety• Better outcomes in terms of joint longevity, infection – SSI and

acquired, complications, readmissions and mortality• Significant taxpayer savings from reduced complications;

infections; readmissions; length of stay and litigation; better directed care pathways; reduction in loan kit costs; and introduction of evidence based procurement and procedure selection.

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Published in 2012

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Data sources – 12 sets of data collected for each trust• Data accumulation and collation is complete

• A comprehensive orthopaedic dashboard has been created for each provider. Data sources include:

• NJR (disappointingly not all data is available by provider – e.g. Longevity/revision rate by different prosthesis/weight bearing surface etc)

• HES• HSCIC• NHS Comparators• NHS Indicators• Productivity Metrics• PROMS• National data sources – waiting times etc• National Hip Fracture Database• NHS Litigation Authority• NHS Atlas of Variation • Arthritis Research UK Musculoskeletal Calculator

UNIQUE Data Set For Each Trust

Visits started in SeptemberPeer to Peer reviewTrust receives data 14 -21 days before visitWe want to understand the data

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Variation Huge and Widespread Surgical site infections – 10 Trusts in same City

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Nos of Orthopaedic processes reported

% with infections –initial patient spell

% with infections – initial patient spell+ readmission

Trust 1 349 1.43% 1.43%

Trust 2 116 1.72% 1.72%

Trust 3 809 1.11% 2.47%

Trust 4 685 0.58% 0.73%

Trust 5 156 3.85% 4.49%

Trust 6 2657 0.68% 1.05%

Trust 7 454 0.00% 0.22%

Trust 8 544 1.47% 2.21%

Trust 9 -- -- --

Trust 10 521 0.00% 0.19%

0.19% - 4.49%

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Setting Standards Patient Outcomes - Cost of Infection• Prevention

• SOHs – infection rate THR/TKR = 0.2%

• National Infection rate = 1- 5%

• Treatment

• Average cost £75,000- £100,000

• Hidden costs – loan kit £1000 – £9,000 + per case

• Savings to NHS annually = £200- £300million per annum

• Up to 60,000 joint replacements

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Source: NEQOS Trauma & Orthopaedic dashboard

Total Knee Replacements within 1 year of Arthroscopy (%)

Timeframe: 1 Jan 09 to 31 Dec 11 (TKRs: 1 Jan 09 to 31 Dec 12)

(Patients aged 60 and over)

Trust 2

Trust 3

Trust 4

Trust 5Trust 6

Trust 7

Trust 8

Trust 9

Trust 10

Trust 1

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Litigation data – 10 Trusts same City (trust number not shown)

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Claims in 2011/12

Estimated Cost of claims during 2011/12

Estimated Cost per Orthopaedic Spell

* * *

12 £1,214,315 £99.28

5 £661,890 £41.55

3 £472,500 £50.56

6 £945,000 £43.04

10 £1,418,375 £36.47

7 £1,102,500 £60.27

29 £3,987,113 £134.90

8 £644,655 £31.13

16 £2,090,698 £50.39

National average cost per orthopaedic spell is £54.42

* Permission from trust not given to access this data.

JudgementTissue damageProcedureUnsatisfactory Outcome

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Knees – 12 month surgeon profile (205 Hospitals)

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

CategoryTotal

Operations*Total

Surgeons Average Ops per

surgeon

Nos of surgeons conducting

5 or fewer (%)

Nos of surgeons

conducting 10 or fewer (%)

Total Knee 80299 1675 47.9 109 (6.5%) 263 (15.7%)

Unicondylar Knee Replacement

7068 719 9.8 352 (49%)535 (74.4%)

Patello-Femoral Replacement

1304 390 3.3 313 (80.3%) 369 (94.6%)

Knee Revision 6309 1011 6.3 531 (53.0%) 818 (81.7%)

Source: NHS Choices website, 2012 data. (%)

Note: Not all consultants have consented to releasing this data. If this is the case for the Trust, then the values above may under-represent the true values for the

Trust. A full listing of the consultants who have not consented, and their reasons for doing so can be found at the NHS Choices website.

* To create totals those with a note of <5 are counted as 5, this may impact on the average number per surgeon.

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Low volumes of specialist activity• Average 21 shoulder replacements per

trust (increased by 8 higher volume specialist centres) Usually 6 at most centres

• Average 4 elbow replacements (increased by 11 higher volume centres)

• Average 4 ankle replacements (increased by 11 higher volume specialist centres –generally less than 2 at most trusts)

• Average 59 spinal fusions (increased by 15 higher volume specialist centres).

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

6

1

2

31

1

32

Example - Elbow replacements and revision across trusts in Manchester

Trust 1

Trust 2

Trust 3

Trust 4

Trust 5

Trust 6

Trust 7

Trust 8

Trust 9

Trust 10

46 elbow replacements

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Is there a need for more robust national guidance on cement?

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cemented vs Uncemented across Manchester

Cemented Uncemented

NB – not part of confidential NJR dataset

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Measuring Outcomes - NJR• Scrutiny of practice

Funnel plot for hips>45 trusts above 95%

Funnel plot for knees>48 trusts above 95%

Must have level playing field

RNOHT REVISION RATE AT FIVE YEARSTHR - 0.64% (2.14%)TKR – 0.55% ( 2.37%)

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Country Borough of Teeside(red line indicates boundary)

North Tees Hospital Catchment Population 226,798

South Tees Hospital Catchment Population 523,256

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GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

North and South Tees LAT Analysis (GIRFT)

North Tees And Hartlepool (FT)

South Tees Hospitals (FT)

Population 226,798 523,256

Epidural 691 245

Facet joint 924 304

Injection into joint

132 49

Nerve root 243 529

Others 111 63

Total 2101 1190

SpinalNorth Tees And Hartlepool (FT)

South Tees Hospitals (FT)

Population 226,798 523,256

Anterior lumbar fusion (+/- decompression) - 3

Cervical spine: decompression (+/- fusion) 95 133

Lumbar decompression discectomies (without fusion) 140 527

Primary posterior lumbar fusion (+/- decompression) 116 65

Revision lumbar decompression 7 35

Revision lumbar fusion (+/- decompression) 7 9

Total 365 772

Disc and Fusion

Note: Using Commissioning Spinal Services - getting the service back on track definitionsWhy the variation in practice and interventions?

GIRFT Visits have engineered change – Joint MDT working

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Procurement. What are we buying and paying?Primary Hip – Total Implant Cost

Price MoP CoP CoC

Median £1026 ($2000)

£1495 £1674

Mean £1068($2136)

£1488 £1781

Min £438($876)

£513 £1062

Max £4902($9804)

£3872 £4519

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Loan Kit CostsAverage £200,000Maximum £750,000

Volume not reflected in cost in 90% of cases

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What did the GIRFT Pilot in Orthopaedics tell us?• Huge variations in practice and outcomes in terms of device and procedure

selection, clinical costs, infection rates, readmission rates, and litigation rates.

• Scope to tackle many of these variations and drive short, medium and longer- term improvements in quality of delivery (through adopting best practice), reducing supplier costs (for example of implants) and generating savings, for example from reduced readmission and re-operation rates.

• Many of the answers are already out there

• There is no consensus as to what constitutes best practice in areas of activity where there is no NICE or formal guidance from the BOA or other professional sub-specialty association. This provides a significant opportunity to drive efficiency.

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Implementation Support from the ProfessionGIRFT implementation steps:• We will be sending to all Trusts in England the latest version of

the GIRFT dashboard, with updated data

• The British Orthopaedic Association (BOA) has issued detailed implementation guidance.

• The BOA strongly encourages individual surgeons to share their personal National Joint Registry activity and outcome data with colleagues, as well as their appraiser and CD.

• In addition to the implementation guidance, the BOA has also produced a position statement on data transparency.

• It places a focus on clinical leadership responsibility on the CD

• Revisits top 25% and bottom 25%

• BOA Hospital visits coordinated with GIRFT Team

• Support from : Prof. Howie Immediate Past President

Mr. Tim Wilton President of BOA

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Lesson 8. –Networks /Hub & Spoke Model

“Getting it right first time”-Pilot orthopaedics in England

• Critical Mass of Specialists - One site Specialist Units

• Networks• “Ring fenced elective

beds”• Dedicated theatres• MDT working• Range of models/networks

Clinical Reference Group for Specialised Orthopaedics

• Defines specialist units and centres

• Minimum numbers• Gold standard • Infection rate <1%• Audit• Robust Review of outcomes

Improving quality Improving training

Elderly population not disadvantagedPatients will feel safe

Significant savings

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

ExamplesLeicesterGuysNorthern

30-40 UnitsLondon 5-6

Fewer CentresCollect the dataChange the TariffEg. MTCs

STANDARDS

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Leicester 2012

GENERAL

(Elective)

7 Theatres

33 Consultants

3 Wards

GLENFIELD

(Elective)

OPD & Diagnostics Only

ROYAL INFIRMARY (Trauma, Paeds & Sarcoma)

3 Theatres 25 Consultants 3 Wards

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• Project began in May ‘13 and project reporting completed

• Report published March 2015

• Over 98% of all trusts visited, voluntary - one refusal only

• >130 GIRFT visits 211 hospitals completed

• Team have travelled 18,000+ miles, met 1708 surgeons, met 435 managers,

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Progress to Date - England

What Changes Have We Seen?

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Knee Length of Stay Trend

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Primary Hip Replacement Length of Stay- 2012/13

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Primary Hip Replacement Length of Stay- 2014/15

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Hip fixation trend in the over 65s

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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30 day readmissions all orthopaedics

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Results of the GIRFT Pilot in Orthopaedics

• Cost - £200,000 Grant from NHS England and DH

• Length of stay

• Use of Cemented implants – patients70+

• Ring Fenced beds

• Reduction loan kit costs

• Reduction in costs of THR and TKR

• Reduction in arthroscopy rates

• Low volume surgeons changing practice

• Savings to date - £60 -£90 Million

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Improved Quality of CareReduction of complications

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Introducing the orthopaedics dashboard• This is the first dashboard produced by the

GIRFT programme and will provide regular updated

• summary information as well as trend data.

• Ambition: to identify areas of unwanted variation in clinical practice and/or divergence from the best evidence.

• This work will also support the development of Model Hospital dashboards, which will provide Trusts with a set of measures to compare all areas of efficiency and productivity alongside their quality indicators and standards.

• It will allow acute trusts using a number of indicators and benchmarks, to understand productivity by clinical specialty.

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Working with the Care Quality Commission, England’s independent regulator of health and social care

• The CQC makes sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

• They monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and publish what we find, including performance ratings to help people choose care.

Categories of evaluation - is this provider:• Caring?• Safe?• Effective?• Response?• Well led?• And does it make good use of its

resources?

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Mirroring the CQC data domains

Effective

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Ring fenced bedsDeep infection rate THR/TKR

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Mirroring the CQC data domains

Responsive

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Model Hospital and Productivity

• Productive Theatre

• 2 session day – 4 cemented joint replacements (or equivalent)

• 40% of operating theatre time spent operating

• Whole pathway in hospital streamlined and efficient

• Enhanced recovery programme – 50% home day 3, 50% home by day 5.

• Anaesthetics vital to achieving this – block room, regional anaesthetics

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Assessing the productivity of acute trusts

• Productivity measures compare inputs to outputs.

• Trusts which use fewer inputs per unit of output are more productive.

• Inputs can be measured in a number of ways, including:- Costs- Number of staff- Number of items used (e.g. syringes)

• Outputs can also be measured in a number of ways, including:- Number of patients treated- Number of bed days- Number of outpatients appointments- Number of Weighted Activity Units (WAUs)

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The Weighted Activity Unit (WAU)

• The type of treatments provided by acute trusts differ substantially (casemix).

• This makes it difficult to make robust comparisons between trusts using simple measures of output.

• Both in the UK and elsewhere (e.g. US, Australia), this issue is tackled by using a measure of cost-weighted output.

• Cost-weighting is used to adjust for differences in casemix between trusts.

• Lord Carter has pioneered the use of the Weighted Activity Unit (WAU).

• One WAU is the equivalent of an elective inpatient admission, based on the cost of providing that treatment (≈£3,500).

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1 Weighted Activity Unit =

1 typical elective admission (£3,500 each)

6 typical episodes of Chemotherapy (£600 each)

30 typical outpatients appointments (£120 each)

1300 typical direct access pathology tests (£3 each)

One WAU is the equivalent of an elective inpatient admission, based on the cost of providing that treatment (≈£3,500).

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Total Cost Per WAU

• The headline measure of trust productivity recommended by Lord Carter is the Total Cost Per WAU.

• This shows the total amount spent by the trust compared to the total clinical output generated.

• Across all acute trusts the average cost per WAU is £3,500.

• Individual trusts range from around £4,100 to £3,100.

• This metrics suggests the least productive trusts spend more than 20% more per unit of activity than the most productive trusts.

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Breakdown of the Total Cost Per WAU

• The overall cost per WAU for a trust can be broken down into the various types of cost that contribute to the total expenditure by the trust.

• This breakdown can then be compared to the national average, or to that of trusts considered peers.

• In this way trusts are able to see which areas of expenditure are greater than average, and in which areas they appear to be making good use of resources.

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Medical staff cost per WAU by specialty

• On average, medical staff costs in Trauma and Orthopaedics are around £400 per WAU.

• The most expensive trusts appear to be spending nearly twice as much on medical staff per WAU than the least expensive trusts.

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Key outcomes of the programme

• Delivering a clinically-led, provider-side focused catalyst for:

Improvements in quality and reductions in costs. Informing the setting up and/or enhancing of robust clinical networks. Supporting the direction of travel being developed by the Clinical Reference Groups who guide

specialised commissioning within NHS England. Enhancing the quality and consistency of care. This will provide reassurance to CCGs that what

they purchase will be consistent across England and of the highest quality and at the most effective price.

Tackling price variations of medical devices to reduce cost and assure efficient and sustainable supply.

Supporting delivery of the Five Year Forward View:“NHS gets infrastructure and operating investment to rapidly move to new care models and ways of working leading to bigger efficiency gains worth 2-3% per year, combined with staged funding increases will close the £30bn gap in full”

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Clinically-led quality and efficiencyprogramme

• A Department of Health 3 year programme under the NHS Procurement & Efficiency Programme, across ten clinical specialties utilising the methodologies of Getting It Right First Time :

• Elective Orthopaedics – implement solutions

• Cardiothoracic

• General Surgery

• Oral and Maxillofacial

• Urology and Renal

• Neurosurgery

• Gynaecology & Obstetrics

• Paediatric Surgery

• Ear Nose and Throat (ENT)

• Vascular

• OphthalmologyDH – Leading the nation’s health and

care

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

20th July 2015 Awarded£2.6 Million3 year programme10 surgical specialities

Spines

Upscale and UrgentIncludes all surgical and medical specialities In Provider network“The only game in town”

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To maintain timely care with ageing and financial austerity we must: “Get it Right First Time”

• WE ALL HAVE THE SAME PROBLEM

• Accumulate and follow the WORLD evidence- transparency

• Must do things differently – change behaviour LOW VOLUMES

• Re-empower clinicians, environment “Ring fenced beds”

• Reduce variation in practice – COMPLEX CASES

• Appropriate selection of patients for right procedure

• Implants – outcome and cost

• Maximise outcome

• Reduce complications – infection

• Litigation – contain and reduce

Outcome: - Improving Care, Reducing Unwanted Variation, Best Value

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

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Solutions to the The Perfect Storm • Must be Clinically Driven

• Looking to Surgical Leaders

• Clinicians will need to rise to the challenge

• Politicians and managers do not have the answers

• We have a golden opportunity to take control and drive the changes required

• High quality cost effective evidence based treatments

• GIRFT OF ALL ASPECTS OF BREAST SURGERY??

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Thank you

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Clinical Leadership and Lean Management

NHS Management

GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

RNOHT 1991-1992 2013-2014 % Increase

Medical and Dental 65 170 161%

Nursing 303 401 32%

Admin and Clerical 71 407 473%

Total 708 1417 100%

Inpatients 4950 16,736 238%

Turnover £24 Million £ 136 Million 500%

“Clinically Driven Effective Management.Working together with Clinicians for A Sustainable NHS”

Tim Briggs and Rob Hurd

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The GIRFTProcess

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GETTING IT RIGHT FIRST TIMEImproving the Quality of Orthopaedic Care within the National Health Service in England

Clinicians must provide the solutionsClinicians can drive the changeWe need to “stand up to the plate”

Providers and CCGs need to work in collaboration

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Report of the RCP Future Hospital Commission (2013)

Guiding principles:

Hospitals serve the needs of patients and must deliver:

• High quality care 24 hours per day, seven days a week

• Continuity of care for patients delivered with compassion

• Stable medical teams for patient care and education

• Effective relationships between medical teams & community

• Appropriate balance between specialist and general care

• Transfer realistically allocating responsibility for further action

Hospitals meet the needs of the maximum number of patients and must deliver services as efficiently as possible and without unwarranted variation

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• …growing demand if met by no further annual efficiencies and flat real terms funding would produce a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21.

• …to sustain a comprehensive high-quality NHS, action will be needed on all three fronts – demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two…

• The NHS’ long run performance has been efficiency of 0.8% annually, but nearer to 1.5%-2% in recent years…. 3% by the end of the period – provided… (we) see a bigger share of the efficiency coming from wider system improvements…… [October 2014]

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• Continuous quality improvement. The payment system

needs to promote the long-term, sustainable well-being of the

whole person by reimbursing providers for delivering specified

quality outcomes for patients rather than particular treatments

or inputs.

• Sustainable service delivery. The payment system needs to

incentivise best practice efficient and accessible delivery of

care, to make sure that NHS funding goes as far as it can for

patients.

• Appropriate allocation and management of risk. The

payment system can help to make sure that financial risks in

the NHS, caused by demand pressures or operational

performance, sit with those organisations, whether

commissioners or providers, that are best able to influence or

absorb them in the context in which they arise.

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• Hospitals and hospital chains all over the world have

adopted a common set of metrics to monitor and

improve the productivity of their operations.

• These include cost per adjusted admission to provide a

consistent and accepted currency with which they can

compare the relative performance of their hospitals.

• By adopting such an approach productivity improves –

no suitable metric exists for the NHS, so we have no

way of comparing NHS hospital efficiency.

• By adopting the Adjusted Treatment Index (ATI), the

NHS will be able to measure hospital efficiency and will

align with global best practice.

• Further Patient Level Information & Costing Systems

(PLICS) work in progress

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• ATC based on each trust’s total cost expenditure and activity outputs, calculated by dividing Reference Cost expenditure by the Cost Weighted Output (the mean cost of delivering activity). An ATC of greater than £1 suggests services are more expensive than the average trust.

• Potential savings opportunity calculated by benchmarking trusts’ Reference Cost expenditure relative to mean for each HRG. All HRGs are allocated to 1608 different calculation points; the difference between the actual and expected (national average) cost estimated for each point. [If savings exceed 50% of mean they are capped at 50%]. Performance better than the mean is excluded from the calculation.

• Potential savings opportunity only accrue in areas where it performs below the national mean. Thus, overall ATC can be < £1.00 (overall performance > average) but specific services show savings opportunities.

• This analysis is a proxy for potential savings at any trust to highlight possible further investigation.

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• In essence total (average) HRGs for the institution to

represent costs (including outpatients) are used to

create weighted activity units.

• How the HRGs are allocated across service lines will

vary; some (eg hip replacement) easy. Others (complex

medical problems) less so.

• Weighted activity units vs cost weighted outputs vs

ATCs

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Improving Clinical Services: Are we efficient ?

• Efficiency will become the name of the game (with safe, effective, caring,

responsive to patient need and well-led services)

• Early evidence suggests we are not efficient.

• Drill down is needed to define ‘what good looks like’:

• Cardiology

• Intensive Care

• General medicine much more difficult:

• Focus on processes and pathways (FHC)

• Focus on out patients a major cost centre

• Focus on patient facing hours (job plans)

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Improving Clinical Services: Are we efficient ?

What is efficiency?

Lafond S et al: Hospital finances & productivity: in a critical condition?Health Foundation 2015

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Lafond S et al: Hospital finances & productivity: in a critical condition?Health Foundation 2015

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Lafond S et al: Hospital finances & productivity: in a critical condition?Health Foundation 2015

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Lafond S et al: Hospital finances & productivity: in a critical condition?Health Foundation 2015

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Lafond S et al: Hospital finances & productivity: in a critical condition?Health Foundation 2015

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Engaging CliniciansOrganisations that engage their employees have higher levels of productivityand performance. Key to effective medicalengagement: clinical leadership, closer working to improve doctors’ relationships with managers, understanding one’s role within the organisation and health system, measuring engagement within the organisation, empowering clinicians to identify and lead change.Tackling variationPotential ways to tackle variation include: supporting clinicians to utilise data, improving the quality of data, providing data in a systematic way, encouraging the use of locally adapted protocols and guidelines, shared decision-making, programmes and initiatives such asservice-line management (SLM).

Improving NHS productivity: King’s Fund 2012

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Incentivising productivityRe-interpreting the consultant contract, and using job planning and supporting professional activities (SPAs) to align personal objectives withorganisational priorities around productivity. Using non-financial incentives as important, including additional time for research, recognition, and improved training.Developing new ways of workingCommunication and engagement in new ways of working particularly important in effectiveimplementation; training in teamwork in multidisciplinary settings.

Improving NHS productivity: King’s Fund 2012

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Improving Clinical Services: Are we efficient ?

• Efficiency will become the name of the game (with safe, effective, caring,

responsive to patient need and well-led services)

• Early evidence suggests we are not efficient.

• Drill down is needed to define ‘what good looks like’:

• Cardiology

• Intensive Care

• General medicine much more difficult:

• Focus on processes and pathways (FHC)

• Focus on out patients a major cost centre

• Focus on patient facing hours (job plans)

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Cardiology & cardiac surgery

• Outpatient reference costs:• New• Follow up

• Cancelled procedures & operations:• Bed availability

• Length of stay vs readmissions • Case complexity

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Improving Clinical Services: Are we efficient ?

• Efficiency will become the name of the game (with safe, effective, caring,

responsive to patient need and well-led services)

• Early evidence suggests we are not efficient.

• Drill down is needed to define ‘what good looks like’:

• Cardiology

• Intensive Care

• General medicine much more difficult:

• Focus on processes and pathways (FHC)

• Focus on out patients a major cost centre

• Focus on patient facing hours (job plans)

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• The standards apply to all units capable of delivering care for level 2 & 3 dependency patients; provide a concise definition of what is necessary to ensure the best levels of care and outcome, and effective management.

• Alongside each is relevant research to support it. The document distinguishes between advisable and required standards.

• Core Standards are divided into staffing, operational, equipment and data collection.

• Staff-to-patient ratios, frequency of ward rounds, availability of senior personnel and the training requirements for staff are defined; as is max number of agency or bank nurses on duty at any one time.

• Criteria for managing the admission, transfer, rehabilitation and discharge of patients.

• Standards for the provision of adequate pharmacy, physiotherapy and dietician cover.

• Methods of ensuring accurate and standardised data collection on outcomes.

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2014 Workforce Advisory Group Position Paper [Board-approved October 2014]

• Accepted as a statement of current provision and projected need for ICU services in England and Wales, recognising that local and regional variation will influence both demand and supply.

• Standards for medical workforce provision that appear in General provision of intensive care services (2015) is used to guide workforce planning.

• The work of the CfWI is accepted as a broad indicator of workforce demand, using the limits provided by Scenarios 1 and 2 [see paper] to guide modelling for the numbers of trainees needed.

• That in depth analysis is performed in two regions to apply the GPICS standards to critical care facilities there; to identify gaps in the workforce and model the recruitment needed (to both the medical and non medical workforces).

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Productivity Issues (1)Problems with skill set & practice

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• Medical patients have multiple clinical problems and are often frail, but:• Relatively few physicians, increasingly running whole hospital (including

surgical wards) 24/7 • Training (and prestige) focussed on specialism• General medicine not a separate speciality, practised only out of hours

(many train in it then give up ASAP) • Sessions in job plans mis allocated

• Maybe 1-2 sessions for ward care • Individual targets focussed on procedures (appraisal)• LOS ignored (see 1)

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The Hospital of the Future & the Future Hospital Commission

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Productivity Issues (2)Delayed discharge

• Delayed discharges a huge issue, but:

• Lack of rehabilitation/’re enablement’ facilities • Lack of community nursing (vs ‘care’) facilities • Primary care variably involved, rarely integrated (IT)• Lack of daily review• Pre set targets (for discharge) rare • ‘Ward care’ difficult to deliver for diverse patient population

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Medical Division: Patient Centred Care

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Royal College of Physicians: Workforce data 13 major specialties (2014-15)

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Productivity Issues (3)Out patients: non admitted care

• Out patient appointments major part of reference costs:• Place in pathway not established • Appointments systems antiquated (on line)• Remote access possible in many instances (FU)• Remote monitoring arriving• Often managed separately from in patient portion of pathway• No clinical leadership/coordination

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Service lines

Arrhythmia New structure:

Inpatients:• [Other] hospitals [network] • Acute access, assessment, intervention • Organ support & transplant

Non admitted pt [information exchange]:• [Other] hospital based [network]• Hospital based [restructured OPD]• Community based [GP, independent]

Clinical support: • Anaesthesia• Genetics

Diagnostics:• Imaging, physiology, labs

Access:• Patients: Call centre, email, apps• Clinicians: + telemed, remote monitor• Researchers: Call centre, email.

Research & Clinical Governance

Resources:• IT [data set], • Biobank • Programmed investigation unit (PIU) trials

SHD Revasc Heart FailurePAHCHD (A,C)

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• The variation in efficiency between NHS organisations exists: The report of the Health Foundation ‘Hospitals finances & productivity: In a critical condition? (April 2015) states (P 5) ‘…our analysis shows the relative efficiency and productivity performance of individual hospitals very little over the past five years. Eighty one percent of those that were above or below average in 2009/10 stayed above or below average in 2013/14.

• A clinically led initiative has found precisely the same variability in a single specialty: The findings of GIRFT, produced by the BOA, have been accepted by the clinicians who recognise that ‘unwarranted variability’ must be addressed and are already engaged in driving change.

• Our remit was expanded from 32 to 136 trusts based upon the pilot work carried out in the first cohort. All recognise our systems are not perfect be see the need for efficiencies and want to get involved.

• We need to identify what good looks like (in specialties and processes) and optimise performance in each part of the model hospital.

Conclusions