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
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