better value in the nhs - innovate stage, 3.30pm, 2 september 2015
TRANSCRIPT
Better value in the NHS:
Lessons from the past and opportunities
for the future
Prof John Appleby
Chief Economist
The King’s Fund
www.kingsfund.org.uk/bettervalue
• Generic prescribing • Lengths of stay • Day case surgery
Percentage of primary care prescribed items by
generic/proprietary prescribing and dispensing: England,
1976/7 to 2013/14.
Estimated saving in 2013 total net ingredient cost due to
increases in generic prescribing and dispensing between
1976 and 2013
£7.1 bn
Saving by 2013/14 of increased
generic prescribing since 1976
Variation in generic prescribing by GP practice: England
2013/14
Trends in acute medical and surgical patient lengths of
stay: English NHS: 1974-2014
11% (Extra beds that would have been needed in 2013 if
no reduction in LOS since 1998)
61% (Increase in bed
throughput 1998-2013)
International comparisons of average length of stay (all
types of patient): OECD countries
+1.3 m
Proportion of all patient activity carries out as day
cases: England 1974-2014
Roll out of PbR
Two key lessons from the past 1. The drivers of change are multiple and overlapping
Common drivers:
› Health technology developments
› Clinical/managerial culture
› Patient pathway design
› Data and information
› Frontline support to enable change
› Financial incentives
› Financial pressures/support
2. Improvement takes time and occurs through a series of
small steps rather than giant leaps forward
Opportunities
for the future
Variations in clinical practice
By PCT/CCG*:
• Diagnosis of coronary heart disease ranges from 52 to 89%
• Diagnostic tests:1000-fold difference in rate GPs order blood glucose tests
• Prescribing practice: 25-fold difference number of anti-dementia drug prescriptions
• Management of chronic disease: patients with COPD who had review in past 15 months ranges from 77 to 87%
• Rates of clinical procedures: rate of elective tonsillectomy in children ranges from 145 to 424 per 100,000 <17 years
• Length of stay in hospital: 11-fold difference in elective breast surgery LoS
• Health outcomes: mortality rate from pneumonia in 75+ ranges from 4 to 11 per 100,000 population
Overuse
• Monitor estimated £0.2 – £0.6 a year potential saving from by stopping low-value elective procedures like knee washouts and tonsillectomies.
Overtreatment in hospitals
• NICE estimate that following their prescribing policy for antibiotics for respiratory tract infections would reduce prescribing by £3.7m
Overprescribing
• Eliminating inappropriate pathology testing could save the NHS £1 billion a year
Overdiagnosis and use of diagnostic
tests
Underuse
• In 2012/13 only 60 per cent of people with diabetes received all eight recommended care processes
Underuse of effective
interventions
•1 in 8 people over 35 has COPD but remains undiagnosed Underdiagnosis
•Between a third and half of drugs prescribed for long-term conditions are not taken as recommended
Medicines not taken properly
Misuse (preventable harm)
• Additional days in hospital as a result of adverse events are estimated to cost the NHS in England and Wales £1 billion each year
• Direct cost of falls in hospital estimated to be £15 million in 2007
Adverse events in hospital
• Estimate based on 10 GP practices found error rate of around 7%
Adverse events outside
hospital
Care of long-term conditions
Opportunities for: • Earlier detection and diagnosis • Involving patients in decision
about their care • Supporting patients to manage
their own health • Care co-ordination • Integrated approaches to mental
and physical health needs
Care of older people living with frailty and
complex needs
Opportunities for: • Avoiding preventable and
inappropriate hospital admissions
• Improving the patient flow within hospitals
• Better discharge and reablement
End of life care
Opportunities for: • Reducing time in hospital at the
end of life • Better care co-ordination • Training generalist staff in end-
of-life care
Agenda for action
Frame the productivity debate around
quality and outcomes
Hugh Alderwick Ruth Robertson Phoebe Dunn David Maguire
More information: www.kingsfund.org.uk/bettervalue
@jappleby123
www.kingsfund.org.uk