long term conditions: long term conditions what’s wrong and what do we need?
DESCRIPTION
Dr Steven Laitner (Co-Chair of the NHS East of England Long-Term Conditions Programme Board, GP and Associate Medical Director)Steve will talk about the East of England Vision for improving the lives of people with Long Term Conditions like COPD, diabetes, CHF etc. He will then talk about the need for innovation to support patients in managing their own long term conditions and improving their health and the productivity of health services.TRANSCRIPT
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©2009 . Private and Confidential
NHS East of England
Long Term ConditionsLong Term Conditions
What’s wrong and what do we need?
Dr Steven Laitner, Co-Chair, LTC Programme Board
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©2009 . Private and Confidential
A significant challenge
- 2 -
Source: “How cold will it be? Prospects for NHS funding 2001-17”, The Kings Fund, July 2009
Tepid
Cold
Arctic
£millions (2010/11 prices)
1. “ARCTIC” Real funding cuts (First 3 years: -2%, next 3 years, -1%)
2. “COLD” Zero real growth (0% every year)
3. “TEPID” Real increase (First 3 years: 2%, next 3 years, 3%)
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©2009 . Private and Confidential
•What’s the problem with LTC Care
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©2009 . Private and Confidential
HCC National
Patient Survey
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©2009 . Private and Confidential
….and
• 82% of those with an LTC want to do more self care
• 75% would feel confident about self care if they had more guidance/ support
• Half did not have a clear plan
• More than half had not been encouraged to self care
MORI
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©2009 . Private and Confidential
….and some quotes from our Service User Reference Group
“recognise the “patient” as an expert in themselves
“listen to us”
“don’t only concentrate on the clinical”
“be aware that management of the LTC is only a small part of my life”
“I want to be seen as a whole person”
“support us in seeing the same GP more than once!”
“stop using language and knowledge as a barrier”
“come down to our level”
“speak to me with respect”
“ don’t give too much information in one go”
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©2009 . Private and Confidential
What’s the problem – care model?
• An overly medical and paternalistic model
• Insufficient personalisation, support for self care or Informed Decision Making
• Variable service quality and customer experience
• Lack of integration:– Generalist and specialist care
– Physical and mental health
– Medical and nursing, therapy
– Medical and social
• Unwarranted Variation in activity
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8
Top 30 PCTs(Lowest Rates)
Next 31 PCTs
Next 30 PCTs
Next 31 PCTs
Bottom 30 PCTs (Highest Rates)
Top 30 PCTs(Lowest Rates)
Next 31 PCTs
Next 30 PCTs
Next 31 PCTs
Bottom 30 PCTs (Highest Rates)
Top 30 PCTs(Lowest Rates)
Next 31 PCTs
Next 30 PCTs
Next 31 PCTs
Bottom 30 PCTs (Highest Rates)
Musculoskeletal programme- variation in knee replacement costs
Primary Knee Replacement - AgeSexNeeds standardised cost per 1000 population for PCTs
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151
PCT
AgeSexNeeds standardised cost (£
per 1000 population)
London
Primary knee replacements cost £5,808.
There is a 4-fold variation in expenditure between PCTs(adjusting for age, sex and need).
The coefficient of variation is 21.0%.(This takes into account all PCTs, not just the top and bottom PCTs.)
The potential savings are £39M(if PCTs with rates higher than the median reduced to this level).
Total Inpatient
Expenditure (£M)
Potential Saving using
50th percentile (£M)
Potential Saving as % of
Total Inpatient Expenditure
392 39 10.0%
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What’s the problem – system?
• Inexorable demand with an forthcoming unprecedented reduction in resources(we need to do much better with much less)
• Historical inability to manage demand using current levers
• Poor alignment of incentives
• “Micro-contracting” of an incredibly complex business process/ care pathway/ supply chain
• Lack of clinical and financial management and accountability across the pathway
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©2009 . Private and Confidential
•So what can we do about it?
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©2009 . Private and Confidential
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©2009 . Private and Confidential
OUR VISION FOR LTCs
• Personalisation
– Person not Long Term Condition Label
– Holistic Health - Physical, Emotional and Social
– Care according to needs and preferences
– Patient outcomes as well as clinical outcomes and experience
– Personal Health Planning
• Self Care and “co-production”
– Supported Self Care
– Rehabilitation
– Personal Health Planning
• Commissioning of Long Term Conditions
– Co-production at the strategic level
– Whole pathway approach
– User and carer engagement in re-commissioning
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©2009 . Private and Confidential
so what “new” do we need to buy?
• Demand Mx including Admission Avoidance
• Specialist advice and support to 1’ care
• Referral triage
• Primary care clinical management (QOF++)
• Shared Decision Making
• Personal Health Planning
• Supported Self Care
• Holistic Biopsychosocial Approach
• Integration
• The “Holy Grail” of clinical and financial accountability
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Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Emotional Behavioural Social Clinical
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Knowledge
and health
beliefs
EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Knowledge
and health
beliefs
EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Knowledge
and health
beliefs
EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical
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Engaged,
informed patient
HCP committed to
partnership working
Organisational processes
Commissioning- The foundation
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Emotional Behavioural Social Clinical
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Knowledge
and health
beliefs
EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical
The clinic experience
Registration, recall, review, and follow up
Access & communication
Named contact
IT templates
Awareness of approach to self-management
Consultation skills /
competencies
Multi-disciplinary team working
Knowledge of local options
Clinical expertise
Structured education/ Information
Awareness of process & options
Pre-consultation results
Access to own records
Emotional & psychological support
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Engaged,
informed patient
HCP committed to
partnership working
Organisational processes
Commissioning- The foundation
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Emotional Behavioural Social Clinical
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Individual ’s story Professional ’s
story
Share and discuss information
Goal Setting
Action ActionActionAction
Knowledge
and health
beliefs
Knowledge
and health
beliefs
EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical
The clinic experience
Registration, recall, review, and follow up
Access & communication
Named contact
IT templates
Awareness of approach to self-management
Consultation skills /
competencies
Multi-disciplinary team working
Knowledge of local options
Clinical expertise
Structured education/ Information
Awareness of process & options
Pre-consultation results
Access to own records
Emotional & psychological support
Developing the menu
Linking micro-to macro-
Commissioning care planning
Measurement User involvement
Money / contracts
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0% 25% 50% 75%
CA-Prostatectomy
CAOrchiectomy*
coronary bypass*
coronary bypass
hysterectomy
hysterectomy*
mastectomy
back surgery
mastectomy*
bphprostatectomy
bphprostatectomy
Standard Care
D-Aid
.
Decision Aids reduce rates of discretionary surgery
RR=0.76 (0.6, 0.9)O’Connor et al., Cochrane Library, 2009
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Standard
care, $2,751
Video
Decision Aid ,
$2,026Video Decision
Aid plus
Coaching, $1,566
$0 $500 $1,000 $1,500 $2,000 $2,500
Kennedy et al. JAMA2002; 288: 2701-2708
HysterectomyHysterectomy
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GIVE PEOPLE THE CARE THEY NEED AND NO LESS,
THE CARE THEY WANT AND NO MORE
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A Whole Pathway Approach
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Where do we buy it from?
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The traditional commissioner approach
• The traditional providers and…
• The “add ons”
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Traditional model – methods of controlling Demand and delivering savings
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My proposed transformational approach
• An integrating “pathway hub approach” with whole pathway (programme budget) clinical AND financial responsibility
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Programmed budget modelDemand management
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A Pathway Hub or
Whole Pathway Provider/ Prime Vendor and
Subcontractor to:
• Provide, performance manage and subcontract• Deliver Care Closer to Home (an alternative to hospital outpatients)• Identify and meet training needs of primary care • Ensure quality and VFM from 1’ Care• Manage the demand for secondary care services• Improve population and individual health (includes prevention responsibility)
• Ensure provision of self care support, care planning, informed decision making
• Manage the Programme Budget(s) on your behalf
ALIGNING CLINICAL AND FINANCIAL INCENTIVES -CLEAR ACCOUNTABILITY ACROSS THE PATHWAY
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Summary - what do we need?
• Support for Personal Health Planning• Support for Self Management/ Self Care• Navigation support• Support for Informed Decision Making• Access to information• Access to support• Empowering services
• Oh….and a integrating provider/ provider group to do this and more…..