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DHF Presentations between 2004 an d2009 +44(0)1423 506 848 +44(0)789 907 4881 Kent House 42 Duchy Rd Harrogate HG1 2ER.

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Presentation on theme: "DHF Presentations between 2004 an d2009 +44(0)1423 506 848 +44(0)789 907 4881 Kent House 42 Duchy Rd Harrogate HG1 2ER."— Presentation transcript:

1 DHF Presentations between 2004 an d2009 +44(0)1423 506 848 +44(0)789 907 4881 Kent House 42 Duchy Rd Harrogate HG1 2ER

2 Diffusion of MRI Units, 2000 Source: OECD Health Data, 2003

3 Cost of Waiting for Elective Surgery (OECD, Working Paper no.6, 2003) Deterioration in condition, death at the extreme Loss of utility from delay Rise in the cost of total treatment Example: · A study of patients waiting for varicose vein surgery in the UK found ‘considerable deterioration’ in their condition while waiting for surgery (Sarin et al, 1993)

4 Opportunity Costs 856.8 work days lost each year in the UK due to sickness, Statutory Sick Pay & Incapacity Benefit: In England, 5- 10% of the patients on elective waiting lists are on sick leave from work 1,047,890 people waiting for NHS in-patient treatment, June 2000. Out-patient treatment (hospital tests, specialist consultations) 13 week wait lists for 308,760 people (of which 128,532 were waiting over 26 weeks).

5 What is day surgery? Ambulatory care. Out-patient care. Short-stay. Minimally invasive surgery. Diagnostic procedures. Minor injuries. Non-surgical interventions.

6 Prices and Costs e.g. ENT (figures available in 2002) HRG code C22 Septoplasty £366/ £905/ £2302 HRG code C24 Bilateral dissection tonsillectomy £250/ £853/ £4676

7 (50%) possible as day cases : Lasar prostatectomy Trans cervical resection endometrium (TCRE) Eyelid surgery inc tarsoplasty, blepharoplasty Hallux valgus ("bunion") operations Arthroscopic menisectomy Scope’ shoulder surgery (subacromial decomp) Subcutaneous mastectomy Rhinoplasty Dentoalveolar surgery Tympanoplasty

8 (50%) possible as day cases : Laparoscopic cholecystectomy interval appendicectomy Laparoscopic herniorrhaphy Thoracoscopic sympathectomy Submandibular gland excision Partial thyroidectomy Superficial parotidectomy Breast cancer wide axillary clearance Haemorrhoidectomy Urethrotomy Bladder neck incision

9 Possible as day cases : Tonsillectomy in children Correction squint Bat ears/minor plastic procedures SMR Reduction nasal fractures Cataract extraction Laparoscopy  sterilisation Termination pregnancy TUR/laser/diathermy/limited resection bladder Ts Pilonidal sinus excision and closure


11 Waste from unplanned admissions


13 Pharmacological spend as % of total health spend

14 OTC and non-prescription drugs as % of total drugs

15 Admissions per 1000 patients

16 Average LOS

17 Hospital Beds per 1000 population

18 Bed Occupancy

19 “ if you’re a fit young man who needs a knee operation, you don’t want to go into a general hospital and lie next to somebody who has a bed-sore and MRSA” Hospital Doctor (09-09-2004) NHS Improvement Plan: Part Three, Treatment Centres are not a threat DHF


21 Govt’s Target 18 weeks to include · OP · Dx · WL DHF

22 Wait Times


24 Drivers Waiting times, lists & capacity Choice, Access and Quality Contestability, Plurality and VFM DHF

25 PFI PPP Capacity Growth Services FM

26 Performance Management & KPIs KPIs SUIs Outcome measures DHF

27 Procedure v Patient Year Price by procedurePrice by patient year Low volumesHigh volumes High priceLow Price Narrow spread of priceWide spread of price High Consistency of ResourceUnpredictable Resource Large populationsSub populations Specified Intervention onlyChoice of Interventions Interventions always neededValue avoiding interventions

28 ElectiveEither WayCDM Total hipSquintAsthma CataractChemotherapyPsoriasis CholecystectomyClub footRheumatoid Arthritis HerniorrhaRadiotherapyExcema C.A.DReconstructionDepression T.O.P. PhyHair lipSchizophrenia Pain blocksExtreme obesityThyroid dysfunction DentalIncontinenceDialysis Chronic painAngina Osteo Arthritis Chronic pulmonary disease

29 CSS v CPS The CSS contains everything that should help us specify our procurement safely for the NHS The CPS only contains that which we consider essential to the ITT and which will deliver a VFM bid

30 Input and process specifications So the sponsor can integrate ISTC care with the rest of the health economy. · e.g. what is expected from the NHS may differ between one cholecystectomy package (with a very limited follow up) and another.

31 Input and process specifications Ministers will find it hard to defend untoward events in the absence of process specifications or standards Provider can easily offer a strong argument that he was not at fault for a poor outcome ( by citing biological variability)

32 Input and process specifications Some procedures require specific data for national registers and these have to be specified · e.g. NCEPOD · Cataract National Dataset · e.g. National Joint Registry

33 Outcomes The difficulty with outcome(s) is that the results should be attributable to the treatment

34 Measures KPIs · 25 ISTCs · NHS TCs Outcome Measures · NHS TCs · ISTCs

35 Outline Current NHS organisation Aspects of the NHS Fears of the NHS Opportunities in the NHS Politics of the NHS

36 History Churches & Charities Poor Houses and other reforms to 1911 Lloyd George and the panel 1942 to 1948 : The NHS 1968 to 1989 reforms Mrs Thatcher & Waiting times 1992 April Mr Blair & Plurality

37 Waiting Lists 199224 months (+ 6months) 2002-2004…9 Months for treatment 2002… 900K (to 150K) 2008 … 18 weeks total

38 Early (2002) Capacity Predictions FFCEs

39 PM’s Target 18 weeks to include · O.P4/52, · Diagnostics 4/52 · treatment 8weeks……?

40 Differences... Spot Prices Speciality to Procedure Information, Refining Procedures’ Descriptions (severity, co morbidity, and case mix) Patient Care Pathways Clinical Engagement in real costings & interfaces Financial Flows anticipated

41 Fears: commoditisation of health Contract Failure & VFM Delivery Failure : Impact on - NHS viability - Private Practice: volume -prioritisation Poor Quality

42 Fear of Overcapacity PCTs (allowing lists to go up again) Acute Trusts SHAs DH Risk to NHS estate and base Challenge to National strategy

43 Fear of clinical incompatibility Personal habit Agreed team practice /SAgreed local customs P/SNationwide custom P/SNationwide best practice P/SInternational best practice P/SRobust evidence practice /SLegal requirement

44 Credentialing People Facilities Organisation GMC Specialist Register Training Buildings, equipment, consumables systems, information, registration HCC

45 Status of US Industry: Shift from Inpatient to Outpatient 35000 25000 20000 15000 10000 5000 0 30000 19841988199019921994199619981986 2000 Annual Number of Surgeries (in Thousands) Total Hospital Inpatient Surgeries Total Outpatient Surgeries

46 Diagnostics (direct access) Discharge to NHS - GP - Intermediate Care -Subsequent necessary care Essential OP follow- up as required Acute Inpatient Follow-up ? Surgery & Recovery Pre-op Assessment OP Follow-upOP Consultation NHS OP Consultation (and waiting list) A CB D diagnostics + - E New Provider Assessments (Outpatients) New Provider Surgery (FCEs) (£A) (£S) ISTC Programme TCs Patient Flow Diagram diagnostics + - GP Consultation with Patient

47 Grow capacity VFM Delivered quickly Maintain quality Improve access TCs

48 On or Off NHS property Near or far away In their buildings With or without their staff NHS Trusts & PCTs

49 Movable leased refurbished (modular) Buildings

50 Joint Service Reviews actions agreed at previous meetings routine data, identification of any problem areas, and agreed actions ad hoc reports and the results of any investigations, identification of problem areas, and agreed actions figures for the ISTCs concerned, compared with other ISTCs; all findings from reviews of random case records presentation by the provider to the sponsor of the results of their clinical audit

51 Source of dataAnomalyExample Routine reports Absolute statistical Patients waiting longer than contracted maximum Routine reports Relative statistical Procedure time in the highest decile of all comparable providers; visual acuity following cataract surgery in lowest decile of all comparable providers Ad hoc reportsSignificant event Unplanned transfer of patient to NHS provider Ad hoc reportsComplaintsPatient had not understood proposed treatment when giving consent to surgical treatment Review randomly from case records ----- Triggers for review

52 Consequences of review No problem detected No penalty, but may be other consequence as per contract AProvider to take remedial action within specified timescale; possibly increased level of monitoring BFailure points, proportionate to issue(s) CFinancial penalties DContract termination

53 Perceptions of quality risk National govt. Local Govt. Providers (new territories) Investors (due diligence) Professions (mixed interests) Media Public

54 Opportunities Acute Capacity for NHS Other capacity for NHS · Diagnostics (radio, pact, physiological, endoscopy) · LTC (diabetes) · Primary Care (e.g. CWICs) · Chlamydia etc · Mental Health · LD · Care of Elderly Chambers · Surgeons · Physicians · Other clinical/Health/Well being · Sa a provider, as a FM

55 Two’s company, Virtuous contract PayerProvider Client £ ServiceHappiness

56 Three’s a crowd Two third party payers Payer Provider Govt Client £ £ £ services happiness control

57 Inpatient versus Day Surgery: US Number of Procedures (thousands) Source: SMG Marketing

58 Freestanding Ambulatory Surgery Centres in the United States

59 Types of Surgery Centres in the U.S. Hospital owned Joint Venture (Hospital & Physicians) Physician Owned Management Companies with or without physician ownership

60 Driving Forces behind the “Surgery Centre Movement” Physicians / Surgeons Hospitals Government / Insurance Industry Patients

61 Designing the Process “When schemes are laid in advance, it is surprising how often the circumstances fit in with them” Sir William Osler

62 Risk Classification The Johns Hopkins Risk Classification System

63 Pre-Op Testing: a sample matrix for minimally invasive surgery

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