1. Siân Williams NHS London Respiratory Team Programme Manager Creating a case for a 1% shift Improving value in programme budgets

2. Imagine we used the value framework Health Outcomes Patient defined bundle of care CostValue = Health Outcomes Cost of delivering Outcomes Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

3. To invest appropriately in interventions for people with COPD Triple Therapy £35,000- £187,000/QALY LABA £8,000/QALY Tiotropium £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £1,000/QALY in “at risk” population

4. Jiminez Ruiz et al Nicotine and Tobacco Research 2011 ~500 smokers with severe COPD Mean age 58 years 60 pack-years of smoking High nicotine dependence 10 intensive behavioral interventions with medication: 233 Nicotine Replacement Therapy & 190 Varenicline 48.5% abstinence at 6 months 61% with Varenicline and 44% with NRT Safe Even those with severe disease

5. Because even before that paper we knew enough to proceed at a clinical level ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’ NICE 2010

6. J Health Serv Res Policy. 2011 Jul;16(3):133-40. Emergency respiratory admissions: influence of practice, population and hospital factors. Purdy S et al. Academic Unit of Primary Health Care, BristolPurdy S et al. For every 1% increase in prevalence of smoking in your COPD population there is a 1% increase in COPD admission rates For every 1% increase in prevalence of smoking in your asthma population there is a 1% increase in asthma admission rates And at a population level

7. Either from a zero base, or to add to existing interventions Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0 200 out-patients with SMI 60% current smokers (mean age 44) 23% COPD prevalence (self-reported) Only 36% reported having COPD treatment 147 Medicaid patients with SMI 31% COPD prevalence; 50% as co-morbidity Annual costs for SMI and COPD were 4 x higher 45% (5/11) deaths due to respiratory disease Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257

8. And there is still unmet need in primary care eg Southwark dashboard 2013 Prevalence of current smoking where status recorded in last 15 months 1550/3335 = 46.5% COPD smokers in last year receiving evidence based stop smoking support – 17.5%

9. So what if we reduced smoking prevalence by 1%.....

10. So what if we did this by shifting resources to where the people are?

11. Where are the people? Sick smokers in hospital beds Smokers in mental health services In prisons Quietly stoical at home Multiple prescriptions

12. Would it tackle…. Premature mortality Optimising bed days Waste – human spirit, staff resources, time, prescriptions

13. Primary care management of tobacco dependence and long term conditions, ongoing, sustained, LES, QOF Supporting sick smokers: CQUIN, NRT, stop smoking champions Fall in children's asthma admissions equivalent to 6802 fewer hospital admissions in 3 years after smoking ban.http://pediatrics.aappublications. org/content/earl y/2013/01/15/pe ds.2012- 2592.abstract …http://pediatrics.aappublications. org/content/earl y/2013/01/15/pe ds.2012- 2592.abstract … http://jpubhealth.oxfordjou rnals.org/content/34/1/37.l onghttp://jpubhealth.oxfordjou rnals.org/content/34/1/37.l ong 200 public health interventions analysed for cost-effectiveness 15% were cost -saving 85% were under 20k per QALY

14. Martin McShane, NHS CB Lead for Long Term Conditions Care (Domain 2), December 2012 If we had £1200 per person per year, the gearing is: £100 – GP, £200 community, £600 acute, £300 specialist If acute goes up by 4% have to take 24% out of primary or 12% out of community; £300 specialist won’t change! If we had £1200 per person per year, the gearing is: £100 – GP, £200 community, £600 acute, £300 specialist If acute goes up by 4% have to take 24% out of primary or 12% out of community; £300 specialist won’t change! Why shift? It’s all about value….

15. Programme budget illustrations

16. Respiratory programme budget

17. Tariffs 2013-14 (* non-mandatory) 1 st single 1 st multi FU single FU multiNon face to face* SpellTrim- point (days) Respiratory medicine OP 18924510414523 COPD or bronchitis with NIV without intubation with CC emergency admission 277124 Stop smoking West Midlands (2012- 13*) General pop’n no Rx Target ed pop’n no Rx General pop’n with Rx Targeted pop’n with Rx (4 week quitter94136166214) 12 week quitter – verified in primary care 129271228427

18. What does 1% look like - in Southwark? 1% of respiratory OP spend £18,940 1% of total respiratory secondary care £136, 090 1% of respiratory primary care prescribing £40,470 2010/11 Programme budget –usual caveats about coding

19. Imagine we shifted some of that to where the people are– eg a mental health stop smoking adviser, or a system-wide education and training programme or a joined up stop smoking service – would we achieve greater value?

20. Potential Savings 20