Commissioning for Value Leeds 10th March 2015 Session 2 Commissioning for Value and population health improvement

Professor Brian Ferguson Chief Economist Investing in prevention: common ground for public health and the NHS Commissioning for Value event, Leeds 10th March 2015 Professor Brian Ferguson Chief Economist

Ideas “The difficulty lies not so much in developing new ideas as in escaping from old ones” (John Maynard Keynes) “There are few new ideas in NHS reform, just ones that have found their time”

Take-home messages We have a once-in-a-lifetime opportunity to shift the focus to commissioning for population health Commissioning for value is all about culture change It requires a sustained focus on outcomes and investing in areas of proven cost-effectiveness It requires us to operate collectively as a system with the right incentives in place We need high-quality and timely intelligence that is also joined-up across systems

A strong and shared case

NHS 5-year forward view The health and wellbeing gap: if the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness.

NHS 5-year forward view: PHE’s priorities Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals. We support these priorities and will work to deliver them. While the health service certainly can’t do everything that’s needed by itself, it can and should now become a more activist change of health-related social change. That’s why we will lead where possible, or advocate when appropriate, a range of new approaches to improving health and wellbeing.

Wanless got it right Wanless (2007): “Without improvements in productivity and greater efforts to tackle the causes of ill-health, even higher levels of investment in the NHS will be required than envisaged by the fully engaged or solid progress scenarios” ‘Fully engaged scenario’: levels of public engagement in relation to their health are high: life expectancy increases go beyond current forecasts, health status improves dramatically and people are confident in the health system, and demand high quality care. The health service is responsive with high rates of technology uptake, particularly in relation to disease prevention. Use of resources is more efficient.

Diabetes Prevalence rising due to ageing population and obesity levels – new shared focus on prevention Good control (HbA1C etc) in primary care Getting people screened and achieving consistent screening rates across the country Avoiding hospital admissions for (e.g.) lower limb amputations PbR system and perverse incentives i.e. we talk about prevention then reward more of the wrong type of activity

Commissioning, Value and Culture

Focus of commissioning to date Transactional or transformational?

Source? Focus area Description 3 Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health 4 Lead continuous and meaningful engagement with clinicians to inform strategy and drive quality, service, design and resource utilisation 6 Prioritise investment according to local needs, service requirements and the values of the NHS 7 Effectively stimulate the market to meet demand and secure required clinical, health and well-being outcomes 8 Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration 11 Make sound financial investments to ensure sustainable development and value for money

Don Berwick (2001) “….measurement alone does not hold the key to improvement….measuring could be an asset in improvement if and only if it were connected to curiosity - were part of a culture primarily of learning and enquiry, not primarily of judgement and contingency” CfV is an improvement tool – performance management systems lead to defensive behaviour that is not conducive to a culture of improvement

Long-term agreements – a good old idea Marks & Spencer – quality / value / service Regular dialogue with suppliers Detailed technical / quality specifications Length of relationship Focus not all on cash flow Power balance Could argue that M& S have been ‘commissioning for value’ for years

Population health systems: going beyond integrated care (King’s Fund Feb.’15) Key features of health systems that focus on population health: organisations working together across systems to improve health outcomes for defined population groups population-based budgets to align financial incentives with improving population health systems have developed different strategies for different segments of the populations they serve community involvement in managing their health and designing local services integrated health records scaled-up primary care systems close working with individuals to understand the outcomes and services that matter to them supporting and managing individuals to manage their own health

Jönköping and the Triple Aim initiative improve the health of the population enhance the patient experience of care (including quality, access and reliability) reduce, or at least control, the per capita cost of care "The Jönköping work has been shaped by an agenda focused on quality and safety which places the citizen at the heart of its services The Jönköping model underlines the strategic role public health plays in improving the health and wellbeing of a population. The commitment to embedding quality improvement methodology and ensuring the needs of local populations are the key priorities for each organisation Jönköping's commitment to partnership working across sectors, providing an almost seamless pathway for patients, is clearly one of the many reasons for its success

Jönköping: main themes The vertical integration of a quality improvement approach to healthcare. The board receive performance reports that are generated from systems implemented by staff trained in change management and who have an ethos of strong quality improvement as an expectation of their employment A corporate approach to systems improvement that enables cross- departmental process development with notable clinician- management co-operation Cohesion and consistency between the delivery of healthcare and public health and social policy A strong link between systems development and the financial reporting required to service any change in systems reporting that might result from the improvement work.

The concept of value – remember QIPP? Quality Innovation Productivity Prevention Initial focus: allocative efficiency / value for money / cost-effectiveness It became all about cost-cutting Quality improvement itself can save money, and be efficient

Value for money vs cashable savings Cost-effectiveness / efficiency / value for money are not the same as cost- cutting / cost savings Investing in prevention makes economic sense But will it release cash in the short term? Implementing interventions that are deemed cost-effective within NICE cost/QALY thresholds will not necessarily save money most of the public health interventions that have been analysed are highly cost-effective still a need to prioritise Wider return on investment approach is needed CfV needs both a short and long term focus on prevention

The NHS has a strong role to play in prevention

Working with the NHS Population health; public health is not just what PHE does Investing in primary prevention tackling obesity, alcohol and the wider determinants Systematic, at scale secondary prevention tackling unwarranted variation doing what we know works ‘Investing’ in prevention does not always need money: it needs energy to be focused in the right areas Next 2 slides courtesy of Chris Bentley who led the National health Inequalities Support Team………

So what else is needed?

One system working together across the NHS, public health and social care a focus on individuals - integrated care pathway work from CfV programme integrated budgets and joined-up commissioning genuinely commissioning for population health

The right supporting environment alignment of incentives conflict between ‘Payment by Results’ in the hospital sector while we encourage more preventative care to keep people out of hospital health and social care working together (avoiding cost-shifting) realistic time horizons recognising the need for short-term changes without losing focus on longer-term wider determinants real public engagement in debates about prioritisation “It is disappointing that so few boards identified public engagement as a priority, and there is no evidence of boards being creative in reaching out to local communities through, for example, social media” (King’s Fund report on H&WBs, Oct ‘13) permission to be bold about (dis)investment decisions

Knowledge & intelligence skills knowledge management expertise to: synthesise data and evidence to create timely health intelligence business cases for public health investment (identifying value gained from resources invested) a ‘common currency’ for assessing impact of health & well-being identifying the impact of cost-effective interventions on health inequalities more focus on quality and outcomes data presenting intelligence effectively to different audiences knowledge transfer skills to make a difference to care / service delivery …..oh, and integrated health records!

Spend & Outcome Tool (SpOT) Atlases of Variation

Spend & Outcome Tool (SpOT) Has been produced for several years now for the NHS (previously at PCT, now CCG, level) Essential starting point to know where to look further at areas of (e.g.) high spend / poor outcome Could we develop a similar tool for local government? We all know that transport, education and housing contribute to health and wellbeing – can we start to look at those using a common framework? And look at the NHS-facing information alongside the local government information – single conversation within Health & Wellbeing Boards

Programme Quadrant Chart Shows how all programme budgets in your chosen organisation perform against the respective national averages, using modified z- scores plotted on axes. Spend plotted on the horizontal, outcome on the vertical. Can be viewed with weighted analysis (multiple outcome measures) or unweighted (single relevant outcome measures). SPOKEN: “In this example, we can see that our chosen local authority has a Public Health programme marker that lies outside the 1z box and is close to the 2z box on the outcome axis. A local commissioner may want to explore this programme further and can start this journey by assessing how the contributory sub-programmes for Public Health individually perform.” TECH NOTES: The vertical and horizontal central lines that bisect the quadrant charts represent the national averages of spend and outcome. Spend is plotted on the horizontal, outcome on the vertical. There are two boxes that represent 1SD and 2SD limits. The 2SD box is analogous to where 95% of organisations would be expected to fall. A programme lying outside the solid +/- 2 z scores box indicates that either the spend or outcome is sufficiently different to the national average to possibly warrant further review of either its spend, outcome or both.

Atlases of Variation First published in 2010 then 2011 Followed by a series of six themed atlases covering specific diseases or patient groups. New Atlas of Variation Compendium (a collaboration between Public Health England, NHS England and Right Care) coming soon.

Summary We know what needs to be done; it just needs to be done systematically and at scale Getting incentives right and aligning them across different parts of the system NHS and public health system working together on the investing in prevention agenda Maintaining the focus on long-term outcomes (the time horizon dilemma) The culture of commissioning is far more important than the process

Population health systems: going beyond integrated care (King’s Fund Feb.’15) “The permissive framework set out in the NHS five year forward view, with its emphasis on integrated care and health improvement, also provides a favourable policy context for the ideas set out here. Acting on these ideas should be seen as part of the health and care system’s efforts to achieve the ‘fully engaged scenario’ outlined by Derek Wanless more than a decade ago”

Real life stories NHS IQ Long Term Conditions team – Leena Sevak Leeds City Council - CVD and Respiratory – Lucy Jackson

LTC Dashboard … ….a wealth of data

Adding local value to Commissioning for Value Lucy Jackson Consultant in Public Health Leeds City Council

What did we do with Commissioning for value? Ensured it made sense locally. Choose issue for a local reason too. Added local data – to add to the pathway and triangulate. Wider footprint of Leeds but local too - 3 CCGs agreed on the same 2 areas. Brought all players together – Clinicians; CCG commissioners; Local Public Health with PHE. Citywide and within each CCG to work through. Ownership of approach - Conversations with clinical fora in each CCG – does this make sense , prioritise actions?

Local Strategic Context – Leeds Joint Health and Well Being Strategy Vision - Leeds will be a healthy and caring city for all ages Principle - People who are the poorest will improve their health the fastest Outcome one - People will live longer and have healthier lives

Use CFV but also locally what fits - the life expectancy gap by cause of death Scarf chart showing the breakdown of the life expectancy gap between Leeds as a whole and England as a whole, by cause of death, 2009-2011 How to put GP referrals in here Will NHS comparators activity be different from the spend?

NHS LEEDS SOUTH AND EAST CCG Local Data: GP audit and healthy living service referral data summarised by CCG NHS LEEDS NORTH CCG NHS LEEDS SOUTH AND EAST CCG NHS LEEDS WEST CCG Leeds CHD prevalence 3.3% 3.8% 3.1% 3.4% Health checks uptake 60.2% 65.2% 51.5% 57.7% Smoking 18.6% 27.0% 22.0% 22.7% Smokers referred to smoking services (including prompted self referral) 9.0% 9.1% 4.2% 7.0% Obesity 19.5% 25.7% 19.9% 21.7% Recorded BMI >30 referred to weight management service 2.2% 2.1% 1.5% 1.9% Alcohol Short screening (FAST or AUDIT-C) 6.3% 6.7% Completed full AUDIT screening 1.1% 0.7% 4.1% 2.3% Screened as positive (Hazardous/harmful/dependant drinkers) 9.9% 21.5% 34.9% 30.8% Brief intervention (in GP practice) 4.5% 8.7% Scoring 20+ on AUDIT who have been referred for specialist advice for dependant drinking 1.8% 0.4% 0.5% Local Data Local agreement with all GPs in Leeds to audit their data

Local Data: Obesity prevalence Obesity prevalence versus % weight management referrals Low obesity prevalence High weight management referrals High obesity prevalence High weight management referrals Practices which have high obesity prevalence and low percentage of weight management referrals : (For a full list of all practice's see appendix 5) Practice cluster GP practice name % Obese Referrals Pentagon 21.7% 0.9% Triangle 22.7% 1.7% Kite 21.3% 0.4% Hexagon 20.4% 0.6% 20.0% 25.7% 19.5% 2.2% 1.6% Circle 23.1% 0.7% 26.7%* 0.0% Mapped prevalence and referral data Low obesity prevalence Low weight management referrals High obesity prevalence Low weight management referrals * Statistically different to the CCG Practices within the dotted line do not have statistically different level of obesity prevalence and % of weight management referrals to the CCG as a whole

Local Data: Smoking prevalence Smoking prevalence versus % smoking referrals Local Data Low % smokers High% smokers referred High % smokers High% smokers referred Practices which have a high % of smokers and low percentage of smokers referred: (For a full list of all practices see appendix 5) Practice cluster GP practice name % Smoking Smoking referrals Triangle 30.3% 8.3% 33.2% 4.7% 29.1% 8.1% 34.2% 1.4% 34.1% 3.3% Oval 6.6% 39.9% 4.6% 37.1% 3.4% Circle 33.4% 3.8% 31.5% 2.0% 33.6% 5.3% 32.3% 6.9% 37.4% 4.1% No cluster 27.8% 3.6% Low % smokers Low% smokers referred High % smokers Low % smokers referred Practices within the dotted line do not have statistically different level of smoking prevalence and % of smoking referrals to the CCG as a whole

Overarching messages for Leeds -CVD Summary: Public health focus on prevention; specifically smoking prevalence (Leeds South & East and Leeds West) smoking cessation (All) and Obesity (Leeds South & East) Significant benefit to patients if improvement to Primary Care management indicators were made (All) High emergency admissions for CVD (Leeds South & East), costs (Leeds North and Leeds South & East) and lengths of stay (All) High costs for CHD emergency admissions (Leeds North and Leeds South & East) and high costs for CHD elective admissions (Leeds South & East) High emergency admissions for Heart Failure and Stroke (Leeds South & East and Leeds West) High costs for Angiography procedures (All), CABG procedures (All) and Angioplasty procedures (Leeds West) High lengths of stay for Angiography procedures (Leeds West)

Respiratory Summary Summary on a page Public health focus on prevention; specifically smoking prevalence (Leeds South & East and Leeds West) and smoking cessation (All) Significant benefit to patients if improvement to Primary Care management indicators were made (All) High emergency admissions for Influenza & Pneumonia (Leeds South & East and Leeds West) High COPD emergency readmissions (Leeds South & East and Leeds West) High costs for Respiratory (All), COPD (Leeds North and Leeds West), Asthma (Leeds South & East), Upper Respiratory (Leeds South & East) and Other Acute lower (Leeds South & East and Leeds West) emergency admissions High lengths of stay for Upper Respiratory (Leeds South & East) and Other Acute Lower (Leeds North and Leeds South & East) Significant variation in corticosteroids prescribing between practices (All) Summary on a page

Actions ………….. Public Health – challenge to jointly re look at commissioning of healthy living services key priority for the Council. Primary care – variation target work with key practices and embed into engagement schemes in each CCG Whole pathway – flow and variation – LIQH. CCG commissioning – using packs as part of prioritisation framework Transformation work streams -Acute – elective care value approach; Integrated Care – Pathways work; PYLL trajectories.

The LIQH approach

LIQH – focussed areas CVD improving the management of chest pain; optimise outcomes and quality of care for people requiring interventions/ treatment for suspected/confirmed arrhythmia and to prevent inappropriate use of secondary services. to improve the physical and psychological health of patients’ post-MI with new or existing anxiety / depression. COPD support people with COPD to manage their own condition and to reduce the likelihood and impact of exacerbations; reduction in variation of approach to COPD patients in crisis; Improving the early and accurate diagnosis of COPD whilst improving patient experience.