Clinical Directors Forum Donal O’Donoghue National Clinical Director

Clinical Directors Forum

Donal O’Donoghue

National Clinical Director

• For the NHS

• For Renal Medicine

• For you as Clinical Directors

The Challenges

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nDuring the recession, government expenditure has continued to grow whilst receipts have fallen:

Expenditure

Receipts

£154bn borrowing last year

• Highest spending since 1982–83• Lowest tax burden since 1960–61• Highest borrowing since WWII

• The Nicholson challenge

• The cost of liberation

• No decisions about me without me

• Quality, Innovation, Productivity and Prevention

The Macro Challenge

The challenge is immense:

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-2%

0%

2%

4%

6%

8%

10%

12%

14%

16%public expenditure

NHS expenditure

Change in real current spending

“Quality, Innovation, Productivity and Prevention (QIPP) productivity gains… will release up to £20 billion more funding into frontline services for patients over the four years [2011/12 to 2014/15].” (The Operating Framework for the NHS in England: 2011/12, December 2010)

“But this will not protect the NHS from the need to secure efficiency savings and to control pay and prices in the NHS. If we can secure those efficiency savings, we can reinvest them in the NHS to deliver improving outcomes for the public.” (Secretary of State, Today, May 2010)

Focus on quality retained following the change ofgovernment…

Safety

Patient Experience

Effectiveness

Will I be protected from healthcare acquired infections

and avoidable accidents?

What will my experience of the NHS be like? Will I be treated with

compassion, dignity and respect in a clean, safe and well managed

environment?

How will my clinical procedure be carried out?

What will its result be? What about my quality of

life after treatment?

Safety

Patient Experience

Effectiveness







environment?



environment?







NICE Quality Standards, Quality Accounts, CQUIN, measuring for quality improvement, the National Quality Board are all key features of the new system

“Building on Lord Darzi’s work, the Government will now establish improvement in quality and healthcare outcomes as the primary purpose of all NHS- funded care”

But, an important shift in focus towards outcomes…

“All too often, the NHS has been hamstrung by a focus on nationally determined process targets which have had a distorting effect on clinical priorities, disempowered healthcare professionals and stifled innovation. We need to recalibrate the whole of the NHS system so it focuses on what really matters to patients and what we know motivates healthcare

professionals – the delivery of better health outcomes.”Transparency in Outcomes- a framework for the NHS July 2010

Equity and Excellence: Liberating the NHS set out a vision of a NHS that achieves amongst the best outcomes of any health service in the world. To achieve this, it outlined two major shifts:

•A move away from centrally-driven process targets which get in the way of patient care;

•A relentless focus on delivering the outcomes that matter most to people

Adult Social Care

Public HealthNHS

ASC and NHS:Supported discharge fromNHS to social care.Impact of reablement services on reducing repeat emergencyadmissions.Supporting carers and involving in care planning.

NHS and Public Health:Preventing ill healthand lifestyle diseasesand tackling theirdeterminants.

ASC and Public Health:Preventing avoidable ill health or injury, including through re-ablementservices and earlyintervention.

ASC, NHS and Public Health:Departmental Business Plan ‘impact’ indicators and DHcontribution to Public Services Transparency Framework

Adult Social Care

Public HealthNHS

ASC and NHS:Supported discharge fromNHS to social care.Impact of reablement services on reducing repeat emergencyadmissions.Supporting carers and involving in care planning.

NHS and Public Health:Preventing ill healthand lifestyle diseasesand tackling theirdeterminants.

ASC and Public Health:Preventing avoidable ill health or injury, including through re-ablementservices and earlyintervention.

ASC, NHS and Public Health:Departmental Business Plan ‘impact’ indicators and DHcontribution to Public Services Transparency Framework

GOAL: Aligned outcomes frameworks for the NHS, publichealth and adult social care

The NHS Outcomes Framework will set direction andprovide enhanced accountability

Preventing people from dying prematurely

Enhancing quality of life for people with long-term conditions

Helping people to recover from episodes of ill health or following injury

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and protecting them from avoidable harm

Effectiveness

Domain 1

Domain 2

Domain 3

Domain 4

Domain 5

Patient experience

Safety

The framework will be organised around 5 national outcome goals / domains covering the breadth of NHS activity

How EFFECTIVE the care provided by the NHS isWhat the patient EXPERIENCE is likeHow SAFE the care provided is

These will help the public and Secretary of State for Health to track:

THE NEW QUALITY LANDSCAPE: How will the NCB deliver the NHS Outcomes Framework?

• How to make change happen in the new system will feel very different.

• Even though many of the levers remain, top down performance management of providers or commissions won’t be a feature of the new system.

• There will be no NHS Headquarters - this is not the role of the NHSCB.

• The focus on outcomes will require a far more sophisticated accountability model than we have had in the past.

• Unlike process measures where it is easier to make black and white judgements about performance, outcome measures are far more complex to understand and interpret - this is a good thing as it will require real understanding of the issues

• There will be a temptation to pull every available lever in an attempt to affect change – the reforms, however, are about liberating the intrinsic motivators of staff to deliver high quality care and better outcomes

The QIPP programme is supporting the NHS to meet the challenge

Supporting commissioners to commission for quality and efficiency – e.g. through improved clinical pathways, decommissioning poor value care

Provider efficiency – supporting providers to respond to the commissioning changes and efficiency pressures by transforming their businesses

Shaping national policy and using system levers to support and drive change e.g. primary care contracting & commissioning

Care closer to home

More standardisation

Earlier intervention

Empowered patients

Fewer acute beds

Reduced unit costs

Characteristics of a sustainable system:

Areas covered by Quality, Innovation, Productivity and Prevention (QIPP) programme

Commissioning and pathways

Provider efficiency

System enablers

• Right Care• Long Term Conditions• Urgent Care • End of Life Care

• Back Office Efficiency and Optimal Management• Procurement• Clinical Support Rationalisation (Pathology) • Productive Care• Medicines Use and Procurement • Safe Care

• Primary Care Contracting and Commissioning• Technology and Digital Vision• Workforce

Thirteen national QIPP workstreams will help local organisations respond to this challenge:

Enhancing quality of life for people with long-term conditionsHelping people to recover from episodes of ill health or following injury

One frameworkdefining how the NHS will be accountable for outcomes

Five domainsarticulating the responsibilities of the NHS

Ten overarching indicatorscovering the broad aims of each domain

Thirty-one improvement areaslooking in more detail at key areas within each domain

Fifty-one indicators in totalmeasuring overarching and improvement area outcomes

The NHS Outcomes Framework 2011/12at a glance

Treating and caring for people in a safe environment and protect them from avoidable harm

1 2 3

5

Overarching indicators

1a Mortality from causes considered amenable to healthcare(The NHS Commissioning Board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate)1b Life expectancy at 75

Improvement areas

Reducing premature death in people with serious mental illness1.5 Under 75 mortality rate in people with serious mental illness*

Reducing deaths in babies and young children1.6.i Infant mortality*1.6.ii Perinatal mortality (including stillbirths)

Overarching indicator

2 Health-related quality of life for people with long-term conditions (EQ-5D)**

Improvement areas

Ensuring people feel supported to manage their condition2.1 Proportion of people feeling supported to manage their condition***

Improving functional ability in people with long-term conditions2.2 Employment of people with long-term conditions

Reducing time spent in hospital by people with long-term conditions2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)2.3.ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers2.4 Health-related quality of life for carers (EQ-5D)**

Enhancing quality of life for people with mental illness2.5 Employment of people with mental illness


3a Emergency admissions for acute conditions that should not usually require hospital admission3b Emergency readmissions within 28 days of discharge from hospital***

Improvement areas

Improving outcomes from planned procedures3.1 Patient-Reported Outcomes Measures (PROMs) for elective procedures

Preventing lower respiratory tract infections (LRTI) in children from becoming serious3.2 Emergency admissions for children with LRTIs

Improving recovery from injuries and trauma3.3 An indicator needs to be developed.

Improving recovery from stroke3.4 An indicator needs to be developed.

Improving recovery from fragility fractures3.5 The proportion of patients recovering to their previous levels of mobility / walking ability at i 30 and ii 120 days***

Helping older people to recover their independence after illness or injury3.6 The proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into rehabilitation services***


5a Patient safety incident reporting5b Severity of harm5c Number of similar incidents

Improvement areas

Reducing the incidence of avoidable harm5.1 Incidence of hospital-related venous thromboembolism (VTE)5.2 Incidence of healthcare associated infection (HCAI)

i MRSAii C. difficile

5.3 Incidence of newly-acquired category 3 and 4 pressure ulcers5.4 Incidence of medication errors causing serious harm

Improving the safety of maternity services5.5 Admission of full-term babies to neonatal care

Delivering safe care to children in acute settings5.6 Incidence of harm to children due to ‘failure to monitor’

Reducing premature mortality from the major causes of death1.1 Under 75 mortality rate from cardiovascular disease*1.2 Under 75 mortality rate from respiratory disease*1.3 Under 75 mortality rate from liver disease*1.4 Cancer survival

i One- and ii five-year survival from colorectal canceriii One- and iv five-year survival from breast cancerv One- and vi five-year survival from lung cancer

Ensuring that people have a positive experience of care4Overarching indicators

4a Patient experience of primary care4b Patient experience of hospital care

Improvement areasImproving people’s experience of outpatient care4.1 Patient experience of outpatient services

Improving hospitals’ responsiveness to personal needs4.2 Responsiveness to in-patients’ personal needs

Improving access to primary care services4.4 Access to i GP services and ii dental services

Improving women and their families’ experience of maternity services4.5 Women’s experience of maternity services

Improving the experience of care for people at the end of their lives4.6 An indicator needs to be developed based on the survey of bereaved carers

Improving experience of healthcare for people with mental illness4.7 Patient experience of community mental health services

Improving children and young people’s experience of healthcare4.8 An indicator needs to be developed.

Improving people’s experience of accident and emergency services4.3 Patient experience of A&E services

*Shared responsibility with Public Health England

**EQ-5D™ is a trademark of the EuroQol Group. Further details can be found on their website: http://www.euroqol.org

***Indicator also included in the adult social care outcomes framework

Indicators in italics are placeholders, pending development or identification of a suitable indicator

Preventing people from dying prematurely Enhancing quality of life for people with long-term conditionsHelping people to recover from episodes of ill health or following injury

One frameworkdefining how the NHS will be accountable for outcomes

Five domainsarticulating the responsibilities of the NHS

Ten overarching indicatorscovering the broad aims of each domain

Thirty-one improvement areaslooking in more detail at key areas within each domain

Fifty-one indicators in totalmeasuring overarching and improvement area outcomes

The NHS Outcomes Framework 2011/12at a glance

Treating and caring for people in a safe environment and protect them from avoidable harm

1 2 3

5


1a Mortality from causes considered amenable to healthcare(The NHS Commissioning Board would be expected to focus on improving mortality in all the components of amenable mortality as well as the overall rate)1b Life expectancy at 75

Improvement areas

Reducing premature death in people with serious mental illness1.5 Under 75 mortality rate in people with serious mental illness*

Reducing deaths in babies and young children1.6.i Infant mortality*1.6.ii Perinatal mortality (including stillbirths)

Overarching indicator

2 Health-related quality of life for people with long-term conditions (EQ-5D)**

Improvement areas

Ensuring people feel supported to manage their condition2.1 Proportion of people feeling supported to manage their condition***

Improving functional ability in people with long-term conditions2.2 Employment of people with long-term conditions

Reducing time spent in hospital by people with long-term conditions2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)2.3.ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers2.4 Health-related quality of life for carers (EQ-5D)**

Enhancing quality of life for people with mental illness2.5 Employment of people with mental illness


3a Emergency admissions for acute conditions that should not usually require hospital admission3b Emergency readmissions within 28 days of discharge from hospital***

Improvement areas

Improving outcomes from planned procedures3.1 Patient-Reported Outcomes Measures (PROMs) for elective procedures

Preventing lower respiratory tract infections (LRTI) in children from becoming serious3.2 Emergency admissions for children with LRTIs

Improving recovery from injuries and trauma3.3 An indicator needs to be developed.

Improving recovery from stroke3.4 An indicator needs to be developed.

Improving recovery from fragility fractures3.5 The proportion of patients recovering to their previous levels of mobility / walking ability at i 30 and ii 120 days***

Helping older people to recover their independence after illness or injury3.6 The proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into rehabilitation services***


5a Patient safety incident reporting5b Severity of harm5c Number of similar incidents

Improvement areas

Reducing the incidence of avoidable harm5.1 Incidence of hospital-related venous thromboembolism (VTE)5.2 Incidence of healthcare associated infection (HCAI)

i MRSAii C. difficile

5.3 Incidence of newly-acquired category 3 and 4 pressure ulcers5.4 Incidence of medication errors causing serious harm

Improving the safety of maternity services5.5 Admission of full-term babies to neonatal care

Delivering safe care to children in acute settings5.6 Incidence of harm to children due to ‘failure to monitor’

Reducing premature mortality from the major causes of death1.1 Under 75 mortality rate from cardiovascular disease*1.2 Under 75 mortality rate from respiratory disease*1.3 Under 75 mortality rate from liver disease*1.4 Cancer survival

i One- and ii five-year survival from colorectal canceriii One- and iv five-year survival from breast cancerv One- and vi five-year survival from lung cancer

Ensuring that people have a positive experience of care4Overarching indicators

4a Patient experience of primary care4b Patient experience of hospital care

Improvement areasImproving people’s experience of outpatient care4.1 Patient experience of outpatient services

Improving hospitals’ responsiveness to personal needs4.2 Responsiveness to in-patients’ personal needs

Improving access to primary care services4.4 Access to i GP services and ii dental services

Improving women and their families’ experience of maternity services4.5 Women’s experience of maternity services

Improving the experience of care for people at the end of their lives4.6 An indicator needs to be developed based on the survey of bereaved carers

Improving experience of healthcare for people with mental illness4.7 Patient experience of community mental health services

Improving children and young people’s experience of healthcare4.8 An indicator needs to be developed.

Improving people’s experience of accident and emergency services4.3 Patient experience of A&E services

*Shared responsibility with Public Health England

**EQ-5D™ is a trademark of the EuroQol Group. Further details can be found on their website: http://www.euroqol.org

***Indicator also included in the adult social care outcomes framework

Indicators in italics are placeholders, pending development or identification of a suitable indicator

Preventing people from dying prematurely

• The kidney care quality landscape• Renal QIPP• Integrated Care and AWP • Planning and uncertainty

The Speciality Challenge

NICE quality standard for CKD

• AV fistula• Immunisation• HCAIs reduced• Transport for HD• Pre-emptive transplants• Care planning• Conservative kidney care

• Testing for CKD• Progression• Referral• BP control• Anaemia management• AKI risk management• Personalised information

CQUINs

The Commissioning of Quality and Innovation (CQUIN) payment

framework are one way to achieve quality:

The renal CQUINS cover acute kidney injury and home dialysis. The indicators

of quality that have been chosen are:

• Percentage of emergency admissions to have both 1. physiological scoring performed to identify patients at high risk of clinical deterioration (eg MEWS score) and 2. senior review (consultant or equivalent within 12 hours of admission).

• Percentage of emergency admissions with a major risk factor for AKI to have both: 1. medication review and 2. serum creatinine re-checked within 24 hours of admission.

• Percentage of patients requiring maintenance dialysis to be receiving home haemodialysis, peritoneal dialysis or assisted automated peritoneal dialysis.

Dialysis transport savings year after Sept 2009 Before Changes After Changes

No. on hospital transport 66 44

Taxi journeys 300-350 approx 0

Costs

Saving

£6,000

£0

£6000

Volunteer drivers journeys 3,000 approx 1,536

Costs

Saving

£13,350

(£4.45 per journey)

£6,830

£6520

Hospital Car Transport Journeys 11,500 approx 6,300

Costs

Saving

£86,250

(£7.50 per journey)

£47,250

£39,000

Ambulance (£8,892 per pt per year) 18 6

Costs

Savings

Total Saving

£160,056 £53,352

£106,704

£158,224

ImpactQuality:Patient complaints reduced12 patients came off ambulance transport

Productivity:• Number of journeys reduced by approx 33%• Number of patients requiring transport reduced from 51% to 34%

Savings:• Cost savings in one kidney centre: £158,224• Potential National savings: £25,500,000

• Transport costs reduced

• Overall Service improvement

Chronic kidney disease: e-consultationProvided by: Bradford Teaching Hospitals NHS Foundation Trust

NHS Evidence assessment of the degree to which this particular case

study meets the criteria is represented in the evidence summary graphic:

Giving intravenous iron in patients homes and community hospitals

Provided by: Royal Cornwall Hospitals Trust

QIPP Evidence provides users with practical case studies that address the quality and productivity challenge in health and social care. All examples submitted are evaluated by NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria of savings, quality, evidence and implementability; each criterion is given a score which are then combined to give an overall score. The overall score is used to identify the best examples, which are then shown on NHS Evidence as ‘recommended’ or ‘highly’ recommended’.

Integrated Care:

AWP – Any Willing Provider …

Planning …

Variation in Home Haemodialysis:

Adapted from Renal Registry 12th Annual Report 2009

%HHD prevalence in dialysis popn

2008

Shared Decision Making:

The care team communicates to the

patient personalised information about the options, outcomes, probabilities and scientific uncertainties of the various treatments.

“is a fundamental part of care planning and promotes the best choice in what otherwise can be a complex and overwhelming situation.”

The patient communicates his or her values and relative importance he or she places on the potential benefits and harms.

• How will Best Practice Tariff Work?

• Organising complex non-RRT Care

• Activating Patients

• Motivating and energising staff

The Front Line Challenge

Timely Vascular Access

Standard 3“All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

The haemodialysis tariff covers a session of dialysis, defined as each session of dialysis treatment on a given day for each patient:

Haemodialysis tariff prices HRG code

Description Tariff per session £

LD01A Hospital haemodialysis/filtration with access via haemodialysis catheter 19 years and over

128

LD02A Hospital haemodialysis/filtration with access via arteriovenous fistula or graft 19 years and over

159

LD03A Hospital haemodialysis/filtration with access via haemodialysis catheter with blood borne virus 19 years and over

146

LD04A Hospital haemodialysis/filtration with access via arteriovenous fistula or graft with blood borne virus 19 years and over

182

LD05A Satellite haemodialysis/filtration with access via haemodialysis catheter 19 years and over

128

LD06A Satellite haemodialysis/filtration with access via arteriovenous fistula or graft 19 years and over

159

LD07A Satellite haemodialysis/filtration with access via haemodialysis catheter with blood borne virus 19 years and over

146

LD08A Satellite haemodialysis/filtration with access via arteriovenous fistula or graft with blood borne virus 19 years and over

182

Peritoneal dialysis tariff prices HRG code

Description Tariff per day £

LD11A Continuous ambulatory peritoneal dialysis 19 years and over 46

LD12A Automated peritoneal dialysis 19 years and over 56

The peritoneal dialysis tariff prices cover a day of treatment:

Assisted APD - Now

• There is currently no capacity to differentiate between APD and assisted APD in the new chapter LD HRG.

• Therefore both aAPD and APD activity will result in the generation of an APD HRG with its associated National Tariff.

• For the next 12 months it will be necessary to agree locally the commissioning and re-imbursement for the ASSISTANCE portion of the costs, and a means of communicating this activity.

Assisted APD – proposed HRG solution

• The items in the current NRD which define the current HRG include separately;– Modality (CAPD, CCPD, Haemodialysis)– Supervision (Hospital, Satellite, Home, Shared)

• The supervision is currently used to differentiate Home from Satellite and Hospital HD in HRG.

• In the future it is proposed to use the currently un-used “Shared” supervision code to differentiate– Assisted APD (CCPD+Shared)– Self administered APD (CCPD+Home)

Assisted APD – HRG timescale

• A request will be made in May 2011 to revise the current HRG to include aAPD.

• The modest change requested, and the existing items in the NRD make it likely to be a quick modification.

• In preparation providers can collect data on aAPD using the future (CCPD+shared) scheme now if they wish.

• The current HRG grouper ignores supervision if the modality is CCPD so it will still result in the same APD HRG, but will allow immediate transition to the new HRG when these are released.

Elements required to collect data• The ideal is

– A close to real-time record of individual HD treatment sessions for all unit HD patients which includes the access used for the individual treatment session, and the dialysis location (hospital or satellite).

– An electronic treatment prescription which a patient will be self administering if doing a home therapy (CAPD, CCPD, HHD) containing a minimum of modality and the number of delivered treatments per week.

– An electronic record of a patients blood borne virus status (mimimum = positivity to one or more of HepBsAg, HepCAb, HIV test) for all unit HD patients.

– An electronic record of the patients age (<19 v.s >=19yrs).

Data flow

NRD Source extracted from renalunit clinical computer system

.csv file passed through local grouperto convert codes to HRG

Finance divide activity by PCT

Finance also provide patient levelData as part of contract for assurance

PCT pay provider for activity

Provider invoice for activity by HRG

Data flow

ICD-10 and OPCS Source extractedfrom hospital PAS







Data flow








NRD data remain in thegrouper output file

Invoice for aAPD

aAPD identified using NRDcodes rather than HRG

Data flow








Data submitted to SUS for grouping

Provider and commissioner bothreview same activity data in SUS

Outpatient attendance tariffs:

CONSULTANT-LED

WF01BFirst attendanceSingle Professional(£)

WF02BFirst attendanceMulti Professional(£)

WF01AFollow up AttendanceSingle Professional(£)

WF02AFollow up AttendanceMulti Professional(£)

Nephrology 198 328 128 257

Chronic Care Model

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organisation

Improved Outcomes

www.renalpatientview.org

"If there is one lesson to be learnt, it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks that matter".

Documents

Clinical Directors Forum Donal O’Donoghue National Clinical Director