How to make changes in the NHS Keith Willett

Prof of Orthopaedic Trauma Surgery University of Oxford prev. National Clinical Director for Trauma Care

Medical Director for Acute Care; NHS England

ATOCP Conference Oxford 2016

Universal health care

Funded by taxation

8.7% of GDP (17.6, 10.9)

UK 3.6k, Can 5.7k, US 9.1k US$

NHS Quality Framework to drive improvement

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

“Compelling evidence that it is possible to change professional

behaviour to improve quality of care, reduce cost ….. for better VALUE”

QUALITY:

clinical effectiveness, patient safety, experience of patients

The NHS is an amoeba . . . . .

Desmond Morris and Keith Willett

First, identify the key interventions in the care pathway that will really

improve care and outcomes ……………

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

Changing practice for quality improvement in

healthcare at scale

7

Multi-

professional

clinical and

patient advisory

group

Review of

all current

evidence

and

guidelines

Activity data from

registries and Hospital

Episode Statistics

NICE standards

health economics

operational delivery

workforce

Recommendations

Measurable

commissionable

aligned payments

Cost-effective

Secondly, agree the metrics by which care can be

appropriately judged by patients and all clinicians

NHS Hospital Episode Statistics data do not measure quality

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

Hip Fracture - agreed best practice metrics

Time to surgery (<36 hours)

1. Arrival in Emergency Dept (or diagnosis if an inpatient) to start of anaesthesia

Involvement of the multi-professional team: 2. Admitted under the joint care of a Consultant Geriatrician and a Consultant

Orthopaedic Surgeon

3. Admitted using an assessment protocol agreed by geriatrics medicine, orthopaedic surgery and anaesthesiology

4. Assessed by a Geriatrician in the perioperative period

Consultant or senior resident within 72 hours of admission

5. Postoperative Geriatrician-directed: 1. Multiprofessional rehabilitation team

2. Fracture prevention assessments (falls risk and bone health)

6. Dementia Assessment: Mental test score at admission and prior to discharge by nurses

National Clinical Audit / Registry

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

Thirdly incentivise the clinical behaviour and

patient flow changes in the care pathway

money follows the right patient care ……..

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

12

Pay by performance tariff

• Base tariff set below national average cost • Sum of base tariff and BPT higher than national average cost

Base tariff for each HRG

Additional payment for best

practice Reduction in base tariff

for current compliance

Payment

per

patient

Original

base tariff Best

practice

tariff

2-part tariff for best practice initially 9% now 19% of HRG

£1235 of £6500 HRG

HRG

tariff

price

Link to national registry to drive change

LOCAL

HOSPITAL

CLINICAL

TEAM

Commissioner Insurer/Payer

National Hip

Fracture

Registry Unique identifier

Individual patient data

BPT compliance

Additional

payments

pay tariff uplift (~19%) £500k to £1m per year

per hospital in extra

income

(300-500 cases a year)

Improvement in Hip Fracture Care 2010 - 2014 Best Practice Tariff: percentage attained for each criteria; all criteria 24 to 64%

Admitted under joint geriatric/anaesthetic protocol increased from 64 to 97%;

Surgery within 48 hours rising from 65 to 77% in 36 hours, to 87% in 48hrs;

Seen acutely by a Geriatrician up from 48 to 90%; bone health assessment up 72 to 97%

16 quarter-on-quarter improvement

100%

Too difficult to solve for 25 years . . . .

MAJOR TRAUMA

Life threatening

or life-changing serious

physical injury – often

multiple

15

MAJO

R T

RAU

MA

Typified by delay,

inappropriate care,

avoidable death and

disability

Preferred acute patient pathway

16

MAJO

R T

RAU

MA On scene triage 24/7 network coordinator

in Ambulance Service

Medical consultant advice

direct transfer

(<45mins)

indirect transfer

(geography, time-critical

intervention)

MAJOR TRAUMA CENTRE

Consultant led trauma team

Immediate operating theatre

All specialties: neurosciences

Immediate CT scan

Interventional radiology

Specialist critical care

Trauma Unit

trauma team

immediate CT

resus, assess

and ? transfer

enhanced

care team

Preferred rehabilitation pathway Network Director for Rehabilitation

17

MAJO

R T

RAU

MA

Directory

of Rehab

services

PRESCRIPTION

for rehabilitation

physiotherapy, OT, SALT,

social work, mental health

neuropsychology

MAJOR TRAUMA CENTRE

Consultant Clinical Lead

Acute Trauma Rehabilitation Manager

Full multi-disciplinary team

Care & Rehabilitation Coordinator

Trauma Unit

or Local Hospital

Identified Lead for

Trauma Rehab Services

Key worker

Level 1

complex

Level 2

specialist

Level 3 general

independence Vocational / Educational

All networks and MTCs

implemented in April 2012

• Set-up 22 regional trauma

networks (27 MTCs) – pop 53m

• Cover 1.4m to 5.2m population

• Ongoing quality assurance

through TARN trauma registry

• Nationally Commissioned

– NHS England

– Clinical Reference Group

18

MA

JO

R T

RA

UM

A

= established Major Trauma Centre

Best Practice Tariff Criteria

Level 1 ISS > 8 and the following criteria met: the patient is treated in an MTC Complete patient data submitted to TARN registry within 40 days of discharge MDT Rehabilitation prescription is completed for each patient Tranexamic acid administered within 3 hours of injury

Level 2 ISS > 15 Level 1 criteria are met, plus either: Patient received by a trauma team led by a Consultant within 30 (5) minutes of

arrival If the patient is transferred as an ‘urgent’ transfer then the transfer should take place

within 2 calendar days of referral from the trauma unit.

Driving performance improvement

. . . . . . . with a best practice tariff

MAJOR

TRAUMA

CENTRE

Commissioners / payer Trauma Audit

Research

Network (TARN)

Individual patient data

unique identifier

KPI compliance

Additional best practice

tariff per patient

£1500 - £3000

Major Trauma

Centres only

financially viable if

delivered best

practice care …….

MAJO

R T

RAU

MA

ISS 16-75 Best Practice tariff compliance 2012-13

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

months

Level 1 criteria only

Level 1 and 2

criteria met

13,000 patients

Consultant led

trauma team

Transfer 2 days

National Dashboard: All Major Trauma Centres

Consultant-led Trauma Team on arrival, patient ISS>15

80%

70%

60%

50%

40%

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2011 2011-12 2012-13 Year

2013-14

Q1 Q2

P = 0.001

Q3 Q4

4,000 patients

11,300 patients

National Dashboard: All Major Trauma Centres

Tranexamic acid within 3h injury

80%

70%

60%

50%

40%

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2011 2011-12 2012-13 Year

2013-14

Q1 Q2 Q3 Q4

81.5%

MAJOR TRAUMA NETWORKS INTRODUCED

25-40% increase in

survival

Ws breakdown (Major Trauma Centres and Trauma Units)

After MTC designation (from April 2012)

PROBABILITY of SURVIVAL band

Number in Ps group

EXPECTED number of survivors

ACTUAL number of survivors

Actual number of

deaths

Difference (W) = (Actual vs

Expected / N/100)

Fraction in the TARN

database

Case mix standardised

(adjusted) difference (Ws = total)

>95% 33176 32722 32835 341 0.339 0.673 0.2278

0.90-0.95 10522 9793 9755 767 -0.364 0.159 -0.0579

0.75-0.90 5379 4572 4687 692 2.138 0.085 0.1817

0.50-0.75 2917 1926 1993 924 2.290 0.046 0.1053

0.25-0.50 1542 572 602 940 1.922 0.025 0.0480

0.00-0.25 784 105 138 646 4.144 0.012 0.0497

54,320 Ws = 0.555

equates to ~600 lives saved

-10

-50

510

.5 1 1.5 2 2.5precision (1/seWs)

Ws -2SD

+2SD target

-3SD +3SD

Before Major Trauma Centre DesignationUniversity teaching hospitals before designation as a Major Trauma Centres

-10

-50

510

0 .5 1 1.5 2 2.5precision (1/seWs)

Ws -2SD

+2SD target

-3SD +3SD

After Major Trauma Designation

University teaching hospitals after designation as a Major Trauma Centres

21326 pts, 47% ISS >15

Continuous assurance, reappraisal, comparison

and sharing ……….

public reporting and peer review

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

Rate of Survival

The role of management is to create a culture and reward

system that guides thousands of decisions in the direction of better

quality and service at reduced cost

A Enthoven

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

The role of management is to create a culture and reward

system that guides thousands of decisions in the direction of better

quality and service at reduced cost

K Willett

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality

clinicians is to

Clinical risk

Payer risk

Operational risk

Provider risk

Service specifications

Professional standards

Payment systems

Quality assurance

Leadership is the capacity to turn vision into reality

Warren Bennis

LESSON 1

Clinical teams in a universal healthcare system can be trusted to design and commission best practice and best value services and select the measures by which their services should be fairly judged

Leadership is the capacity to turn vision into reality

LESSON 2

Deriving policy through multi-professional and patient consensus has credibility and ensures engagement and ownership in provider clinicians for delivery

Leadership is the capacity to turn vision into reality

LESSON 3

Linking payment for

performance and public

reporting are key, and

ensures government buy-in

We must not be naïve

Leadership is the capacity to turn vision into reality

LESSON 4

We need to move healthcare systems from summative assessment (targets) …… ….. to clinically credible and formative assessment

Healthcare System change in the NHS: If I were doing it again Locally

1. Always question why you are doing it that way?

2. If you have a vision, energy, and passion you will always win through

3. Keep adding to ‘your’ design with others views and ideas

4. What problem is on the managers desk not yours? Can you help it?

Nationally

1. Educate, then use patients and the public more to construct the narrative

2. Work with the next generation of enthusiasts (but beware the fanatics)

3. Take what you could get in the battles you cannot win – it’s iterative

4. Mesh with as many other strategies as possible, but not to be dependent

5. Appreciate the operational delivery and financial complexities early

6. Political will is not essential unless you want to divert or need more funds

7. Be ready for your moment in the sun ……………

Redesigning the whole of Urgent and Emergency Care

39

Bring clarity

to quality

Measure

quality

Publish

quality

Reward

quality

Leadership

for quality

Innovate for

quality

Safeguard

quality