OldhamDoing It Differently

Dr Hugh SturgessDirector, Pennine MSK Partnership

Context

• New White Paper– Root and branch reform of NHS in England– Unprecedented financial challenge for NHS

• Deep seated failings in the NHS– Model of Care – System of Care

What’s wrong with the system?

• System of Care

• “Disintegration!”

• Micro-commissioning complex pathways

• Perverse incentives – PbR• KPIs process driven not population level

improvement or patient experience• No effective performance management of care

Variation in MSK Spend

Programme Budget Commissioning

• Different from standard approach

– Commission with the lead accountable provider for defined programmes of care with a defined budget

– Commissioners have population quality based KPIs

– Lead accountable provider shares responsibility for care co-ordination, quality and performance management across the entire pathway

One thing I have always found is that you have got to start with the customer experience and work backwards to the technology.

Steve Jobs 1955-2011

8

Patients want more involvement

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Analysis: Satisfaction with Total Knee Replacement (NJR)

Satisfaction questions were completed by 8095 patients

Overall- 81.8% were satisfied- 11.2% were unsure

- 7.0% were not satisfied

The OKS varied according to patient satisfaction (p<0.001)

Source: National Joint Registry

Challenges

• Lack of faith in new system• Lack of interest/support from grass root GPs• Dismantle existing systems• Financial instability• Threat of competition• Ageing population, more expensive treatments,

increasing co-morbidities and LTCs• Lack of integrated care

– Much spoken of – hardly ever delivered– Need to shift investment from Acute trusts to community

and primary care

Oldham

Pennine MSK Partnership

• Primary Care based organisation commissioned by NHS Oldham to provide non admitted care in rheumatology, orthopaedics and chronic pain

• Consultant led – provide 97% rheumatology and take patients to point of listing in Orthopaedics

• From May 2011 control £23m programme budget for MSK using prime vendor model

• Psychological medicine for chronic pain• 11,000 new referrals a year• Deliver traditional hospital based services from community –

biologics and infusions• GP and Specialist training• Research

Primary care holistic assessment and care

COMMUNITY MULTIDISCIPLINARY

SPECIALIST SERVICE (Pathway Hub)

Prime contractor

Highly specialised, intensive, episodic hospital care

Referral triage

SUBCONTRACTING

Hub functions:

•Referral triage•Skilling up 1’ care•Specialist Assessment•Specialist integrated care•Shared Decision Making•Personal Health Planning•Supported Self Care•Patient & carer support•Voluntary sector provisionPATHWAY MANAGEMENT

Referral

NHS Oldham Programme Budget

• MSK - £23m - Pennine MSK 1st May 2011– Primary Care

• Local enhanced services– Community Care

• Pennine MSK• Physiotherapy, podiatry

– Secondary Care• All activity included

Outcomes Of Programme Budget

• We are incentivised to performance manage the entire pathway

• Invest in Shared Decision Making and Self Management

• Work with primary care to reduce variation• Work with secondary care to ensure best

practice is followed• Work with commissioner – high value care

within budget

Delivering Integration

• Commissioner will focus on clinical outcomes rather than process metric

• Patients at the centre of our redesign

• Work with third sector

• Use self management and self referral were clinically appropriate

Challenges and Opportunities

• Acute Trust attitude• Change in commissioning• Financial constraints• GP support

– Initial suspicion– Wider support as triage spreads to all referrals

• Clinician support

Knee Pathway (O/A)

Triage of Referral within 24 hours on

CaB – Signpost patient to NHS PDAs

Face to face assessment ESP with 2

weeks with diagnostics –

telephone FU if needed

Listing – after choice – 18 week compliance

by week 7

Shared Decision Making

– Tested and Implemented the AQuA model past 2 years

– Looked at impact of implementing SDM on patient reported outcomes for those who have had knee arthroplasty, year before implementation compared to the two years since

– Already know SDM results in patient expectations being more realistic

– High dissatisfaction in knee arthroplasty (19% of patient ambivalent about or regret surgery)

– Joint project with NHS England

Shared Decision Making Implementation

• Developed and trialed the NHS patient decision aids• Staff training• Organisation changes – standard board reports, staff

induction, measuring decisional conflict• Patient empowerment – Ask three questions• AQuA collaborative• All patients:

– Given A3Q leaflets– Signposted to PDAs– All front line staff trained in SDM, many in Motivational

Interviewing too

Better Health OutcomesUsed Patient Reported Outcome Measures (PROMs) data on EQ-5D index to show:

• Oldham’s knee replacement patients received an average health gain of 0.27 in 2009/10 and 0.35 by 2011/12.

• A statistically and clinically significant increase in Oldham’s patients health outcomes.• The England average health gain was 0.30 throughout the period.

Period of improvement matches the introduction of SDM.

• Involving patients in decision to treat appears to lead to better outcomes.

• Treated increasingly sicker patients in Oldham, but restored to same good health level.

Improvement delivered within financial constraints in period with:

• Arthroscopies growing at 8% in Oldham compared to 12% nationally.

• Musculoskeletal spend per head decreasing by £10 in Oldham compared to an increase of £10 nationally.

Pennine MSK ImpactReducing per capita cost whilst maintaining quality

Pennine MSK ImpactReducing per capita cost whilst maintaining quality

Thank You

Dr Hugh SturgessTel: 0161 628 3628

Mob: 0780 893 7788E-mail: hugh.sturgess@nhs.net