Siân Williams NHS London Respiratory Team Programme Manager

Creating a case for a 1% shift

Improving value in programme budgets

Imagine we used the value framework

Health OutcomesPatient definedbundle of care

CostValue=

Health Outcomes Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

To invest appropriately in interventions for people with COPD

Jiminez Ruiz et al Nicotine and Tobacco Research 2011

~500 smokers with severe COPD

Mean age 58 years60 pack-years of smokingHigh nicotine dependence

10 intensive behavioral interventions with medication:233 Nicotine Replacement Therapy & 190 Varenicline

48.5% abstinence at 6 months61% with Varenicline and 44% with NRTSafe

Even those with severe disease

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

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, Bristol

• 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

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

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%

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

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

Where are the people?

Sick smokers in hospital bedsSmokers in mental health servicesIn prisonsQuietly stoical at homeMultiple prescriptions

Would it tackle….

• Premature mortality• Optimising bed days• Waste – human spirit, staff resources,

time, prescriptions

Asymptomatic smokers: Tobacco control policies, very

brief advice, education, smoke-free environments, community-based stop smoking services,

quitlines, self-referral,

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/early/2013/01/15/peds.2012-2592.abstract …

http://jpubhealth.oxfordjournals.org/content/34/1/37.long 200 public health interventions analysed for cost-effectiveness 15% were cost -saving 85% were under 20k per QALY

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!

Why shift? It’s all about value….

Programme budget illustrationsRespiratory as proportion of total -

Southwark illustration 2010-11

Total respiratoryTotal programme budgets (ex GMS and miscellenous)

Respiratory categories as proportion of total respiratory

COPDAsthmaRespiratory other

11X

Respiratory programme budget

Spend by care setting Southwark illustration 2010-11 (note nothing coded as health promotion)

%Primary prescribing & pharma services

_x001F_Inpatient: Elective and Daycase

_x0017_Inpatient: Non-elective

Outpatient

_x0014_Other secondary care

Ambulance

_x0014_A&E (inc. MIU & WIC)

_x0004_Care

& social care provided in other setting

_x000c_ social care

Tariffs 2013-14 (* non-mandatory)1st single

1st multi

FU single

FU multi Non face to face*

Spell Trim-point (days)

Respiratory medicine OP 189 245 104 145 23

COPD or bronchitis with NIV without intubation with CC emergency admission

2771 24

Stop smoking West Midlands (2012-13*)

General pop’n no Rx

Targeted pop’n no Rx

General pop’n with Rx

Targeted pop’n with Rx

(4 week quitter 94 136 166 214)

12 week quitter – verified in primary care

129 271 228 427

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

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?