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OldhamDoing It Differently
Dr Hugh SturgessDirector, Pennine MSK Partnership
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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
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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
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Variation in MSK Spend
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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
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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
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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
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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
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Oldham
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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Pennine MSK ImpactReducing per capita cost whilst maintaining quality
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Pennine MSK ImpactReducing per capita cost whilst maintaining quality