dr bharat patel - the new nhs

April 12, 2023

The new NHS and implications for microbiology laboratories

Friday 10 November 2006

Dr Bharat Patel

HPA London

Centre for Infections

Wilson Lecture Theatre

Colindale

Topics in Microbiology Management

BSMT National Conference

The NHS Plan

More & Better paid staff

Reduce waiting times

Improvements in local hospitals and surgeries

Extra Beds, doctors, nurses, hospitals etc

New system of earned autonomy

National Standards & regular inspections eg CHI

National Institute for Clinical Excellence

Modernisation Agency spreading best practice

Freedom to run own affairs

Social Services & NHS come together

Modern contract for GPs and Consultants

Nurses & others to extend roles

Patients have a real say

Private providers concordat

July 2000

27 July 2000

The New NHS

Department of Health

Support delivery

4 New Directors of Health and Social Care

replaces Regional Offices

Strategic Health Authorities

30 SHA – role strategic development & performance manage

Primary Care Trusts

Assess need, plan, secure health service & improve health

Acute Hospital Trusts

Provide service

July 2001

• Empowering frontline staff & Empowering patients

• Changing the culture & structure of the NHSJuly 2001

Health Protection Strategy

Protecting Public Health

Surveillance

Control communicable disease

Handling chemical incidents

Environmental hazards

Communicable disease law review

Community Infection Control

Robust chemical incident control

Emergency Planning

February 2001

Strengthening Health Protection

Chapter 10

Getting ahead of the curve – A strategy for infectious diseases ( including other aspects of health protection) CMO Jan 2002

Key Priorities

New & emerging infections

Tuberculosis

Health care associated infections

Antimicrobial resistance

Infectious diseases in children

Blood-borne & sexually transmitted viruses

Chronic diseases

New vaccines

Terrorism10th January 2002

Creating a patient-led NHS, delivering the NHS Improvement plan

Capability as well as capacity

The NHS Improvement plan

Learning and leadership

17 March 2005

Health and social care objectives

The NHS Plan

July 2000

Choosing Health – white paper

November 2004

NHS Improvement plan

Networks

Care in the community

Drivers, leavers and hooks

UK NHS Hospital Activity 2000-01• Average daily available beds per 1000 population:4.1

• Cases treated per available bed:43.1

• Total Accident & Emergency attendances: 17,534,00

NHS OVERSPENDS BY HALF A BILLION In Just One Year

Capital’s Trusts in Debt:

NHS Organisation: Forecast year end deficit:

University College London Hospitals

NHS Foundation Trust £32.5m

Hammersmith Hospitals NHS Trust £22m

St George’s Healthcare NHS Trust £12.5m

North West London Hospitals NHS Trust £11m

Hounslow Primary Care Trust £10.6m

Barking, Havering & Redbridge Hospitals

NHS Trust £10m

Queen Mary’s Sidcup NHS Trust £10m




Lewisham Hospitals NHS Trust £10m

Kensington & Chelsea Primary Care Trust £9.0m

Barnet & Chase Farm Hospitals NHS Trust £9.0m

North Middlesex Hospital NHS Trust £8.4m

Kingston Primary Care Trust £7.5m

Mayday Healthcare NHS Trust £6.8m

North Central London Strategic Health Authority £6.5m

Whipps Cross University NHS Trust £5.8m

Bexley Care Trust £5.7m

Royal Free Hospital NHS Trust £5.2m

Queen Elizabeth Hospital NHS Trust £5.0m




Waltham Forest Primary Care Trust £3.25m

King’s College Hospital NHS Trust £2.4m

Wandsworth Primary Care Trust £1.7m

Havering Primary Care Trust £1.6m

West Middlesex University NHS Trust £1.5m

Sutton & Merton Primary Care Trust £1.0m

Newham University NHS Trust £0.7m

The Whittington Hospital NHS Trust £0.7m

Royal National Orthopaedic NHS Trust £0.6m




Croydon Primary Care Trust £0.5m

Homerton University Hospital NHS Trust £0.5m

Greenwich Primary Care Trust £0.4m

Islington Primary Care Trust £0.4m

Moorfields Eye Hospital NHS Trust £0.3m

West London Mental Health NHS Trust £0.1m

Letter from Tony Blair to Patricia Hewitt Summer 2006

Primary Care

National Service framework

Points structure

Competition

PCT based commissioning to practice based commisioning

GPs retiring

Commissioning

Commissioning a patient-led NHS

Practice based commissioning (PBC)

Commissioning specialised services

The Health and social care system

Managing the system

Delivering primary care

Delivering social care

Integrated care

Organisation that work with DH

Health Objectives

10 High Impact changes (1-5)

Treat day surgery (rather than inpatient surgery) as the norm for elective surgery

Improve patient flow across the NHS system by improving access to key diagnostic tests

Manage variation in patient discharge, thereby reducing length of stay

Manage variation in the patient admission process

Avoid unnecessary follow-ups for patients and provide necessary follow-ups in the right care setting

10 High Impact changes (6-10)

Increase the reliability of performing therapeutic interventions through a Care Bundle approach

Apply a systematic approach to care for people with long-term conditions

Improve patient access by reducing the number of queues

Optimise patient flow through service bottlenecks using process templates

Redesign and extend roles in line with efficient patient pathways to attract and retain an effective workforce

The modern NHS – the vision

Payment by results

Patient choice

Care Bundles

Foundation hospitals

Plurality of delivery

Public private partnership

New technologies

Discharge strategies

Care in the communityPractice bases commissioning

Current state of the NHS

Managed Networks

Agenda for change

Technology transfer

What will private laboratories focus on ?

More automation

More reliance on molecular technology

Uneven playing field

Private companies interested in delivering pathology

- profitable tests

- High cost testsElectronic patient record

NHS in Crisis

Crisis or flux

Reducing beds

Surgical procedures out sourced

Slimmer more compact hospitals

Specialist tertiary care units

Care

Acute care

Community Care

Specialist care

Surgical capacity in NHS cut

Theatre lists reduced

Treatment centres

High street Primary care

ACAD

BCAD

Trust Mergers

Merging of Services

Paediatrics and Obstetrics

Rationalisation

Accident and Emergencies

Walk in Centres

Bed closures

Surgical capacity reduced

Surgeons made redundant

Weekly reports

Diagnostic tests used Pathology Radiology

Will infections go away?

Infections will still continue

HCAIs down?

Nosocomial infections reduced

Community infections rising

Elderly population rising

Bacteraemia slides?

Microbiology- Virology

Molecular suites

Chip technology

Array technology

Near patient testing and point of care testing

- pitfalls

- limitations

April 12, 2023

PbRPayment by results

PbR – the policy context

Chris Watson

Head of Payment by Results Development

pays NHS Trusts and other providers fairly and transparently for services delivered, while managing demand and risk

supports the introduction of patient choice by ensuring that diverse providers can be funded according to where patients choose to be treated

rewards efficiency and quality in providing services

helps match capacity to demand

refocuses discussion from disputes over price to the volume and mix of services that meet population need and the pathway of care for patients.

The move to a national tariff will be phased in over the next 5 years and our proposal is to do this in the following way:

2003/2004 transition using national tariff for each HRG

6 Surgical specialities

Move away from block contracts

SLA explicit links between funding and volume of services provided

No “block” agreements where funding is fixed regardless of the activity provided

SLA should set out clearly how risk will be handled

Prices determined locally rather than national tariff

Opthalmology, Cardiothoracic surgery, ENT, Trauma and orthopaedics, General surgery, Urology

2005 - 2006

The national tariff will be applied to all activity for which HRGs or other appropriate casemix measures are available. This means that almost all NHS Trust activity will be commissioned using Service Level Agreements that:

At specialty level, link funding to the planned volume of services to be provided and the national tariff for HRGs, adjusted for regional differences in costs;

Make clear how funding will be changed where the activity actually delivered, adjusted for casemix, differs from what was agreed;

Manage and share volume risk so as to encourage volume growth only where it is desirable for clinical and access reasons

Progress to full national tariff

Road Testing the PbR National Tariff for 2007/08 – 31 October 2006

http://www.dh.gov.uk/assetRoot/04/14/03/01/04140301.pdf

New Healthcare resource groups Version 4

Adult critical care

Emergency medicine

Pathology

Radiology

Chemotherapy

Radiotherapy

Specialist palliative care

Healthcare resource group

HRG 4 has been developed to support the governments payment by results initiative

It will be used to collect reference costs from 1 April 2007 and as the basis for national tariffs from April 2008

Payment by results

Key objective

Achieve fairer reimbursement by improving the sensitivity of the system to differences in casemix

Healthcare resource groups

Groups of clinically similar treatments and diagnoses which consume similar levelsof healthcare resource

Development is an on going process

Continually adapt to changes in clinical practice and the way services are configured

Sensitive to changes in care pathways that shift routine cases for treatment in community settings resulting in a more complex casemix being treated in hospitals

May –June 2006

HRG Version 4

Will form the basis of the tariff from 2008 and deliver improvements

Increased scope to include all aspects of Inpatient, Daycase and Outpatient activity

Better reflection of modern clinical practice

Consistency in design of all new and revised HRGs aligned across all specialities

Introduction of new HRGs for clinical specialities to accurately reflect patient care regardless of where it is given

Pathology

The efforts to create HRGs for Pathology have been in development for some years. With 1000s of tests to consider the cost-gathering exercise for Pathology HRGs is intricate.

It is envisaged that the HRGs will be setting-independent to cater for the increasing tendency toward supporting patient choice in delivering healthcare and availability of such services at GP practices.

A review of existing costings gathered during the lifetime of the project over the last few years is planned before pilot sites are recruited to test the conclusions. Pilot sites are expected to be recruited later this year.

The project consults with a clinical lead to ensure the delivered product fully respects the needs of pathologists.

Once developed the Pathology HRGs will be delivered to the Department of Health who will determine the tariffs for use within the PbR Programme.

The Pathology HRGs are expected to come into use in 2008.

HRG Labels - 1430

Nervous System Procedures and Disorders

Pain management

Eyes and periorbita procedures and diorders

Mouth Head Neck and Ears procedures and disorders

Thoracic procedures and disorders

Cardiac procedures

Digestive system surgery

Digestive system endoscopies

Gastroenterology Medicine

surgery

Hepatobiliary and pancreatic system endoscopies and radiological procedures

Hepatobiliary and pancreatic system disorders

Orthopaedic trauma procedures

Orthopaedic non-trauma procedures

Spinal surgery and disorders

Musculoskeletal disorders

Breast procedures and disorders

Hepatobiliary and pancreatic system Slin surgery

Skin disorders

Endocrine system disorders

Diabetic medicine

Metabolic disorders

Renal procedures and disorders

Urological procedures and disorders

Renal dialysis for chronic renal failure

Female reproductive system procedures

Assisted reproduction medicine

Obstetric medicine

Paediatric medicine

Vascular procedures and disorders

Radiological procedures

Interventional radiological procedures

Haematological disorders

Chemotherapy

Radiotherapy

Specialist palliative care

Multiple trauma

Emergency and urgent care

Rehabilitation

Immunology, infectious diseases etc

Treatment of mental health patients by non-mental health service providers

Genito-urinary medicine

Outpatients

Neonatal critical care

Paediatric critical care

Adult critical care

High cost drugs

Code of conduct

"We have seen with the first NHS foundation trusts how PbR provides powerful incentives for efficiency; but it is essential that the relationship between commissioner and provider is clearly defined and that both parties live up to their responsibilities. The Code will help ensure that happens and so we welcome it. We will continue to work with the Department of Health to ensure that the benefits from the introduction of PbR are maximised."William Moyes, Executive Chairman, Monitor,

PbRFinancial reformsDelivering the NHS Plan

NHS funding over 5 years – 7.4% real growth

Match European average by 2008

Use resources well – demonstrate value for money

Financial system transparent

Rules-based system for paying Trusts

Reward efficiency

Support patient choice and diversity

Support activity for sustainable waiting time reductions

Payment linked to activity and adjusted for casemix

Fair and consistent basis for hospital funding - rather than being reliant principally on historic budgets and the negotiating skills of individual managers

NHS Financial Flows, instead of being commissioned through block agreements as previously, hospitals (and other providers) will be paid for the activity that they undertake

Primary Care Trusts (PCTs) will commission:

the volume of activity required to deliver service priorities, adjusted for casemix (i.e. the mix of types of patients and/or treatment episodes)

from a plurality of providers

on the basis of a standard national price tariff, adjusted for regional variation in wages and other costs of service delivery

PbRSecondary uses Service (SUS)

Information technology has a key part to play in making the Payment by Results system run smoothly and efficiently. For 2006/07, NHS Connecting for Health have put in place a national reporting system for Payment by Results, which will eventually link directly with patient records. This system is part of the Secondary Users Service (SUS). It collects patient level activity information from providers and makes it available to commissioners. It is a national system, which will apply the tariff to providers’ activity information, calculate the payment due and notify each commissioner. For 2006/07, SUS outputs will be the definitive source of data for transactions under Payment by Results, replacing any local systems that may have been operating in 2005/06.

Key benefits of SUS:

ensuring that Payment by Results rules are applied accurately, consistently and transparently.

reducing bureaucracy, as NHS organisations no longer need separate information flows.

empowering commissioners. Their analysts are free to concentrate on analysing trends in the information rather than simply trying to apply the Payment by Results rules or check that their providers have applied them correctly.

enabling the Department to monitor the local impacts of Payment by Results at national level.

Healthcare Resource Groups (HRGs)

National intervention classifications

Under Payment by Results hospitals are paid according to the number and complexity of cases treated. The system therefore relies on patient-level data about activity in order to assign the appropriate tariff. The more detail that is captured about the patient’s treatment the greater potential for Payment by Results to differentiate different between routine and more complex cases and achieve fairer reimbursement.

For 2006/07 the underpinning classification system (known as OPCS-4.3) has been enhanced:

this is the first major update to the system in over 10 years;

it is co-ordinated with the ongoing development of casemix classifications (known as Healthcare Resource Groups (HRGs) which involves the input of over 250 clinicians representing Royal Colleges and professional bodies.

Commissioning, Casemix and Healthcare resource groups

The classification system has been expanded by nearly 25% (i.e. to date 1767 additional codes and 216 new categories) for improved coding accuracy. This gives a better representation of clinical reality and improved information for planning, monitoring and administration.

New inclusions under OPCS-4.3:

high-cost drugs

specialised services

diagnostic radiology

chemotherapy

interventional radiology

radiotherapy

Commissioning, Casemix and Healthcare resource groups

VisionModernising pathology services

is built around the needs of patients and their clinicians, seeing services from their perspective

enables and empowers staff to work across traditional boundaries to deliver the highest quality care to all

offers patients greater choice in where, when and how they access pathology services

is integrated into wider service developments and improvements.

Impact on Microbiology servicesSmart efficient and modern

Compete for work

Business orientation

Shrinkage in the service

Agenda for change – Deskilling and re-skilling

Fewer commitments

Lean Mean – Six Sigma Small changes count

Improvements in Service

Smart working

Six Sigma

System, process and pathway analysis

Going further faster

Six Sigma

Methodology that focuses on removing variation from processes based on customer requirements

Structured approach to process improvement using 14 steps in 5 separate stages

Considered to have 3.4 defects per million opportunities

Six Sigma

Define: characterise customer-critical issues, initiate project

Measure: Characterise the current process

Analyse: Characterise the vital steps

Improve: Confirm problem areas and optimise

Control: sustain the gains

Tania King, Elizabeth Wolstencroft, Robert Mirsadeghi

Calderdale and Huddersfield and Royal Devon and Exeter

Quality – competing with private companies

Cost cutter

Lidl

Asda

Morrisons

Tesco

Sainsbury

Add value

Infection Services

- University College

- St Thomas

Other pathology specialities

Automation

Haematology Biochemistry Serology Virology Immunology

Microbiology

Workload demand

Do we really need to do this test

What difference will it make to the patient care

Virology

Mycology

Parasitology

Patient focused service

Patient centred care

Patient centred microbiology

More molecular technology

Some laboratories limiting tests

Urine microscopy

In patient stools – 3 day limit

What is required immediately?

What is required immediately?

What is required in a 2 - 3 yr period?

What is required in a 5 -10 yr plan?

How will this be delivered?

24 hour working?

Service modifications?

New technologies in Blood cultures

32 organism chip

Antigen based testing – helicobacter faecal antigen

Staffing

Staff specialisation

Staff deskilling & multiskilling

Add staffing curve

Different areas

Standard benches

Blood culture & CSF

Stool bench

STI bench

Wound bench

Respiratory bench

32 panel chips

Multiplex & molecular

Chlamydia & GC by PCR

MRSA PCR

Multiplex molecular PCRs

What do we need to do?

Lean mean machine

Strive ahead with changes and face the competition

Safeguards in place

Ensure quality systems in place

Added value – pre/post analytical - advice

Be patient focused

What is the best test for the patient?

Clinical adviceAreas to strengthen

Pre and post analytical advise in changing world

Reporting criteria

Clinical advice

Recording advice

Laboratory issues

Maintain standards and quality

Standards and quality for molecular bacteriology

When is Microscopy useful?

When is culture useful?

When is molecular useful?

How best to manage demand?

What levels of service should be offered?

Molecular technology

Bacteriology

Virology

Mycology Parasitology

Service – Fit for purpose

Patient focused

Clinical focused

Rapid diagnosis – influencing patient care – immediate

How should molecular services be used in bacteriology?

MRSA – PCR

rapid – but what to do with result – Care pathways

Chlamydia & GC PCR

Not rapid enough – can this be attached to the clinic

Group B strep PCR

Molecular testing

ILS - distributor

Cebheid

Smart cycler & Gene expert

Both real time PCR

HSV, Bordetella, enterovirus

Norovirus, Flu a & b , RSV, Mycoplasma, GBS, MRSA, SA, mec a

Decide what is suitable?

Open up to do lots of tests?

Real time PCR - gastroenterology

Norovirus PCR – being used in some diagnostic laboratories already – hospital outbreaks

Need Multiplex PCR for Stools

salmonella, shigella, campylobacter, E Coli O157,

Norovirus, Rotavirus, adenovirus

Helicobacter

Neurological PCR – HSV, VZV, EBV, CMV

Respiratory viruses – Multiplex 9 viruses

Real time PCR - neurological

Neurological PCR

– HSV, VZV, EBV, CMV

Meningococcal

Streptococcus pneumoniae

Group B Streptococcus

Respiratory viruses – Multiplex 9 viruses

Real time PCR - respiratory

Respiratory viruses

– Multiplex 9 viruses

Streptococcus pneumoniae

Haemophilus influenzae

Mycoplasma pneumoniae

Legionella

Staphylococcus aureus

(MC)

"Up to 70 per cent of all patient diagnoses depend on pathology but the importance of pathology services to patient care are too often underestimated. The NHS spends £1.5 billion a year on pathology and it is important that we take advantage of the advances made in pathology and improve efficieny. The independent review will put pathology services back in the centre stage and provide renewed vigour to the modernisation programme. Lord Carter of Coles will be leading the review and will be supported by two further members. Professor Chris Price will provide the professional pathology services expertise from his work in the public and private sectors. Marcus Robinson will provide a commercial perspective.“

Lord Warner 2 November 2005

"Up to 70 per cent of all patient diagnoses depend on pathology but the importance of pathology services to patient care are too often underestimated. The NHS spends £1.5 billion a year on pathology and it is important that we take advantage of the advances made in pathology and improve efficieny. The independent review will put pathology services back in the centre stage and provide renewed vigour to the modernisation programme. Lord Carter of Coles will be leading the review and will be supported by two further members. Professor Chris Price will provide the professional pathology services expertise from his work in the public and private sectors. Marcus Robinson will provide a commercial perspective.“

Lord Warner 2 November 2005

Lord Warner of Brockley

Minnister for State for reform

The Review Panel will be chaired by Lord Carter of Coles, who has a wide experience of chairing independent reviews, including; the Commonwealth Games 2002; English National Stadium; Review of Payroll Services; Review of Court Estate; Review of Offender Services, and the Review of the Procurement of Legal Aid.

Chris Price has expertise in pathology technology and evidence based outcomes and is currently the President of the Association of Clinical Biochemists and Vice President for Outcomes Research in Bayer Diagnostics. His previous roles include Cirector of Pathology at Barts and the Royal London Hospital.

Marcus Robinson has worked in a number of industries (including Financial Services, Automotive and Travel), but has concentrated on Government for the last 7 years. His areas of expertise are Finance and Performance Management, Customer Relationship Management and outsourcing. He is a Partner in Accenture Government Services.

The Review Panel’s remit is: ‘to advise Ministers, in the context of current resource constraints, on the timeliness, reliability , capacity and efficiency of current pathology services in England, benchmarked against international standards and the feasibility of and benefits arising from wide-scale service reconfiguration, innovation and modernisation and involvement of the independent sector.’

The review panel is expected to make recommendations to Ministers in spring 2006.

Derbyshire Children’s HospitalSouthern Derbyshire Acute Hospitals NHS Trust

Churchill Hospital, Radiotherapy SimulatorOxford Radcliffe Hospitals NHS Trust

Hammersmith Bridge Road SurgeryHammersmith and Fulham PCT

Neptune Health ParkTipton

GP surgery, pharmacy, optician, community health services, social and community centre and Café, and citizen advice centre

Hove Polyclinic - Hove

30 St Mary AxeDelivering excellence in the Hospital Building Programme

Sevenacres Acute Mental HealthIsle of Wight Healthcare NHS Trust

Datent Valley Hospital Dartford and Gravesham NHS Trust

Gloucestershire Royal Hospital Arts Project- Education CentreGloucestershire Hospitals NHS Trust

April 12, 2023

Thank you for listening

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dr bharat patel - the new nhs

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