Download - Muir Gray: NHS Atlas of Variation
Great innovations of the first and second health care revolution
• MRI and CT scanning• Statins • Antibiotics• Coronary artery bypass
graft surgery• Hip and knee
replacement• Chemotherapy• Radiotherapy• Randomised controlled
trials• Systematic reviews
Gower Street - Doll & Hill
Broad Street - John Snow
The First The Second
- BUT all health services face five major problems:
• Patient harm
• Unwarranted variation in quality and outcome
• Failure to maximise value
• Inequalities
• Failure to prevent
AND new, additional challenges are developing
• Rising expectations
• Increasing need
• Climate change and carbon constraints
• Financial constraints
Value = Outcomes / Costs
Outcome = Good – Bad (Outcome= Effectiveness – Harm)
Costs = MoneyCosts = Carbon + Opportunity Lost
Lower value activities are those which: 1.Have clear evidence that they are ineffective or that they do more harm than good.
2.Have no evidence of effectiveness but are not being delivered in the context of research that would allow evidence to judge effectiveness to be gathered.
3.Have evidence of effectiveness but are being offered to patients whose characteristics are different from the characteristics of the patients in the research studies which produced the evidence of effectiveness.
4.Treat a patient who has not been given unbiased information in a way that they can understand the probability of both benefit and harm of accepting the offer of treatment.
5.Use resources which would produce more value, namely a better balance of benefit to harm, if invested in some other service
Use resources which would produce more value, a better balance of benefit to harm, if invested in some other service.
This may be an investment in:
• another type of intervention for this group of patients eg, switching resources from oxygen therapy to triple drug therapy for people with COPD• a service for another group of patients within the same programme budget eg, switching resources from cataract surgery to fund increased costs for AMD• another programme budget eg, switching resources from the gastrointestinal and liver programme budget, by reducing upper GI endoscopy, to the musculoskeletal budget to fund more hip replacements.
NB: these resources are being released by disinvestment from interventions with evidence of effectiveness so there will be an impact on the group of patients but the decision is made on the principle that greater value will result by the change in investment.
The law of diminishing returns
BVHP The better value health care programme
Benefits
Investment of resources
Harmful effects increase in direct proportion to the resources invested
BVHP The better value health care programme
Harmfulside effectsof care
Investment of resources
After a certain level of investment the health gain may start to decline;
the point of optimality
Benefits
Investment of resources
Harms
Benefits - harm
Higher value
Higher value
Lower value
Reorganise, educate
Higher value
Higher value
Lower value
Reorganise, educate
Destabilise / Atlas
Constrain/programme budgets
No decision about me without me
Population-based accountable integrated care systems
Programme budgets
Population-focused clinicians
Knowledgeable commissioners
Shared decision-making support service
Clinical commissioning insights on major health systems prepared by one cluster for Do Once And Share
NHS Atlases of Variation (2.0 in November +5 specialty atlases)
Annual Programme Budget Review (December)
Health investment packs – spend and outcome data for every PCT/cluster
RIGHTCARE PRODUCTS & SERVICE THE NHS POST REFORM
NHS Atlas 1.0
Published
Nov
2010
Oct2011
Organ donation and
transplantation
Child Health Atlas – in collaboration
with ChiMat
Diabetes themed
Atlas
Portal Launch:- Keynote article(s)
- case-studies- variation bibliog.
2nd Comprehensive NHS Atlas
published – National event.
Feb2012Jan
2012
Cancer-themed Atlas
Marc
h2012
Right Care NHS Atlas – provisional vision line
Apri
l2012
Forward strategy for
NHS Atlas
Kidney CareAtlas
This vision line outlines the proposed publication programme for Right Care Atlases during 2011 and beyond Atlases in dotted callouts are still under consideration and all publication dates are subject to further change arising from on-going discussions and subject to ministerial office approvals
Diagnostics Atlas
Dec2011
Nov2011
DH MinisterialSign-off
Sept
2011
Liver Disease
Atlas
2012/13programme
launched
14/09/2011
www.rightcare.nhs.uk/atlas
CANCER
RESPIRATORY
GASTRO
CANCER
RESPIRATORY
GASTRO
MENTALHEALTH
CANCER
RESPIRATORY
GASTRO
MENTALHEALTH
Medicallyunexplainedphysicalsymptoms
Homeless people
Children
Older people with fouror more diagnoses
Cancers
Respiratory
Gastro-instestinal
Apnoea
COPD (Chronic Obstructive Pulmonary Disease)
Asthma
Triple drug therapy
O2 rehabilitation
A SYSTEM is a set of activities with a common set of objectives ( also known as a service).
A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation).
A PATHWAY is the route patients usually follow through the network.
This is an example of a national service set up as a system
HIERARCHY
NETWORK
AVERAGESPEND
AVERAGEOUTCOME
LOWERSPEND,BETTEROUTCOME
LOWERSPENDWORSEOUTCOME
HIGHERSPEND,BETTEROUTCOME
HIGHERSPEND,WORSEOUTCOME
Cancers
Respiratory
Gastro-instestinal
Apnoea
COPD (Chronic Obstructive Pulmonary Disease)
Asthma
Triple drug therapy
O2 rehabilitation
Innovation to increase value and improve quality
High value innovation
Innovation & disinvestment to increase value and improve quality-
from PBMA to PPPB
Dr Jones is a respiratory physician in the Brighton Hospital Trust and last year she saw 346 people with COPD and to provide evidence-based, patient-centred care, and to improve effectiveness, productivity and safety
Dr Jones estimated that there are 1000 people with COPD in East Sussex and a population-based audit showed that there were 100 people who were not referred who would benefit; she needs to practise
population medicine
Dr Jones, the co-ordinator of the East Sussex COPD Network and Service has responsibility, authority and resources (one day a week and support) for
• network development• localisation of the Map of Medicine• quality of patient information• professional development of generalists, and pharmacists • production of the annual report of the service
She is keen to improve her performance from being 27th out of the 106 COPD services, and of greater importance, 6th out of the 23 services in the prosperous counties.
Information Knowledge technology
Citizens
The Drivers of the Third Industrial Revolution (Manuel Castells)
www.bvhc.co.uk
Neither markets nor bureaucracies can solve the challenges of complexity
BVHC