leicester - patients in control

Increasing Patients’ Participation in their treatment and careOpen House – Leicester 17th June

Luke O’SheaTwitter: @lukeoshea1Dr Alison AustinTwitter: @A_Austin4

Structure of presentation

1. Patient Participation – The NHS Mandate 2. Three great challenges for the NHS. Safety,

changing burden of disease and finance3. Doing more of the same? – increasing

pressure on staff or patients as source of value4. Empowering patients to act – the evidence5. Where are we now and our plans6. Personal Health Budgets

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Patient Participation – The NHS Mandate

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The NHS Mandate – Requires a shift of power to patients.

The NHS Mandate Objective:

• “To ensure the NHS becomes dramatically better at involving patients… empowering them to manage and make decisions about their own care and treatment.”

• “by 2015… more people managing own health… everyone with LTCs including MH, offered a personalised care plan… patients who could benefit have the option to hold a personal health budget… information to make fully informed decisions.”

• Shared decision making, self-management, PHBs, information and personalised care planning all linked

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Three Great Challenges facing the NHS

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1) Safety - Patient participation first line of defence. Francis & Berwick

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“Patient involvement is crucial to the delivery of appropriate, meaningful and safe

healthcare…The goal is to achieve a pervasive culture that welcomes authentic

patient partnership – in their own care”

Berwick Report

“The patient was presented with medication & discharged. No one had told her of her diagnosis.”

Francis Report

Moral case. When your life is defined by NHS – participation in care can transform your life

• Frustrated, articulate man, Robert, with ‘treatment resistant schizophrenia’ miles from home. Wanted flat, a job and friends for years. Care cost £100k per year for 7 years. No plan. No voice.

• Middle aged woman, Mary, with personality disorder, in poor out of area private provision. Shared bathroom between 10 on ‘ward’ with others. Terrible life. No plan.

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“I thought my life had come to an end… machine tied me to

hospital. Home dialysis changed my life.”

Kidney patient.

2) Changing burden of disease: Multiple LTCs the typical LTC.

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Ref: Stewart Mercer based on Scottish study based on data from 310 General Practices.

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2000 2008 2016

Num

ber w

ith lo

ng-te

rm c

ondi

tions

(mill

ions

)

One LTC Two LTCs Three+ LTCs

Sources: ONS population projections and General Household Survey

Source: Department of Health analysis of ONS projections and GHS

Estimate for changes in co-morbidity patterns over the next decade, England

Future growth 3+ LTCs. Single LTC decline. Participation and personalisation vital.

What business are we really in?•15m with LTCs•70% spend•Massive rise in population with a co-morbidity •Most GP sessions LTCs•77% bed days

3) Finance - demands greater patient contribution as greatest untapped source of expertise & value

• 4% rise in activity pa. Pay for activity (PbR) not patient capacity. Need honest debate.

• ‘Call to Action’ - £30 billion shortfall.

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Health Spending 1949-50 to 2010-11

Doing more of the same? – increasing pressure on staff or patients as source of value

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Investing in the capacity of patients to create value in health

• Current model medical staff, tech and drugs create value. QIPP 1 model was pay and provider efficiency.

• More of the same model will mean unsustainable demands on staff.

• QIPP 2 – New model must build capacity of patients to add value into the health system.

• Increasing contribution of 53m patients. All other industries look do this (e.g. banks, supermarkets).

• Contribution of 3m volunteers in health and care

• Iceberg of care – unlocking patient and community value “below the surface” key to NHS survival

NHS | Presentation to [XXXX Company] | [Type Date]12

Empowering patients to act – the evidence base

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Patient Activation - better self mgmt, health outcomes & lower costs.

Patient Activation – knowledge, skills and beliefsKnowing something with help/harm health is not enough

Asset not deficit based measure – building hope & resourcefulness

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Source: J.Hibbard, University of Oregon

Patient Activation leads to better outcomes & lower costs

• Study of 25,047 patients found strong evidence that patients with greater levels of activation experienced better health.

• A study of 479 patients with various long term conditions found that increased activation led to a variety of improved self-management behaviours

• In a study of 5002 patients activated patients were x10 more likely to report high satisfaction. Even seeing same clinician & setting, had much better patient experience.

• Hibbard found that patients with the lowest activation levels had average costs that were 8 % higher in the base year and 21 % higher in the next year than patients with the highest activation levels.

Evidence strong that ‘Patient Activation’ leads to better outcomes & lower costs

Active and empowered

patientEngagewith

clinician more

Reduced service

use Able to workmore

Meds use

improves

Lifestyle improvements

e.g. diet

Infoseeking

Better disease manage

ment

Study of 25,047 patients showed greater levels of activation experienced better health. Other studies show improved self-management behaviours and reduced service utilisation.

Personal Health Budget trial of 2000 people showed improved quality of life and fewer admissions‘Patient Activation’ a term for confidence, skills & knowledge

Interventions that build patient activation – strong evidence base

Shared Decision Making, including Patient Decision Aids

•Better experience of care, some reduction in use of services, less surgery.

Personal Health Budgets & personalised care planning

•RCT: cost effective, improved Quality of Life, best for high needs. Other studies show impact on carer well-being

Self-Management Support, such as Expert Patient

•Impact of behaviours, Quality of life, symptoms and better use of resources.

•Not just technical information, but behaviour change


Where are we now?What are our plans?

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This is a huge challenge and counter cultural in 65+ years history of the NHS

2005 study found 10% and 34% of patients with chronic health conditions at activation levels 1 and 2 – that would be over 6 million people

% who felt as involved in inpatient care as they would like

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An organising model - The House of Care

Plans for 2014-15: commissioning, programmes & partnership

Systems approach to Mandate delivery:

•Partnership working – Coalition for Collaborative Care. Social movement

•Programmes – Personal Health Budgets, Information as Service, Shared Decision Making & Info Standard

•Commissioning – capacity & skills, CSU field force, direct commissioning (e.g. renal programme), legal guidance & tools published, primary care.

•Measurement & Incentives – Patient Activation trial 150k people, GP contract, Standard Contract, long term asset based payment approach

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House of Care

Personal Health Budgets

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Personal Health Budgets stories - families take control & participate


Structure of Presentation

Personal health budgets:

•Nikki’s story

•The commitments

•The evidence

•Next Steps

•As part of the wider personalisation agenda


Nikki’s storyhttp://m.youtube.com/watch?v=u0FSEEWKCj4

• They help people live with their long term conditions and stay out of hospital:

• Change the relationship

• enable people to use NHS funding in different ways, not new monies,

• focus on outcomes,

• centre around a care plan which is agreed by NHS,

• are regularly reviewed to ensure needs are being met and money is spent as agreed,

• facilitate integration across health and social care

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The Challenges……… personal health budgets are part of the solution.

Personal health budgets are not suitable for all NHS Care

Services which are excluded;

• GP services (GP contract),

• Acute unplanned care (including A&E),

• Surgical procedures,

• Medication,

• NHS charges eg prescription charges

• vaccination/immunisation,

• screening,

What can a budget be spent on?

• Services should be appropriate for the state to provide – not gambling, debt repayment, alcohol, tobacco

• Anything agreed in a care plan which will meet health and wellbeing objectives

• Equipment• Personal care• Physiotherapy• Complimentary therapies• Supportive technology (eg computers, ipads,

kindles)

The independent evaluation of personal health budgets has shown that they can lead to improved quality of life whilst meeting health needs and being cost effective (even saving money for some)

The national personal budget survey (POET) involving 195 PHB holders and 117 carers across 12 sites showed that:

•73% reported a positive impact on independence

•69% reported a positive impact on health

•70% carers reported a positive impact on their own quality of life

•Knowing the budget up front is important

A staged approach is being taken to rollout across England

Personal Health Budgets: The Commitments

NHS Mandate Objective: “by 2015… more people managing own health… everyone with LTCs including MH, offered a personalised care plan… patients who could benefit have the option to hold a personal health budget… information to make fully informed decisions.”

Legal Duties: from April 2014 everyone receiving NHS Continuing Healthcare will have the “right to ask” for a personal health budget. From October 2014 this will be a “right to have”. CCGs have to have processes in place to deliver them by April 2014

What we know:

•they work best for those with higher levels of need

•people with higher levels of need are more likely to need both health and social care support

•They are applicable to mental and physical health

•They reduce unplanned care

•They are not right for all NHS Services

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Where next?

What we are working on:

•Clarifying the mandate commitment,

•Going further faster – including people who use mental health services, people with learning disabilities and other people with long term conditions,

•Integration pioneers,

•Mainstreaming,

Where next?

If you’re going to do it… do it right

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Evaluation - benefits of personal health budgets depend on how they were introduced.

Best results – people know budget up front; advice and support available; choice and flexibility over how to spend budget , choice on how it is managed.

Scale-up - challenge of maintaining the integrity of the values.

To work well, personal health budgets need good support from all parts of the system co-production with people with direct experience

Parity of Esteem: Mental health &

learning disabilities

Personal health budgets

Year of Care Finance& value

programme

Integration & Better Care Fund

SEND & Children

Personalised care & support planning

Wider context of personalisation

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To find out more:

Personal Health Budgets •www.personalhealthbudgets.england.nhs.uk

•Twitter:@NHSPHB

•Email: [email protected]

Or tweet Luke O’Shea or Alison Austin

•@lukeoshea1 @A_Austin4

http://www.personalhealthbudgets.england.nhs.uk/

mailto:[email protected]