Commissioning for Value Where to Look pack

Transcription

1 Commissioning for Value Where to Look pack Lancashire and South Cumbria - STP area December 2016 Neurological April 2016

2 Contents Introduction to your Where to Look pack Supporting the STP process NHS RightCare and Getting it Right First Time (GIRFT) Your data Next steps and actions Further support and information Useful links The NHS RightCare programme NHS RightCare and Commissioning for Value 2

3 Introduction to your Where to Look pack What s in this pack? This pack contains data from the CCG Commissioning for Value Where to Look packs, published in October 2016, collated at STP footprint level. The data in this pack includes headline opportunities, improvement opportunity tables and slides showing how CCGs in each STP differ from their peers. An STP opportunity is the sum of all the equivalent opportunities of the CCGs in that area. They do not include negative opportunities or those which are statistically insignificant. Why your STP area should review it The information contained in this pack is personalised for each STP footprint area and can be used to help support local discussions about prioritisation to improve the value and utilisation of resources. By using this information each STP area will be able to ensure its plans focus on those opportunities which have the potential to provide the biggest improvements in health outcomes, resource allocation and reducing inequalities. Legal duties NHS England, Public Health England and CCGs have legal duties under the Health and Social Care Act 2012 with regard to reducing health inequalities; and for promoting equality under the Equality Act One of the main focuses for the Commissioning for Value series has always been reducing variation in outcomes. Commissioners should continue to use these packs and the supporting tools to drive local action to reduce inequalities in access to services and in the health outcomes achieved. 3

4 Supporting the STP process This pack has been created to align with the new Sustainability and Transformation Planning (STP) process. Local service leaders in every part of England are working together for the first time on shared plans to transform health and care in the diverse communities they serve. Commissioning for Value (CfV) supports CCGs and STP footprint areas by providing the most up to date data available. Expenditure data is from 2015/16. Outcomes data is the latest available at time of publication. The time period for each pathway on a page indicator is included on the chart. In addition the key indicators from the seven focus packs (originally published in April/May 2016) will be refreshed in the CfV online tools in early In the meantime, CCGs and local health economies will still be able to use the 2016 focus packs for further investigations as an indication of what to change. Unless a CCG has taken action along a particular pathway, their relative position is unlikely to have altered. 4

5 NHS RightCare and Getting it Right First Time (GIRFT) NHS RightCare and GIRFT are complementary programmes and should be used together to support the delivery of population healthcare improvement and financial sustainability. NHS RightCare s Commissioning for Value workstream supports improvement across systems by focusing on pathways of care from primary prevention to end of life care. Whilst supporting improvement in terms of access to and outcomes from the acute sector, Commissioning for Value has not focused in detail on hospital care. GIRFT provides detailed insight into variation in the acute system in a way that has not been available before. As such NHS RightCare and GIRFT collectively provide clinical improvement insight across the entire health care system. In 2017 NHS RightCare and GIRFT will be working closely together to support STPs and their local health economies. This will begin with a complementary set of analysis on orthopaedic pathways. This pack supports STP thinking on this collective agenda, including by highlighting opportunities for improvement such as by coordinating the reallocation of capacity in the acute system, something that can only be achieved together. See pages 9 and 10. 5

6 Headline opportunity areas for Lancashire and South Cumbria The number in the grey circles below represents how many CCGs within Lancashire and South Cumbria share a particular opportunity area out of 9 CCGs within the STP Spend & Outcomes Outcomes Spend 8 Musculoskeletal 7 Gastro-intestinal 9 Circulation 8 Gastro-intestinal 7 Maternity 8 Musculoskeletal 6 Circulation 6 Endocrine 8 Respiratory 6 Respiratory 5 Neurological 6 Gastro-intestinal 4 Cancer 4 Circulation 5 Neurological These headline lists are based on the contributing CCGs which form the STP. The figure in the grey circle represents the number of times each programme appears in each individual CCG headline list. This is simply the number of CCGs in the STP with a common programme as a headline opportunity. It does not factor in the relative scale of each of the opportunities for this ranking. E.g. an STP with six CCGs may have all six CCGs with a cancer spend opportunity totalling 3m. In this example, cancer would rank above respiratory which appears in the list for five CCGs but has a total opportunity of 4m. This can be explored further in the detailed sections of this pack. Throughout this Lancashire and South Cumbria STP pack, the opportunities for Cumbria CCG have been scaled to the population proportion (38%) of GP registered patients in South Cumbria. 6

7 Which CCGs in Lancashire and South Cumbria - STP share headline opportunity areas? Spend & Outcomes Musculoskeletal Gastro-intestinal Circulation Respiratory Cancer Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, West Lancashire, East Lancashire, Greater Preston, Fylde & Wyre Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, Chorley and South Ribble, East Lancashire, Greater Preston, Fylde & Wyre Cumbria, Lancashire North, Blackpool, Chorley and South Ribble, East Lancashire, Fylde & Wyre Cumbria, Lancashire North, Blackburn with Darwen, Chorley and South Ribble, East Lancashire, Greater Preston Blackpool, Chorley and South Ribble, West Lancashire, Fylde & Wyre Outcomes Gastro-intestinal Maternity Endocrine Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, Chorley and South Ribble, Greater Preston, Fylde & Wyre Blackburn with Darwen, Blackpool, Chorley and South Ribble, West Lancashire, East Lancashire, Greater Preston, Fylde & Wyre Cumbria, Lancashire North, Blackpool, Chorley and South Ribble, East Lancashire, Greater Preston Neurological Cumbria, Lancashire North, Blackpool, West Lancashire, East Lancashire Circulation Cumbria, Lancashire North, Blackpool, Fylde & Wyre Spend Circulation Musculoskeletal Respiratory Gastro-intestinal Neurological Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, Chorley and South Ribble, West Lancashire, East Lancashire, Greater Preston, Fylde & Wyre Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, Chorley and South Ribble, West Lancashire, East Lancashire, Greater Preston Cumbria, Lancashire North, Blackburn with Darwen, Blackpool, Chorley and South Ribble, East Lancashire, Greater Preston, Fylde & Wyre Cumbria, Lancashire North, Blackburn with Darwen, Chorley and South Ribble, West Lancashire, East Lancashire Blackburn with Darwen, Chorley and South Ribble, West Lancashire, Greater Preston, Fylde & Wyre 7

8 What are the potential lives saved per year? A value is only shown where the opportunity is statistically significant If the CCGs within the STP performed at the average of: Similar 10 CCGs Best 5 of similar 10 CCGs Cancer Neurological 5 Circulation Respiratory 5 38 Gastro Intestinal Trauma and Injuries Total Lives Saved The mortality data presented above uses Primary Care Mortality Database (PCMD) and is from 2012 to The potential lives saved opportunities are calculated on a yearly basis and are only shown where statistically significant. Lives saved only includes programmes where mortality outcomes have been considered appropria te. 8

9 Coordinating the re-allocation of capacity Improving a population healthcare system to become high value and optimal requires significant change. It requires change in the practices and perspectives of all of the professions, people and partners engaged in the system. It requires change in how we engage with individual patients and how we engage with our local communities, so that we inform and then seek to understand their perspectives and their preferences. It requires change in how we operate and think about our organisational structures, plans and asset models. And, most importantly of all, it requires us to embrace, collectively and individually, the need to make these changes. Variation data, as contained in the suite of Commissioning for Value packs, highlights that in every health system in England, there exists a significant volume of overuse alongside significant underuse. Overuse leads to waste and harm. Underuse leads to a failure to prevent disease and inequity. Reducing both leads to a better and more sustainable system. In order to do this well, we must work together to coordinate the re-allocation of capacity from unwarranted activity to warranted activity, wherever in the system that may be. 9

10 Coordinating the re-allocation of capacity The next page highlights the potential overuse in bed days for your STP area, as implied by variation data for each of your constituent health economies. STP areas are able to use this information to focus on the opportunity to free up bed capacity, and ask the questions Is this current bed use adding value? and Where might we better use this capacity and resource?. In turn this will allow for discussion and consensus to be reached on where beds add more value if re-allocated for different use. It also allows for discussion and consensus on what current capacity a system could avoid the need for, if resources were re-allocated for non-bed use, to deliver optimal clinical pathways and systems. Avoiding the need for capacity, in this way, is a key component of delivering a sustainable healthcare system. Fully integrated care is very likely to be a key part of these discussions. Identifying together Where to Look and then designing optimal pathways and systems, that is, What to Change, by collectively answering the question What would we look like if we were doing the very best for our population?, is the optimal means of achieving this. 10

11 How different are we on bed days? A value is only shown where the opportunity is statistically significant If the CCGs within the STP performed at the average of: Similar 10 CCGs Lowest 5 of similar 10 CCGs Cancer 8,964 7,398 Endocrine, nutritional & metabolic 2,019 2,866 Neurological 25,491 13,899 Circulation 27,030 15,323 Respiratory 9,246 18,633 Gastro Intestinal 7,839 15,277 Musculo Skeletal 16,594 8,325 Trauma and Injuries 23,680 13,950 Genito Urinary 9,707 11, ,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 Bed Days The bed days data presented above uses Secondary User Services Extract Mart (SUS SEM) and is from financial year 2015/16. The calculations in this slide are based on admissions for any primary diagnoses that fall under the listed conditions (based on Programme Budgeting classifications which are in turn based on the World Health Organisation s International Classification of Diseases). This only includes admissions covered by the mandatory payment by results tariff and includes NHS England Direct Commissioning activity. These figures are a combination of elective and non -elective admissions. Length of stay is derived from admission and discharge date. Spells that have the same admission and discharge date (includin g planned day cases) have a length of stay in SUS as zero. These have been recoded as a length of stay of 1 day in order to capture the impact of these admissions on total bed days for a CCGs. 11

12 How different are we on spend on elective admissions? A value is only shown where the opportunity is statistically significant If the CCGs within the STP performed at the average of: Similar 10 CCGs Lowest 5 of similar 10 CCGs Cancer Endocrine, nutritional & metabolic Neurological 1, ,135 2,284 2,120 Circulation 6,831 2,717 Respiratory Gastro Intestinal 1,120 1,302 1,351 2,134 Musculo Skeletal 11,011 7,710 Trauma and Injuries Genito Urinary 1,666 1, ,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 Total Difference ( 000s) The spend data presented above uses Secondary User Services Extract Mart (SUS SEM) and is from financial year 2015/16. The calculations in this slide are based on expenditure on admissions for any primary diagnoses that fall under the listed co nditions (based on Programme Budgeting classifications which are in turn based on the World Health Organisation s International Classification of Diseases). This only includes expenditure on admissions covered by the mandatory payment by results tariff and includes NHS England Direct Commissioning expenditure. CCGs can explore this expenditure in more detail using the Commissioning for Value Focus Packs. For example, Neurological expenditure contains Chronic Pain, and the focus pack breaks this down by different types of Pain. CCGs should consider whether these admissions should be considered alongside other programmes e.g. CVD, Gastrointestinal, Musculoskeletal problems 12

13 How different are we on spend on non-elective admissions? A value is only shown where the opportunity is statistically significant If the CCGs within the STP performed at the average of: Similar 10 CCGs Best 5 of similar 10 CCGs Cancer Endocrine, nutritional & metabolic ,398 Neurological 1,996 3,456 Circulation 4,218 4,137 Respiratory 2,618 4,594 Gastro Intestinal 1,980 3,916 Musculo Skeletal Trauma and Injuries 3,048 2,523 Genito Urinary 1,205 1, ,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 Total Difference ( 000s) The spend data presented above uses Secondary User Services Extract Mart (SUS SEM) and is from financial year 2015/16. The calculations in this slide are based on expenditure on admissions for any primary diagnoses that fall under the listed co nditions (based on Programme Budgeting classifications which are in turn based on the World Health Organisation s International Classification of Diseases). This only includes expenditure on admissions covered by the mandatory payment by results tariff and includes NHS England Direct Commissioning expenditure. CCGs can explore this expenditure in more detail using the Commissioning for Value Focus Packs. For example, Neurological expenditure contains Chronic Pain, and the focus pack breaks this down by different types of Pain. CCGs should consider whether these admissions should be considered alongside other programmes e.g. CVD, Gastrointestinal, Musculoskeletal problems 13

14 How different are we on spend on primary care prescribing? A value is only shown where the opportunity is statistically significant If the CCGs within the STP performed at the average of: Similar 10 CCGs Lowest 5 of similar 10 CCGs Cancer 885 1,131 Endocrine, nutritional & metabolic 461 3,553 Mental Health Problems 1,532 1,666 Neurological Circulation ,378 Respiratory 3,264 3,127 Gastro Intestinal 1,655 1,744 Musculo Skeletal 1, Trauma and Injuries Genito Urinary 1,115 1, ,000 2,000 3,000 4,000 5,000 6,000 7,000 Total Difference ( 000s) The prescribing data presented above uses Net Ingredient Cost (NIC) from epact.com provided by the NHS Business Services Auth ority and is from financial year 2015/16. Each individual BNF chemical is mapped to a Programme Budget Category and aggregated to form a programme total. The indicators ha ve been standardised using the ASTRO-PU weightings. Opportunities have been shown to the CCGs similar 10 and the lowest 5 CCGs. Prescribing opportunities are for local interpret ation and should be viewed in conjunction with the individual disease pathways. More detailed analyses of prescribing data, outlier practices, and time trends can be produced rapidly using the following re source: 14

15 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality Spend on elective and day-case admissions 4,010 Cancer and Tumours - Rate of bed days Spend on non-elective admissions 1,758 Mortality from all cancers under 75 years Spend on primary care prescribing 2,016 Breast cancer screening % first definitive treatment within 2 months (all cancer) Breast cancer detected at an early stage Mortality from breast cancer under 75 years Bowel cancer screening Lower GI cancer detected at an early stage Cancer & Tumours Mortality from colorectal cancer under 75 years Successful quitters, 16+ Lung cancer detected at an early stage Mortality from lung cancer under 75 years Mortality from all cancers all ages No. of patients, life-years, referrals, etc. 16, , , ,

16 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality Spend on elective and day-case admissions 9,547 Circulation - Rate of bed days Spend on non-elective admissions 8,355 Mortality from all circulatory diseases under 75 years Spend on primary care prescribing 868 Reported to estimated prevalence of CHD Reported to estimated prevalence of hypertension Patients with CHD whose BP < 150/90 Patients with CHD whose cholesterol < 5 mmol/l Patients with hypertension whose BP < 150/90 Mortality from CHD under 75 years Mortality from acute MI under 75 years Patients with stroke/tia whose BP < 150/90 Circulation Problems (CVD) % stroke/tia patients on antiplatelet or anticoagulant Stroke patients spending 90% of their time on stroke unit Emergency readmissions within 28 days for stroke patients % patients returning home after treatment Mortality from stroke under 75 years High-risk AF patients on anticoagulation therapy Reported to estimated prevalence of AF Patients who go direct to a stroke unit (quarter) Stroke patients treated by early supported discharge team (quarter) No. of patients, life-years, referrals, etc. 42, ,331 12, ,248 2, , Endocrine, Nutritional and Metabolic Problems Spend on elective and day-case admissions Spend on non-elective admissions Spend on primary care prescribing 609 Endocrine - Rate of bed days 1,195 % diabetes patients whose cholesterol < 5 mmol/l 4,015 % diabetes patients whose HbA1c is <59 mmol/mol % diabetes patients whose blood pressure is <140/80 % of diabetes patients receiving all three treatment targets % patients receiving foot examination Retinal screening % diabetes patients attending structured education 4,885 3,552 1, ,105 3,391 3,

17 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality Spend on elective and day-case admissions 3,436 Gastro - Rate of bed days Spend on non-elective admissions 5,896 Mortality from gastrointestinal disease under 75 years Spend on primary care prescribing 3,399 Mortality for liver disease under 75 years % 6+ week waits for a gastroscopy (4 month snapshots) Alcohol specific hospital admissions Emergency admissions for alcoholic liver disease condition (19+) Rate of emergency gastroscopies Emergency admissions for Upper GI bleeds Emergency admissions for Peptic Ulcerations Gastrointestinal Reported Clostridium difficile cases % 6+ week waits for a colonoscopy (4 month snapshots) Rate of emergency colonoscopies Emergency admissions for diverticular disease Emergency admissions for gastroenteritis (0-4) Emergency admissions for gastroenteritis (5+) No. of patients, life-years, referrals, etc. 23, Genitourinary Spend on elective and day-case admissions Spend on non-elective admissions Spend on primary care prescribing 3,532 Genitourinary - Rate of bed days 3,123 Reported to estimated prevalence of CKD 2,292 Patients on CKD register with a BP of 140/85 or less Patients on CKD register treated with an ACE-1 or ARB Creatinine ratio test used in last 12 months % home dialysis undertaken % of patients on RRT who have a transplant 21,244 3, ,

18 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality % of delivery episodes where mother is <18 Flu vaccine take-up by pregnant women Smoking at time of delivery Live and still births <2500 grams Breastfeeding initiation (first 48 hrs) Infant mortality rate Emergency gastroenteritis admissions rate for <1s Maternity & Reproductive Health Emergency LRTI admissions rate for <1s % receiving 3 doses of 5-in-1 vaccine by age 2 A&E attendance rate for <5s Emergency admissions rate for <5s Unintentional & deliberate injury admissions for <5s % of children aged 4-5 who are overweight or obese Hospital admissions for dental caries (1-4 years) Neonatal Mortality and Stillbirths % receiving 1 dose of MMR vaccine by age 2 Mental Health Problems (all) Spend on primary care prescribing 3,198 Mortality from suicide and injury undetermined all ages People with mental illness and or disability in settled accomodation No. of patients, life-years, referrals, etc ,021 9,366 10,

19 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality New cases of depression which have been reviewed Assessment of severity of depression at outset IAPT referrals with a wait <28days (quarter) Completion of IAPT treatment (quarter) IAPT: % referrals with outcome measured (6 months) IAPT: % 'moving to recovery' rate (quarter) Mental Health Problems (common) IAPT: % achieving 'reliable improvement' (quarter) Emergency hospital admissions for self harm IAPT: % waiting <6 weeks for first treatment (6 month snapshots) No. of patients, life-years, referrals, etc ,274 1, ,533 2,250 Mental Health Problems (severe) Physical health checks for patients with SMI % Service users on CPA (end of quarter snapshot) Mental health hospital admissions People subject to mental health act (quarter) People on CPA in employment (end of quarter snapshot) Excess under 75 mortality rate in adults with serious mental illness % adults on CPA in settled accommodation (end of quarter snapshot) % of EIP referrals waiting >2 wks to start treatment (Incomplete) (5m) % of EIP referrals waiting <2 wks to start treatment (Complete) (5m)

20 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality Mental Health Problems (dementia) Mortality with dementia, 65+ % dementia deaths in usual place of residence (65+) % short stay emergency admissions aged 65+ with dementia % new dementa diagnosis with blood test Dementia diagnosis rate (65+) Rate of emergency admissions aged 65+ with dementia % of dementia patients with care reviewed No. of patients, life-years, referrals, etc ,496 1, Musculoskeletal System Problems (Excludes Trauma) Spend on elective and day-case admissions Spend on non-elective admissions Spend on primary care prescribing Spend on admissions relating to fractures where a fall occurred 18,721 MSK - Rate of bed days 1,861 % osteoporosis patients treated with Bone Sparing Agent 2,092 % patients 75+ years with fragility fracture treated with BSA 2,355 Hip replacement, EQ-5D Index, average health gain Knee replacement, EQ-5D Index, average health gain Hip replacement emergency readmissions 28 days Hip fractures in people aged 65+ Hip fractures in people aged Hip fractures in people aged 80+ % fractured femur patients returning home within 28 days Hip fracture emergency readmissions 28 days 24, Neurological System Problems Spend on elective and day-case admissions Spend on non-elective admissions Spend on primary care prescribing 3,419 Neurological - Rate of bed days 5,452 Mortality from epilepsy under 75 years 2,938 Emergency admission rate for children with epilepsy aged 0 17 years Patients with epilepsy on drug treatment and convulsion free, , Note: Spend on admissions relating to fractures where a fall occurred is a sub-set of Trauma and Injuries non-elective spend and is not included in the spend for overall MSK non-elective admissions. This indicator as well as Rates of hip fractures, Emergency readmissions to hospital within 28 days for patients: hip fractures and % patients returning to usual place of residence following hospital treatment for fractured femur appear in the quality section of the improvement opportunities table for both Trauma & Injuries and MSK table. This is due to it being in the Trauma & Injury pathway as well as the Osteoporosis pathway. Opportunities for these five indicators have only contributed to the headline; Spend, Outcomes (and hence Spend and Outcomes ) for MSK only. 20

21 Improvement opportunities This table presents opportunities for quality improvement and spend differences for a range of programme areas. These are based on comparing the CCGs within Lancashire and South Cumbria STP to the best / lowest 5 CCGs. A quantified unit is only shown when the opportunity is statistically significant. Disease Area Spend 000 Quality Spend on elective and day-case admissions 2,471 Respiratory - Rate of bed days Spend on non-elective admissions 7,212 Mortality from bronchitis, emphysema and COPD under 75 years Spend on primary care prescribing 6,391 Mortality from asthma all ages Reported to estimated prevalence of COPD % of COPD patients with a record of FEV1 % of COPD patients with review (12 months) Respiratory System Problems % patients (8yrs+) with asthma (variability or reversibility) % asthma patients with review (12 months) Emergency admission rate for children with asthma, 0-19yrs % of COPD patients with a diagnosis confirmed by spirometry No. of patients, life-years, referrals, etc. 27, ,142 2, , Trauma & Injuries Spend on elective and day-case admissions Spend on non-elective admissions Spend on primary care prescribing Spend on admissions relating to fractures where a fall occurred 1,589 Trauma and injuries - Rate of bed days 5,571 Mortality from accidents all ages 1,301 Injuries due to falls in people aged 65+ 2,355 Unintentional and deliberate injury admissions, 0-24yrs All fracture admissions in people aged 65+ Hip fractures in people aged 65+ Hip fractures in people aged Hip fractures in people aged 80+ % fractured femur patients returning home within 28 days Hip fracture emergency readmissions 28 days 37, ,

22 How to read your STP pathways The following slides provide a more detailed look at 19 'Pathways on a page' for each CCG within the STP. The intention of these pathways is not to provide a definitive view, but to help commissioners explore potential opportunities. These slides help to understand how performance in one part of the pathway may affect outcomes further along the pathway. Each row in the matrix represents a CCG in your STP area and how it compares to its similar 10 CCGs across that pathway. The similar 10 CCGs are not necessarily in the same STP. These Pathways on a Page allow an STP to examine which programmes have common opportunities for several CCGs across the entire pathway, or for part of a pathway (such as primary care or detection) for several CCGs. Therefore, STPs may find it useful to scan the charts both horizontally and vertically. The key to the right shows how to interpret the coloured squares and arrows. The STP opportunities underneath each indicator name sum the CCG opportunities benchmarked against the average of the best 5 CCGs, unlike the coloured squares which benchmark against the average of the similar 10 CCGs. Opportunities are calculated for all RAG-rated indicators except for the stated exceptions. p q r s tu r s r s tu CCG is statistically significantly HIGHER CCG is statistically significantly LOWER CCG HIGHER but not statistically significant CCG LOWER but not statistically significant CCG is equal to benchmark CCG WORSE/HIGHER but not statistically significant CCG WORSE/LOWER but not statistically significant CCG BETTER/HIGHER but not statistically significant CCG BETTER/LOWER but not statistically significant CCG is equal to benchmark CCG is statistically significantly WORSE CCG is statistically significantly BETTER CCG has no published data for this indicator or value is suppressed due to small numbers 22

23 Breast cancer pathway / / / / / / (2011) Deprivation Breast cancer prevalence Incidence of breast cancer Obesity prevalence, 16+ Breast cancer screening Primary care prescribing spend Urgent GP referrals (breast cancer) % first definitive treatment within 2 months (all cancer) Emergency presentations for breast cancer Elective spend Breast cancer detected at an early stage <75 Mortality from breast cancer 1 year survival (breast) STP opportunity (to Best 5) Fylde & Wyre 8,113 Ppl. 93 Pats. 37 Ppl. 4 Lives Cumbria p q r q p q s q r r r p p p q p q q r s p q q q p q r q s r r Blackpool p q s p p q s p r s s q q s q p q r s s r q p s q p s r s r s s r q p p q p q r p r s s q q s q p r s s q r r r q p p p s p s r p r r Lancashire North Blackburn with Darwen Chorley and South Ribble West Lancashire East Lancashire Greater Preston Note: We do not calculate potential opportunities for emergency presentations and one-year survival rates owing to missing information in published data. 23

24 Lower gastro-intestinal cancer pathway / / / / / / (2011) Deprivation Colorectal cancer prevalence Incidence of colorectal cancer Obesity prevalence, 16+ Bowel cancer screening Urgent GP referrals (colorectal cancer) % first definitive treatment within 2 months (all cancer) Emergency presentations for colorectal cancer Elective spend Non-elective spend Lower GI cancer detected at an early stage <75 Mortality from colorectal cancer 1 year survival (colorectal) STP opportunity (to Best 5) 2,858 Ppl. 93 Pats. 59K 44 Pats. 7 Lives Cumbria p s r q r r q r r s Lancashire North p p p q q s q s r s Blackburn with Darwen p q s q s r q s s r Blackpool p q s p q s s q r s s q s q q q q s r r West Lancashire q p s q p r r r East Lancashire q p r q s r q s s r Greater Preston q s s q s s q s s r s Fylde & Wyre q p p p r q r q s s r s Chorley and South Ribble Note: We do not calculate potential opportunities for emergency presentations and one-year survival rates owing to missing information in published data. 24

25 Lung cancer pathway / / / / / / / (2011) Deprivation Lung cancer prevalence Incidence of lung cancer Smoking prevalence, 18+ Obesity prevalence, 16+ Successful quitters, 16+ Urgent GP referrals (lung cancer) % first definitive treatment within 2 months (all cancer) Emergency presentations for lung cancer Elective spend Non-elective spend Lung cancer detected at an early stage <75 Mortality from lung cancer 1 year survival (lung) STP opportunity (to Best 5) 1,507 Ppl. 93 Pats. 561K 46 Pats. 100 Lives Cumbria p s p s q q p r r r Lancashire North p p p s q r s q r s r Blackburn with Darwen p q q r q s r q r s s Blackpool p q s p p p s r q r s r s q vw r r q r s r s s r West Lancashire q p s s q r s r q s s r r East Lancashire q q r r q q s r s r s Greater Preston q q q s q s s r r s s Fylde & Wyre q p p r p s p p s s Chorley and South Ribble Note: We do not calculate potential opportunities for emergency presentations and one -year survival rates owing to missing information in published data. 25

26 Severe mental illness pathway STP opportunity (to Best 5) April April /16 Q / / / /16 Q2 2015/16 Q4 2015/16 Q4 2014/ /16 Q2 2015/16 Q2 2015/16 Q2 August 2016 August 2016 (Year End) Deprivation Estimate of people with a psychotic disorder People with SMI known to GPs: % on register Primary care prescribing spend Physical health checks % of EIP referrals waiting <2 wks to start treatment (Complete) % of EIP referrals waiting >2 wks to start treatment (Incomplete) 273 Pats. 20 Pats. 48 Pats. New cases of psychosis served by Early Intervention teams People treated by Early Intervention Teams People on Care Programme Approach % Service users on CPA Mental health hospital admissions People subject to mental health act People on CPA in employment % adults on CPA in settled accommodatio n 50 Pats. 369 Adm. 102 Ppl. 13 Ppl. 687 Ppl. Cumbria p r p p s p q q r s Lancashire North p s s q r s q q q s s Blackburn with Darwen p r p q s r r q q r r s Blackpool p r p p s r r q q s s s q q p p s r q q r West Lancashire q q q q r s r q q s s East Lancashire q s p q s r q q q q Greater Preston q q p q r s q q s Fylde & Wyre q r p p s r s q Chorley and South Ribble Note: There is variation in the quality of care coordination under CPA, meaning CCGs have not been ranked better/worse than their similar peers for these indicators. However, because it is recommended that more users should be offered CPA support, opportunity figures have been provided for % service users on CPA. 26

27 Common mental health disorders pathway / / / / /16 Q4 2015/16 Q4 Oct Mar 2016 Oct Mar /16 Q4 2015/16 Q4 Deprivation % population with LLTI or disability Estimated prevalence of CMHD (% pop) Depression prevalence 18+ New cases of depression which have been reviewed Antidepressant prescribing IAPT referrals: Rate aged 18+ IAPT: Rate beginning treatment IAPT: % waiting <6 weeks for first treatment IAPT: % referrals with outcome measured IAPT: % 'moving to recovery' rate IAPT: % achieving 'reliable improvement' STP opportunity (to Best 5) 786 Pats. Cumbria p p q p p Lancashire North p p s p p Blackburn with Darwen p p p p r q Blackpool p p p p p r q q p p p West Lancashire q q p p q r East Lancashire q p q q q s Greater Preston q q s p q r Fylde & Wyre q p p p p Chorley and South Ribble 2,250 Pats. 139 Pats. 389 Pats. 322 Pats. s s r r s r r r r Note: It isn t possible to robustly calculate an opportunity of number of additional people who should be referred into IAPT.. 27

28 Dementia pathway / /16 Sep 2015 Aug / / / / / % physically inactive adults Smoking prevalence, 18+ Hypertension prevalence, 18+ Dementia prevalence 65+ Dementia diagnosis rate (65+) % new dementa diagnosis with blood test % dementia patients with care reviewed Ratio of Inpatient Service Use to Recorded Diagnoses Rate of % short stay emergency emergency admissions aged admissions aged 65+ with dementia 65+ with dementia 65+ mortality with dementia % dementia deaths in usual place of residence (65+) STP opportunity (to Best 5) 1,496 Ppl. 130 Pats. 129 Pats. 1,070 Adm. 274 Adm. 174 Lives 60 Deaths Cumbria p s r p p r r Lancashire North s s p p s r r Blackburn with Darwen r r q s s r q s s s r Blackpool r p p p s q s r s r q s s s s s s West Lancashire r s s r s r q s s s East Lancashire s r q q s s s Greater Preston s s q s s r r s Fylde & Wyre s r p p s r s r Chorley and South Ribble 28

29 Heart Disease pathway 2015/ / / / / / / / / / / / CHD prevalence Hypertension prevalence, 18+ Reported to estimated prevalence of CHD Reported to estimated prevalence of hypertension Smoking prevalence, 18+ Obesity prevalence, 16+ % CHD patients whose BP < 150/90 % CHD patients cholesterol < 5 mmol/l % hypertension patients whose BP < 150/90 Primary care prescribing spend Elective spend Non-elective spend <75 Mortality from CHD <75 Mortality from acute MI STP opportunity (to Best 5) 1,331 Ppl. 12,756 Ppl. 656 Pats. 2,248 Pats. 2,323 Pats. 3482K 114 Lives 64 Lives Cumbria p r s s q p p r Lancashire North p p s q q s Blackburn with Darwen p q r q r q p r r s Blackpool p p p p s q p s p q s r q r s s p p s s s West Lancashire r s r s q r p p s East Lancashire p q r q s q p s r Greater Preston q q s q s s p p s s r Fylde & Wyre p p r p r r p p Chorley and South Ribble 29

30 Stroke pathway Jan-Mar Jan-Mar 2015/ / / / / / / / / / / Jan-Mar /10-11/ / Stroke or TIA Prevalence, 18+ Smoking prevalence, 18+ Obesity prevalence, 16+ Reported to estimated prevalence of AF % stroke/tia patients whose BP < 150/90 % stroke/tia patients on antiplatelet or anticoagulan t High-risk AF patients on anticoagulati on therapy Primary care prescribing spend % who go direct to a stroke unit % who receive thrombolysis Patients 90% of time on stroke unit Elective spend Non-elective spend % treated by early supported discharge team Emergency readmission s within 28 days % patients returning home after treatment <75 Mortality from stroke STP opportunity (to Best 5) 974 Ppl. 298 Pats. 424 Pats. 1,843 Pats. 145 Pats. 168 Pats. 1829K 31 Pats. 26 Adm. 30 Pats. 45 Lives Cumbria p s q s s p s p s Lancashire North p s q p r r s r r r Blackburn with r Darwen q r s r s r p s r r Blackpool p p p r s p s r r q s s r s r q r s q s r s r r r r s West Lancashire s s q s r q r r r s East Lancashire p r q r r r s p s r r Greater Preston q s q s s q s r r s s r r r Fylde & Wyre p r p s p r p s r r Chorley and South Ribble 30

31 Diabetes pathway 2015/ / / / / / / / / / /16 Diabetes prevalence, 17+ Obesity prevalence, 16+ % diabetes patients cholesterol < 5 mmol/l % diabetes patients HbA1c is <59 mmol/mol % diabetes patients whose BP < 140/80 % of diabetes patients receiving all three treatment targets % patients receiving foot examination Retinal screening % diabetes patients attending structured education Primary care prescribing spend Non-elective spend STP opportunity (to Best 5) Cumbria p q Lancashire North p q Blackburn with Darwen p q Blackpool p p q q West Lancashire q q East Lancashire q q r Greater Preston q q Fylde & Wyre p p Chorley and South Ribble 3,552 Pats. 1,508 Pats. 704 Pats. 1,105 Pats. 3,391 Pats. 3,176 Pats. 832 Pats. 286K q r s r p r s r p s s p r q s r q s q s r r s q s p s 31

32 Renal pathway 2015/ / / / / / / / / Reported CKD prevalence Reported to estimated prevalence of CKD % CKD patients whose BP < 140/85 % on CKD register with hypertension & proteinuria treated with ACE-I or ARB Creatinine ratio test used in last 12 months Primary care prescribing spend Nephrology first outpatient attendance rate Elective spend Non-elective spend Acceptance rate for renal replacement therapy % home dialysis undertaken % of patients on RRT who have a transplant STP opportunity (to Best 5) 3,664 Ppl. 562 Pats. 47 Pats. 1,549 Pats. 1865K 41 Pats. 67 Pats. Cumbria q s r p p s s r Lancashire North p r s r p s q s r r Blackburn with Darwen q s r r p s s s s Blackpool p s p q q r s s p r p p p r s r West Lancashire q s r p s s s s r East Lancashire q s s p s q s s s Greater Preston p r r r p p r r r r s Fylde & Wyre p r r r p p r r s s Chorley and South Ribble 32

33 COPD pathway 2015/ / / / / / / / COPD Prevalence Reported to estimated prevalence of COPD Smoking prevalence, 18+ % COPD patients diagnosis confirmed by spirometry % of COPD patients with a record of FEV1 % of COPD patients with review (12 months) Primary care prescribing spend Non-elective spend <75 mortality from bronchitis, emphysema and COPD STP opportunity (to Best 5) 3,142 Ppl. 2,485 Pats. 572 Pats. 3812K 40 Lives Cumbria p s p Lancashire North p s s p s r Blackburn with Darwen r r s r p s Blackpool p r p r r p r r r s r p r West Lancashire q s s q r s East Lancashire p r r q s Greater Preston q s q s s Fylde & Wyre p r p r Chorley and South Ribble 436 Pats. 33

34 Asthma pathway 2015/ / / / / / Asthma Prevalence % patients (8yrs+) with asthma (variability or reversibility) % asthma patients with review (12 months) Primary care prescribing spend Non-elective spend Emergency admission rate for children with asthma, 0-19yrs Mortality from asthma all yrs STP opportunity (to Best 5) 991 Pats. 1,990 Pats. 714K 656 Adm. 3 Lives Cumbria p p s Lancashire North p r r p s Blackburn with Darwen p s p r Blackpool p r p r s p s r q r West Lancashire p r q s r r East Lancashire p q s Greater Preston s q r s Fylde & Wyre p p Chorley and South Ribble 34

35 Lower gastro-intestinal pathway 2015/ / / / / / /16 (Snapshots for / / / /16 months) 2013/ / / / / Smoking prevalence, 18+ Obesity prevalence, 16+ Reported Clostridium difficile cases Rate of hemorrhoid surgery % hemorrhoid surgeries which are day cases Rate of colonoscopies % 6+ week waits for a colonoscopy Primary care prescribing spend Elective spend Non-elective spend Rate of emergency colonoscopies Diverticular disease - Emergency admissions Gastroenteritis emergency admissions (0-4) Gastroenteritis emergency admissions (5+) <75 mortality from gastrointestina l disease STP opportunity (to Best 5) 147 Cases 56 Cases 1096K 42 Pats. 104 Adm. 897 Adm. 581 Adm. 108 Lives Cumbria s q q s p p p Lancashire North s q s r s s p s r r r Blackburn with Darwen r q p r q p s r r r Blackpool p p r q q s q q s s r q r r q s q p s s s r West Lancashire s q p r q s p r r r r s East Lancashire r q p r q p q r r Greater Preston s q r r r p r q p r Fylde & Wyre r p r s p p r r s r Chorley and South Ribble Note: Colonoscopies are one of 15 key diagnostic tests which the NHS Constitution states less than 1% of patients should wait more than 6 weeks for. CCGs which achieve good performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail, which are available at: 35

36 Upper gastro-intestinal pathway STP opportunity (to Best 5) 2015/ / / / / /16 (Snapshots for / / / / / / (Provisional) months) Smoking prevalence, 18+ Obesity prevalence, 16+ Alcohol specific hospital admissions Rate of bariatric surgery Rate of gastroscopies Rate of gastroscopies (<40) % 6+ week waits for a gastroscopy Primary care prescribing spend Elective spend Non-elective spend Rate of emergency gastroscopies Upper GI bleeds - Emergency admissions 919 Adm. 57 Ppl. 1751K 215 Pats. 140 Adm. 30 Adm. Peptic ulcerations - Emergency admissions <75 mortality from gastrointestinal disease Cumbria s q q p p r p p r r Lancashire North s q q q q s p q r r r Blackburn with Darwen r q s p p p p r r r r r Blackpool p p r q q q s p q s r q r s s s s q p r r r r West Lancashire s q s r r s s q p r r s s East Lancashire r q q p p p p s s r Greater Preston s q q s s s q r r r r s Fylde & Wyre r p s q q p q r r s Chorley and South Ribble 108 Lives Note: Gastroscopies are one of 15 key diagnostic tests which the NHS Constitution states less than 1% of patients should wait more than 6 weeks for. CCGs which achieve good performance compared to their peers may still be missing this target. CCGs are therefore advised to examine their waiting list times in greater detail, which are available at: 36

37 Liver disease pathway 2015/ (Provisional) 2011/ / / / / / / / Obesity prevalence, 16+ Alcohol specific hospital admissions Rate added to liver transplant waiting list Liver transplant rate Non-elective spend Admissions for hep C related end-stage liver disease/hcc Alcoholic liver disease - Emergency admissions Liver cancer incidence <75 mortality from liver disease STP opportunity (to Best 5) 919 Adm. 737K 191 Adm. 95 Lives Cumbria q r r r q r s r Lancashire North q s r r r r r Blackburn with Darwen q s r s r r r Blackpool p r s s q q r r r r s r West Lancashire q s s r s r r s East Lancashire q s s s p r Greater Preston q r r r p r s r Fylde & Wyre p r s r q Chorley and South Ribble Note: Many cases of liver cancer are linked to cirrhosis. Cirrhosis is commonly caused by heavy and harmful drinking, hepatit is C and the build-up of fat inside the tissue of the liver. Liver cancer incidence is therefore related to a number of other indicators in the pathway, meaning CCGs have been rat ed better/worse than their similar peers. However, to be consistent with other cancer incidence indicators, a quantified opportunity figure has not been provided. 37

38 Osteoporosis and fragility fractures pathway 2013/ / / / / / / / / / / / / / / / /16 GP registered pop >75 Rate of DEXA scan activity Primary care prescribing spend - bisphosphonat es Hip fractures in people aged 65+ Hip fractures in people aged Hip fractures in people aged 80+ Mean length of stay for hip fractures Mean length of stay for hip fractures 65+ Elective spend Non-elective spend Spend on fracture admissions after a fall occurred % fractured femur patients returning home within 28 days Hip fracture emergency readmissions 28 days % osteoporosis patients treated with Bone Sparing Agent % patients 75+ years with fragility fracture treated with BSA STP opportunity (to Best 5) 73 Adm. 51 Adm. 44 Adm. 540K 2355K 134 Pats. 15 Adm. 40 Pats. 111 Pats. Cumbria q p p s r r p p p s s s s Lancashire North p p q r r p p q s s r r s Blackburn with Darwen q q q s s r r r s r s r s r Blackpool p r q s r s p p q r r s s q q s r r r p s s r r West Lancashire p p p s s r r p s r r r East Lancashire p p q p p q r s s Greater Preston q q q s r s s s q s s r r s s Fylde & Wyre p p q r r p p q r s s Chorley and South Ribble 38

39 Osteoarthritis pathway 2012/ / / / / / / / / / / / / /10-11/12 % people (over 45) who have hip osteoarthritis (total) % people (over 45) who have knee osteoarthritis (total) % people (over 45) who have hip osteoarthritis (severe) % people (over 45) who have knee osteoarthritis (severe) Rate of hip replacements Rate of knee replacements Primary care prescribing spend Pre-treatment EQ-5D Index (hips) Pre-treatment EQ-5D Index (knees) Elective spend Non-elective spend EQ-5D Index health gain (hips) EQ-5D Index health gain (knees) Hip replacement emergency readmissions 28 days STP opportunity (to Best 5) 156K 231 QALYs 236 QALYs 31 Adm. Cumbria r r r r p p p r r p s s Lancashire North s s r s r p p p p p r s r Blackburn with Darwen r r r r s q q r r s s r r Blackpool p p r r r r p r p p s s s s s s p s q r p r r s r West Lancashire s s s s s s q r r s s s r East Lancashire r r r r r q q s q r s r Greater Preston s s s s p p q r p p r s s r Fylde & Wyre r r r r r r p s r r r s s r Chorley and South Ribble 39

40 Trauma and injury pathway 2015/ / / / / / / / / / / / / / Injuries due to falls in people aged 65+ Unintentional and deliberate injury admissions, 0-24yrs All fracture admissions in people aged 65+ Hip fractures in people aged 65+ Hip fractures in people aged Hip fractures in people aged 80+ Primary care prescribing spend Elective spend Non-elective spend % fractured femur patients returning home within 28 days Hip fracture emergency readmissions 28 days Mortality from accidents all yrs STP opportunity (to Best 5) Cumbria Lancashire North Blackburn with Darwen Blackpool Chorley and South Ribble West Lancashire East Lancashire Greater Preston Fylde & Wyre 596 Adm. 1,438 Adm. 360 Ppl. 73 Adm. 51 Adm. 44 Adm. 5571K 134 Pats. 15 Adm. 71 Lives s r r p q s s r r p q s r r s s r p q r s r r s s r s p q s s r r q p r s r s s q s r r s s p q r s s s r s q p r r r r r r r p q s s 40

41 Maternity and early years pathway 2014/ / / / / / / / / / / / / / /13-14/15 % of delivery episodes where mother is <18 Flu vaccine take-up by pregnant women Smoking at time of delivery % of low birthweight babies (<2500g) Breastfeeding initiation (first 48 hrs) Neonatal Mortality and Stillbirths Infant mortality rate Emergency gastroenteriti s admissions rate for <1s Emergency LRTI admissions rate for <1s % receiving 3 doses of 5-in- 1 vaccine by age 2 A&E attendance rate for <5s Emergency admissions rate for <5s Unintentional & deliberate injury admissions for <5s % of children aged 4-5 who are overweight or obese % receiving 1 dose of MMR vaccine by age 2 Hospital admissions for dental caries (1-4 yrs) STP opportunity (to Best 5) 25 Cases 966 Cases 689 Cases 185 Cases 495 Cases 44 Lives 20 Lives 308 Adm. Cumbria r s r s r r Lancashire North r s r r r s Blackburn with Darwen s r r s r Blackpool r s s s s r r r r r West Lancashire s r s r r s s East Lancashire s s s r Greater Preston s s s s Fylde & Wyre r s r r r r Chorley and South Ribble 558 Adm. 1,021 Cases 9,366 Pats. 10,515 Adm. 507 Adm. 435 Cases 774 Cases 424 Adm. s r r r s s s s s 41

42 Next steps and actions STP areas can take the following steps now: Identify the priority programmes in your locality and compare against current improvement activity and plans Look at the focus packs on the NHS RightCare website for those areas which are a priority for your locality Engage with clinicians and other local stakeholders, including public health teams in local authorities and commissioning support organisations and explore the priority opportunities further using local data Refer to the pages on coordinated re-allocation of capacity and discuss the wider opportunities highlighted in this pack as part of the STP planning process and consider STP wide action Revisit the NHS RightCare website regularly as new content, including updates to tools to support the use of the Commissioning for Value packs, is regularly added Discuss next steps with your local NHS RightCare Delivery Partner. If you don t know who your Delivery Partner is, please rightcare@nhs.net 42

43 Further support and information The Commissioning for Value benchmarking tool, explorer tool, full details of all the data used, and links to other useful tools are available on the NHS RightCare website. Links are shown on the next page. The NHS RightCare website also offers resources to support local health economies in adopting the Commissioning for Value approach. These include: Focus packs for the highest spending programmes covered in this pack Online videos and how to guides Case studies with learning from other CCGs If you have any questions or require any further information or support you can the Commissioning for Value support team direct at: 43

44 Useful links NHS RightCare website: Commissioning for Value packs and products: NHS RightCare casebooks: Five Year Forward View: NHS shared planning guidance for 2017/ /19: 44

45 How have the potential opportunities been calculated? The potential opportunity at CCG level highlights the scale of change that would be achieved if the CCG value moved to the benchmark value of the average of the Best 5 or Lowest 5 CCGs in its group of similar 10 CCGs. Generally, where a high CCG value is considered worse then it is calculated using the formula: Potential Opportunity = (CCG Value Benchmark Value) * Denominator The denominator is the most suitable population data for that indicator eg CCG registered population, CCG weighted population, CCG patients on disease register etc. The denominator is also scaled to match the Value. So if the CCG Value and Benchmark Value are given in per 1,000 population then the denominator is expressed in thousands, ie 12,000 becomes 12. For an indicator, adding the statistically significant opportunities from the CCG packs gives the opportunity for the STP presented in this pack. Throughout this Lancashire and South Cumbria STP pack, the opportunities for Cumbria CCG have been scaled to the population proportion (38%) of GP registered patients in South Cumbria. 45

46 The NHS RightCare programme The NHS RightCare programme is about improving population-based healthcare, through focusing on value and reducing unwarranted variation. It includes the Commissioning for Value packs and tools, the NHS Atlas series, and the work of the Delivery Partners. The approach has been tested and proven successful in recent years in a number of different health economies. As a programme it focuses relentlessly on value, increasing quality and releasing funds for reallocation to address future demand. NHS England has committed significant funding to rolling out the RightCare approach. All CCGs are now working with an NHS RightCare Delivery Partner. We have also aligned Delivery Partners to STP footprints to better support the system. For more information visit: 46

47 NHS RightCare and Commissioning for Value Commissioning for Value is a partnership between NHS RightCare and Public Health England. It provides the first phase of the NHS RightCare approach - Where to Look. The approach begins with a review of indicative data to highlight the top priorities or opportunities for transformation and improvement. Value opportunities exist where a health economy is an outlier and will most likely yield the greatest improvement to clinical pathways and policies. Phases two and three then move on to explore What to Change and How to Change. 47