How to make changes in the NHS

Transcription

1 How to make changes in the NHS Keith Willett Prof of Orthopaedic Trauma Surgery University of Oxford prev. National Clinical Director for Trauma Care ATOCP Conference Oxford 2016 Medical Director for Acute Care; NHS England

2 Universal health care Funded by taxation 8.7% of GDP (17.6, 10.9) UK 3.6k, Can 5.7k, US 9.1k US$

3 NHS Quality Framework to drive improvement QUALITY: clinical effectiveness, patient safety, experience of patients Bring clarity to Measure Publish Reward Leadership for Innovate for Safeguard Compelling evidence that it is possible to change professional behaviour to improve of care, reduce cost.. for better VALUE

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5 The NHS is an amoeba..... Desmond Morris and Keith Willett

6 Bring clarity to Measure Publish Reward First, identify the key interventions in the care pathway that will really improve care and outcomes Lead for q

7 Changing practice for improvement in healthcare at scale Review of all current evidence and guidelines Multiprofessional clinical and patient advisory group Recommendations Measurable commissionable aligned payments Activity data from registries and Hospital Episode Statistics Cost-effective NICE standards health economics operational delivery workforce 7

8 y Measure Publish Reward Secondly, agree the metrics by which care can be Leadership for appropriately judged by patients and all clinicians NHS Hospital Episode Statistics data do not measure

9 Hip Fracture - agreed best practice metrics Time to surgery (<36 hours) 1. Arrival in Emergency Dept (or diagnosis if an inpatient) to start of anaesthesia Involvement of the multi-professional team: 2. Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon 3. Admitted using an assessment protocol agreed by geriatrics medicine, orthopaedic surgery and anaesthesiology 4. Assessed by a Geriatrician in the perioperative period Consultant or senior resident within 72 hours of admission 5. Postoperative Geriatrician-directed: 1. Multiprofessional rehabilitation team 2. Fracture prevention assessments (falls risk and bone health) 6. Dementia Assessment: Mental test score at admission and prior to discharge by nurses

10 re y Publish Reward Leadership for Innovate for Sa q National Clinical Audit / Registry

11 Reward Leadership for Innovate for Thirdly incentivise the clinical behaviour and patient flow changes in the care pathway Safeguard money follows the right patient care..

12 Pay by performance tariff Payment per patient HRG tariff price Base tariff for each HRG Additional payment for best practice Reduction in base tariff for current compliance 2-part tariff for best practice initially 9% now 19% of HRG Original base tariff Best practice tariff 1235 of 6500 HRG Base tariff set below national average cost Sum of base tariff and BPT higher than national average cost 12

13 Link to national registry to drive change National Hip Fracture Registry Unique identifier Individual patient data BPT compliance LOCAL HOSPITAL CLINICAL TEAM Commissioner Insurer/Payer Additional payments pay tariff uplift (~19%) 500k to 1m per year per hospital in extra income ( cases a year)

14 100% Improvement in Hip Fracture Care Best Practice Tariff: percentage attained for each criteria; all criteria 24 to 64% 16 quarter-on-quarter improvement Admitted under joint geriatric/anaesthetic protocol increased from 64 to 97%; Surgery within 48 hours rising from 65 to 77% in 36 hours, to 87% in 48hrs; Seen acutely by a Geriatrician up from 48 to 90%; bone health assessment up 72 to 97%

15 MAJOR TRAUMA Too difficult to solve for 25 years.... MAJOR TRAUMA Life threatening or life-changing serious physical injury often multiple Typified by delay, inappropriate care, avoidable death and disability 15

16 MAJOR TRAUMA Preferred acute patient pathway 24/7 network coordinator in Ambulance Service Medical consultant advice On scene triage direct transfer (<45mins) indirect transfer enhanced care team (geography, time-critical intervention) MAJOR TRAUMA CENTRE Consultant led trauma team Immediate operating theatre All specialties: neurosciences Immediate CT scan Interventional radiology Specialist critical care Trauma Unit trauma team immediate CT resus, assess and? transfer 16

17 MAJOR TRAUMA Preferred rehabilitation pathway Network Director for Rehabilitation MAJOR TRAUMA CENTRE Consultant Clinical Lead Acute Trauma Rehabilitation Manager Full multi-disciplinary team Care & Rehabilitation Coordinator Directory of Rehab services Trauma Unit or Local Hospital Identified Lead for Trauma Rehab Services Key worker Level 1 complex Level 2 specialist Level 3 general PRESCRIPTION for rehabilitation physiotherapy, OT, SALT, social work, mental health neuropsychology Vocational / Educational independence 17

18 MAJOR TRAUMA All networks and MTCs implemented in April 2012 Set-up 22 regional trauma networks (27 MTCs) pop 53m Cover 1.4m to 5.2m population Ongoing assurance through TARN trauma registry Nationally Commissioned NHS England Clinical Reference Group = established Major Trauma Centre 18

19 Best Practice Tariff Criteria Level 1 ISS > 8 and the following criteria met: the patient is treated in an MTC Complete patient data submitted to TARN registry within 40 days of discharge MDT Rehabilitation prescription is completed for each patient Tranexamic acid administered within 3 hours of injury Level 2 ISS > 15 Level 1 criteria are met, plus either: Patient received by a trauma team led by a Consultant within 30 (5) minutes of arrival If the patient is transferred as an urgent transfer then the transfer should take place within 2 calendar days of referral from the trauma unit.

20 MAJOR TRAUMA Driving performance improvement with a best practice tariff Trauma Audit Research Network (TARN) Individual patient data KPI compliance Commissioners / payer Additional best practice tariff per patient unique identifier MAJOR TRAUMA CENTRE Major Trauma Centres only financially viable if delivered best practice care.

21 ISS Best Practice tariff compliance months Level 1 criteria only Level 1 and 2 criteria met 13,000 patients Consultant led trauma team Transfer 2 days

22 80% National Dashboard: All Major Trauma Centres Consultant-led Trauma Team on arrival, patient ISS>15 70% 60% 50% P = ,300 patients 40% 4,000 patients Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Year Q1 Q2 Q Q4

23 80% National Dashboard: All Major Trauma Centres Tranexamic acid within 3h injury 70% 60% 81.5% 50% 40% Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Year Q1 Q2 Q3 Q

24 25-40% increase in survival MAJOR TRAUMA NETWORKS INTRODUCED

25 Ws breakdown (Major Trauma Centres and Trauma Units) After MTC designation (from equates April 2012) to ~600 lives saved PROBABILITY of SURVIVAL band Number in Ps group EXPECTED number of survivors ACTUAL number of survivors Actual number of deaths Difference (W) = (Actual vs Expected / N/100) Fraction in the TARN database Case mix standardised (adjusted) difference (Ws = total) >95% ,320 Ws = 0.555

26 Before Major Trauma Centre Designation University teaching hospitals before designation as a Major Trauma Centres precision (1/seWs) Ws +2SD -3SD -2SD target +3SD

27 University teaching hospitals after designation as a Major Trauma Centres After Major Trauma Designation pts, 47% ISS > precision (1/seWs) Ws +2SD -3SD -2SD target +3SD

28 Innovate for Safeguard Continuous assurance, reappraisal, comparison and sharing. public reporting and peer review

29 Rate of Survival

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31 Leadership for Innovate for Safeguard The role of management is to create a culture and reward system that guides thousands of decisions in the direction of better and service at reduced cost A Enthoven

32 Leadership for Innovate for Safeguard The role of management clinicians is to is to create a culture and reward system that guides thousands of decisions in the direction of better and service at reduced cost K Willett

33 Service specifications Payment systems Payer risk Operational risk Provider risk Clinical risk Professional standards Quality assurance

34 Leadership is the capacity to turn vision into reality LESSON 1 Warren Bennis Clinical teams in a universal healthcare system can be trusted to design and commission best practice and best value services and select the measures by which their services should be fairly judged

35 Leadership is the capacity to turn vision into reality LESSON 2 Deriving policy through multi-professional and patient consensus has credibility and ensures engagement and ownership in provider clinicians for delivery

36 Leadership is the capacity to turn vision into reality LESSON 3 Linking payment for performance and public reporting are key, and ensures government buy-in We must not be naïve

37 Leadership is the capacity to turn vision into reality LESSON 4 We need to move healthcare systems from summative assessment (targets).. to clinically credible and formative assessment

38 Healthcare System change in the NHS: If I were doing it again Locally 1. Always question why you are doing it that way? 2. If you have a vision, energy, and passion you will always win through 3. Keep adding to your design with others views and ideas 4. What problem is on the managers desk not yours? Can you help it? Nationally 1. Educate, then use patients and the public more to construct the narrative 2. Work with the next generation of enthusiasts (but beware the fanatics) 3. Take what you could get in the battles you cannot win it s iterative 4. Mesh with as many other strategies as possible, but not to be dependent 5. Appreciate the operational delivery and financial complexities early 6. Political will is not essential unless you want to divert or need more funds 7. Be ready for your moment in the sun

39 Redesigning the whole of Urgent and Emergency Care 39

40 Bring clarity to Measure Publish Reward Leadership for Innovate for Safeguard