NHS Right Care Deep Dive

Transcription

1 NHS Right Care Deep Dive Northern, Eastern and Western Devon Clinical Commissioning Group Problems of the gastrointestinal system South, Central and West Commissioning Support Unit September 2015

2 Table of figures Figure 1: Programme budget expenditure on problems of the gastro-intestinal system. 2013/ Figure 2: Finished Admission Episodes in an inpatient setting with a primary or secondary diagnosis of obesity in England, 2013/ Figure 3: Lower gastro-intestinal primary prescribing spend per 100,000, 2013/ Figure 4: 'Other' gastro-intestinal primary prescribing spend per 100, / Figure 5: Heptobillary primary prescribing... 6 Figure 6: Primary prescribed items for gastro-intestinal conditions... 7 Figure 7: Cost of primary prescribed items for gastro-intestinal conditions... 7 Figure 8: Lower gastro-intestinal elective/dc spend per 100, Figure 9: 'Other' gastro-intestinal elective/dc spend per 100,000 (00s... 8 Figure 10: Hepatobiliary elective\dc spend per 100, Figure 11: NEW Devon crude rate of admissions for selected HRGs by NEW Devon CCGs... 9 Figure 12: Provider opportunities for gastro-intestinal conditions

3 Overview Figure 1: Programme budget expenditure on problems of the gastro-intestinal system. 2013/14 Primary Prescribing Running Costs Daycase and elective (PBR) Community and integrated care Outpatient (PBR & Non-PBR) Drugs & devices Non-elective admissions (PBR) Critical Care A&E Emergency Transport Source: NHS England NEW Devon CCG is in the highest quintile for discharges with a primary or secondary diagnosis of obesity Analysis and comparison of age standardised elective neurological activity for NEW Devon CCG shows that rates are below the national ; this is in contrast to the spend in this area (see figure 1) which is in the 4th quintile Overall spend in hepatobiliary (areas affecting the liver and gall bladder) is in the highest 40% in the country. Spend in primary care prescribing is in the highest quintile in two of the four subcategories of gastro-intestinal problems, lower gastro-intestinal and other gastro-intestinal problems. Areas under investigation Intestinal infectious diseases Stomach infectious diseases Hernias Cleft palates and lips Other symptoms and signs involving the digestive system and abdomen Haemorrhoids Upper GI including Stomach ulcers Crohns disease Liver disease Hepatitis Cirrhosis 3

4 Key messages In terms of risk factors, NEW Devon shows low admission rates for liver disease linked to alcohol; the CCG is in the second lowest quintile according to the most recent provisional data. However, the CCG is in the highest quintile for discharges with a primary or secondary diagnosis of obesity recorded. This may indicate obesity as a driver for gastro-intestinal spend in primary care, particularly given the potential links between obesity and inflammatory bowel disease and the relatively high spend in related drug classes. Spend in primary care prescribing is in the highest quintile in two of the four subcategories of gastro-intestinal problems, lower gastro-intestinal and other gastrointestinal problems. Whilst upper gastrointestinal spend in primary care prescribing compares well to the rest of the country, hepatobiliary spend is in the second highest quintile. The same areas also appear as potential areas for savings opportunities in scheduled elective and daycase, where hepatobiliary spend for NEW Devon CCG is in the highest quintile (likely driving the higher spend overall in this area) and lower and other gastro-intestinal spend appears in the second highest quintile. prescribing spend occurring in BNF subchapters for laxatives, medications for acute diarrhoea and antispasmodics, all of which are in the highest or second highest quintile in terms of both actual cost and volume of prescribing. In secondary care, the high elective and daycase spend appears driven by high rates of cholecystectomy in the hepatobiliary subcategory, and in HRGs related to inflammatory bowel disease in the lower gastro-intestinal subcategory. Outcomes for liver disease are quite positive, with low mortality and NEW Devon in the lowest quintile nationally. This suggests that the higher spend in the hepatobiliary area may be resulting in better outcomes for patients in the longer term. Overall programme budget spend for gastrointestinal problems for NEW Devon CCG is generally in the middle of the national distribution, which is supported by elective and non-elective directly standardised activity analysis. However, there is variation within the overarching gastro-intestinal category, with overall spend in hepatobiliary being in the second highest quintile nationally. This high spend in both primary care prescribing and elective secondary care appears to be linked to primarily to issues of inflammatory bowel disease, with the highest 4

5 Standerdised rate per 100,000 NEW Devon Deep Dive- Summary Report Population and risks Figure 2: Finished Admission Episodes in an inpatient setting with a primary or secondary diagnosis of obesity in England, 2013/14 3,000 2,500 2,000 1,500 NEW Devon 1, England = 582 per 100,000 0 Source: Health and Social Care Information Centre Problems of the gastrointestinal system are often related to age and lifestyle factors. Obesity has been linked to greater severity of symptoms of inflammatory bowel disease and is identified as a factor for increased risk of gastrointestinal disease generally Devon local authority has a rate of obesity of 21.6%, which is slightly less than the England rate. Plymouth local authority area has an obesity rate (24.7%) that is slightly, but not significantly, higher than the England rate. Obesity being identified as a primary or secondary diagnosis at admission is flagged as an indicator where NEW Devon is in the highest quintile nationally, and has rates above the ten most similar CCGs 1 Reductions in the prevalence of obesity could therefore have a long term impact on the costs, financial and otherwise, of gastrointestinal illness. 5

6 NEW Devon Oxon 'Other' gastrointestinal primary prescribing spend per 100,000 Lower gastrointestinal primary prescribing spend per 100,000 NEW Devon Oxon NEW Devon Oxon Heptobillary primary prescribing spend per 100,000 NEW Devon Deep Dive- Summary Report Primary care NEW Devon has an overall gastrointestinal spend within the middle quintile nationally, but exhibits variation within the category. Of particular interest is the relatively high spend in primary care prescribing, where three of the four sub-categories in the gastrointestinal programme budget chapter are in the 4 th or highest quintile nationally. Figures 3,4 & 5 below illustrates the primary care prescribing spend in each of these three subcategories for NEW Devon CCG against the 10 most similar CCGs in England, and against best quintile and the of the most similar 10 CCGs as general benchmarks. Figure 3: Lower gastro-intestinal primary prescribing spend per 100,000, 2013/ Figure 5: Heptobiliary primary prescribing spend per 100,000, 2013/ Figure 4: 'Other' gastro-intestinal primary prescribing spend per 100, / Of particular note is that NEW Devon has the highest spend of comparable CCGs for both lower gastro-intestinal (figure 3) and other (figure 4) gastro-intestinal areas. In hepatobiliary (figure 5) there is more significant variation between the 11 CCGs compared, and whilst NEW Devon does not have the highest spend, there are clearly opportunities for savings against national best quintile. Table 1 illustrates the savings opportunities potentially available in primary care prescribing for a number of scenarios, for each of lower gastro intestinal, hepatobiliary and other gastro intestinal sub-categories. 2 Table 1: Savings opportunities for NEW Devon CCG in gastro-intestinal primary care prescribing, Area Reduction scenario Spend per 100,000 Lower gastro intestinal primary care prescribing Hepatobiliary primary care prescribing Difference with NEW Devon spend per 100,000 Saving opportunity National , National

7 Area Reduction scenario Spend per 100,000 Other gastrointestinal primary care prescribing Difference with NEW Devon spend per 100,000 Saving opportunity National , In terms of the areas where primary care prescribing is highest, the Figures 6 & 7 below provide an indication of which BNF sub-chapters have the highest volume and cost of prescribing in primary care. 3 Figure 6: Primary prescribed items for gastrointestinal conditions Figure 7: Cost of primary prescribed items for gastrointestinal conditions Antisecretory Drugs & Mucosal Protectants Antisecretory Drugs & Mucosal Protectants Local Prepn for Anal & Rectal Disorders Antispasmodic & Other Drugs altering Gut Motility Local Prepn for Anal & Rectal Disorders Antispasmodic & Other Drugs altering Gut Motility Laxatives Drugs for Acute Diarrhoea Laxatives Drugs for Acute Diarrhoea Dyspepsia & Gastro-Oesophageal Reflux Disease Dyspepsia & Gastro-Oesophageal Reflux Disease Most notable is the class of drugs for acute diarrhoea and antispasmodics and other drugs altering gut motility being in the highest and second highest quintiles respectively in terms of both volume and cost. Laxatives are also in the highest quintile in terms of volumes, but the second highest for cost, which suggests that perhaps lower cost items are being prescribed in this high volume area. Planned care Another area where costs are high for NEW Devon CCG is in elective and daycase work. Figure 8, 9 and 10 show the costs in comparison to the ten most similar CCGs in the same areas of gastrointestinal that were reviewed in relation to primary care prescribing; again, each of these are in the highest or second highest national quintile for NEW Devon CCG. 4 7

8 Oxon NEW Devon 'Other' gastrointestinal elective/dc spend per 100,000 Oxon NEW Devon Oxon Lower gastrointestinal elective/dc spend per 100,000 NEW Devon Hepatobiliary elective\dc spend per 100,000 NEW Devon Deep Dive- Summary Report Figure 8: Lower gastro-intestinal elective/dc spend per 100,000 1,200 1, Figure 10: Hepatobiliary elective\dc spend per 100,000 1, Figure 9: 'Other' gastro-intestinal elective/dc spend per 100,000 (00s 1,400 1,200 1, Top left hand side bar chart (Figure 8) illustrates variation in lower gastrointestinal elective/daycase spend between NEW Devon CCG and 10 most similar CCGs, against the overall spend of the 10 most similar, and national top quintile. Top right hand side bar chart (Figure 10) illustrates variation in hepatobiliary elective/daycase spend between NEW Devon CCG and 10 most similar CCGs, against the overall spend of the 10 most similar, and national top quintile. Bar chart to the right (Figure 9) illustrates the same for other gastrointestinal elective/daycase spend. Whilst NHS Oxfordshire has the highest spend in this area for all three subcategories, NEW Devon CCG has the highest or second highest spend of the remainder of the peer group. Table 2 illustrates the savings opportunities potentially available in elective and daycase spending for a number of scenarios, for each of lower gastrointestinal, hepatobiliary and other gastro intestinal subcategories. 5 Table 2: Savings opportunities for NEW Devon CCG in gastro-intestinal elective/daycase Area Reduction scenario Spend per 100,000 Lower gastro intestinal system problems elective and daycase Hepatobiliary elective and daycase Other gastrointestinal elective and Difference with NEW Devon spend per 100,000 Saving opportunity National , National , National ,886 8

9 Crude rate per 1,000 for HRGs with greatest potetial opportunities HONITON SURGERY - SEAMARK IMPERIAL SURGERY CHIDDENBROOK SURGERY HATHERLEIGH MEDICAL CENTRE BLACKDOWN PRACTICE HILL BARTON SURGERY WESTBANK PRACTICE NEWCOMBES SURGERY ST LEONARDS PRACTICE AXMINSTER MEDICAL PRACTICE BOW SURGERY BRADWORTHY SURGERY TOWNSEND HOUSE MEDICAL CENTRE HEAVITREE PRACTICE TOPSHAM SURGERY PINHOE SURGERY COLLEGE SURGERY PARTNERSHIP SHEBBEAR SURGERY WALLINGBROOK HEALTH CENTRE ROLLE MEDICAL PARTNERSHIP CASTLE PLACE PRACTICE LYNTON HEALTH CENTRE IDE LANE SURGERY BARNFIELD HILL SURGERY CLARE HOUSE SURGERY FREMINGTON MEDICAL CENTRE WEMBURY SURGERY WOODA SURGERY MOUNT PLEASANT HEALTH CENTRE RALEIGH SURGERY LITCHDON MEDICAL CENTRE SOUTH MOLTON HEALTH CENTRE WYCLIFFE SURGERY CHARD ROAD SURGERY BOUTPORT MEDICAL CENTRE NORTH ROAD WEST MED.CTR. SALTASH ROAD SURGERY NORTHAM SURGERY BUDSHEAD MEDICAL PRACTICE DEAN CROSS SURGERY REDFERN HEALTH CENTRE PATHFIELDS PRACTICE WYNDHAM HOUSE SURGERY NORTON BROOK MEDICAL CENTRE OKEMENT PRIMARY CARE CENTRE STOKE SURGERY EAST STREET SURGERY LISSON GROVE MEDICAL CTR. IVYBRIDGE HEALTH CENTRE WOODBURY SURGERY YELVERTON SURGERY ELM SURGERY HIGHLANDS HEALTH CENTRE ADELAIDE STREET SURGERY FRIARY HOUSE SURGERY WEST HOE SURGERY OAKSIDE SURGERY PEVERELL PARK SURGERY BEAUMONT VILLA SURGERY THE MANNAMEAD SURGERY CROWNHILL SURGERY NEW Devon Deep Dive- Summary Report daycase Area Reduction scenario Spend per 100,000 Difference with NEW Devon spend per 100,000 Saving opportunity Diving deeper into the details of the elective and daycase work reveals a number of variances in patterns when compared to the best five most similar CCGs; for example in Colonoscopies for Patients 19 Years and Over, NEW Devon CCG had a much higher number of diagnostic colonoscopies (with or without biopsy) and a much lower number of therapeutic colonoscopies than would be expected when compared with the pattern shown by the comparator CCG group. Similarly, for Diagnostic Endoscopic Procedures on the Upper GI Tract (19 years and over) only 45% of endoscopies for NEW Devon included a biopsy compared with 65% for the comparator CCGs. With cholecystectomies there was a much higher proportion of admissions that had complications and comorbidities recorded. Where there were no complications, NEW Devon CCG had a much higher proportion of admissions with a zero length of stay than its comparator CCGs. 6 In terms of both volume and cost, the HRGs with the greatest potential opportunities are: Abdominal Hernia Procedures 19 years Inguinal Umbilical or Femoral Hernia Repairs 19 years and over Major Therapeutic Open or Endoscopic Procedures 19 years and over Inflammatory Bowel Disease with length of stay 1 day or less Diagnostic Flexible Sigmoidoscopy 19 years and over Anal procedures (major, intermediate 19+, minor) The distribution of this activity at practice level is very variable; only crude rates are available at this level, but figure 11 clearly illustrates the wide range of rates per 1,000 for the HRGs listed above. If all practices reduced rates of this kind of work to lowest quintile, 2,269 daycase admissions could be saved, thus contributing substantially to the opportunities outlined in table 2 above. 7 Figure 11: NEW Devon crude rate of admissions for selected HRGs by NEW Devon CCGs Practice values CCG rate CCG top quintile 9

10 Provider opportunities Figure 12: Provider opportunities for gastrointestinal conditions Torbay and Southern Devon Health and Care NHS Trust South Devon Healthcare NHS Foundation Trust Royal Devon & Exeter NHS Foundation Trust Royal Cornwall Hospitals NHS Trust Plymouth Hospitals NHS Trust Northern Devon Healthcare NHS Trust 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 Emergency Readmission (14 day) Managing First Follow Up Outpatient Appointment DNA Reducing Length of Stay There are potential opportunities to increase value and patient experience by reducing the need for emergency readmission within 14 days to hospitals linked to NEW Devon CCG. For example if the readmission rate is reduced to the national best practice benchmark then potential 1,000,000 could be saved. Additionally there may be opportunities in reducing length of stay for patients admitted for a gastrointestinal condition. Outcomes Gastro-intestinal outcomes for NEW Devon patients are good, with the CCG ranked in the lowest quintile nationally for mortality from liver disease in the under 75s. This may in part be driven by relatively low problem drinking rates, which could impact significantly on incidence of liver disease, as evidenced by low rates of alcohol related liver disease admissions. 8 For this latter measure, NEW Devon is in the second lowest quintile nationally, and the alcohol specific mortality rate as shown in local alcohol profiles are the lowest in the region. Opportunities Primary prescribing Lower gastro intestinal primary care prescribing: between 692,000 and 1,561,000 Hepatobiliary primary care prescribing: between 26,000 and 213,000 Other gastro-intestinal primary care prescribing: between 777,000 and 2,426,000 and Oxfordshire CCGs are best in most similar 10 CCGs. Planned Care Reducing activity in lower gastro intestinal elective/daycase: between 791,000 and 2,146,000 Reducing Hepatobiliary outpatient spend: between 589,000 and 1,756,000 Other gastro-intestinal primary care prescribing: between 803,000 and 1,886,000 Reducing variation in GP admission rates for HRGs with the highest potential 10

11 Data sources Data source Time period Link Programme budgeting 2013/14 CCG Outcomes Indicator Set HSCIC CCG Prescribing data (FP10) HSCIC Lifestyle Statistics Hospital Episode Statistics (HSCIC) ONS Population Statistics 2013/ / / /15 (access by permission only) 2014/15 index.html?nscl=population 1 HSCIC Lifestyle Statistics 2 Programme Budgeting, ONS Population Statistics 3 HSCIC CCG Prescribing data (FP10) 4 Programme Budgeting 5 Programme Budgeting, ONS Population Statistics 6 Hospital Episode Statistics 7 Hospital Episode Statistics, Open Exeter 8 CCG Outcomes Indicator Set 11