Sustainable Care Pathways Guidance. Launch Event. 19 th October 2015

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1 Sustainable Care Pathways Guidance Launch Event 19 th October 2015

2 Sustainable Care Pathways Guidance Launch Event Agenda 2.00 pm Registration 2.15 pm Welcome and introductions Welcome and introductions Importance of sustainability in health The sustainable development strategy and care models NICE, care pathways and sustainability Louise Newport Sonia Roschnik Jennifer Watts 2.50 pm Care pathways guidance An overview of the CSPM Introducing the guidance Tom Penny Simon Aumônier & Michael Collins 3.15 pm Sustainable care pathway examples High dose haemodialysis: towards a more clinically effective & sustainable care pathway Why care pathways are interesting Julie Aspin Anne Gadegaard 3.45 pm Networking Time for questions and networking with attendees Canapes and drinks (alcoholic and non-alcoholic) are provided 5.00 pm Close

3 Sustainability and Climate Change why it matters for health Dr Louise Newport Sustainable Care Pathways launch, 19/10/2015 1

4 Sustainability - balancing social, economic and environmental needs A health and care system (in the widest sense!) that operates within existing resources and does not deplete those of future generations Environmental sustainability: Living within planetary limits Social sustainability: Healthy and resilient people and communities Health Economic sustainability: Fair and sustainable economic system 2 Sustainability and Climate Change - why it matters for health

5 The UK Government s commitments to sustainability legislation and policy Local Government Act 2000 power for local authorities to do anything which they consider is likely to promote or improve the economic, social or environmental wellbeing of their area DPHs, SC The Climate Change Act 2008 committed the UK to steep reductions in greenhouse gases and set up the independent Committee on Climate Change Public Services (Social Value) Act 2012 requires public authorities in public procurements to consider how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area Welsh Government Well-being of Future Generations (Wales) Act 2015 world first to encompass and consider CC and sustainability in all future policy making. The UN Framework Convention on Climate Change, Paris, Dec. with the goal of producing a legal treaty. The Sustainable Development Goals agreed and taken seriously ensure healthy lives and promote well-being for all at all ages [goal 3] 3 Sustainability and Climate Change - why it matters for health

6 Why sustainability matters particularly to the Department of Health We face a number of strategic challenges for a sustainable health and care system - making the books balance, financially, socially and environmentally. For example: Financially ensuring the health and care sector delivers ambitious efficiency savings, whilst Socially improving quality and safety of care, and Environmentally reducing impacts from climate change Sustainability provides a different lens through which to identify solutions 4 Sustainability and Climate Change - why it matters for health

7 We face a challenge from climate change Increased heat-related illness, skin cancer, sunburn and death from respiratory and cardiovascular disease. The 2003 pan-european heatwave caused 70,000 deaths across Europe and 2000 deaths in England and Wales this would be a normal summer by Flood-related illness, mental health and displacement From 2007 summer floods, a 2-5x increase in mental health symptoms seen in flood victims. Increase in food, water and vector-borne diseases Climate-sensitive diseases - Dengue and malaria have migrated up into Southern Europe UK vectors now seen. Health impacts relating to air quality and aeroallergens Increased ozone exacerbating asthma and 12x increase in pollen including from invasive plant species. Pressure on healthcare providers to keep services running in extreme weather Currently 90% of hospital wards are at risk of overheating and 6-8% of hospitals, care homes and surgeries at risk to river and coastal flooding Climate Change risks undermining the last half century of health gains [Lancet Commission on Climate Change and Health] 5 Sustainability and Climate Change - why it matters for health

8 But we also have a strong health business case for action Model Hospital NHS Energy Efficiency Fund The 50m NHS Estates Efficiency Fund is on track to deliver savings of 100.6Mkg of carbon dioxide per year and some 2.4% of the entire 2012 NHS building energy related carbon footprint. Savings for this project will add up to 69.8m in the first five years of operation [Lord Carter s interim report, June 2015, p13] Procurement - 9bn of NHS expenditure area of focus for Lord Carter 6 Sustainability and Climate Change - why it matters for health

9 But we also have a strong health business case for action Active Travel James Jarrett, James Woodcock, Ulla K. Griffiths, Zaid Chalabi, Phil Edwards, Ian Roberts, Andy Haines Lancet Sustainability and Climate Change - why it matters for health

10 But we also have a strong health business case for action Barts and the London 8 Sustainability and Climate Change - why it matters for health

11 But we also have a strong health business case for action Nottingham University Hospitals NHS Trust 9 Sustainability and Climate Change - why it matters for health

12 But we also have a strong health business case for action - Integrated care for an ageing population - Severe floods in 2009 in Cockermouth, Cumbria, acted as a catalyst to integrating health and social care services. - A new hub for healthcare in the community was established called Centre for the Third Age, with co-location of GP surgeries and community services with referral services geared to meet patient needs. - The centre offers a range of support services in one place including advice on benefits, supported discharge from hospital, friendship groups and help at home. - The result has been improved cooperation between health services, the third sector and the community. By supporting independence and improving overall health and wellbeing for the elderly, hospital admissions and associated costs have been reduced. 10 Sustainability and Climate Change - why it matters for health

13 Our goal: save carbon and reduce costs, whilst improving care An early example of putting figures on: - money saved - environmental harm reduced - health improved. g.uk/infographic 11 Sustainability and Climate Change - why it matters for health

14 Summary: Why we all need to take sustainability seriously? To save money don t break the bank To comply with regulations and law - don t break the law To adapt to change, manage risk to improve resilience To engage staff, public, and partners positively to add social value To take appropriate action in the face of scientific evidence to be ethically responsible organisations To improve health, and reduce inequalities, now and in the future core health business 12 Sustainability and Climate Change - why it matters for health

15 This is just the start Greening Health Systems Sustainable care pathways Prevention focus To a sustainable future! Thank you. Louise.newport@dh.gsi.gov.uk 13 Sustainability and Climate Change - why it matters for health

16 Sustainable Development Strategy New Models of care Sonia Roschnik Sustainable Development Unit 19 th October

17 A health issue?

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19 The Public s view Ipsos MORI 2011 and % thought it important or very important for health system to be more sustainable 36% said it should even if cost more money

20 Cross system support

21 A sustainable health and care system Reduce the negatives Enable the positives

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23 A sustainable system that protects and improves health within environmental and social resources now and for the future Vision for sustainable health and care

24 Goal 1 A healthier environment

25 Goal 2 Communities and services are resilient to changing times and climates

26 Goal 3 Every opportunity contributes to healthy lives, communities and environments

27 Care model for a healthy life

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31 Thank you

32 Sustainable Care Pathways Jennifer Watts, Associate Director Adoption and Impact Programme National Institute for Health and Care Excellence

33 The NICE portfolio in 2015 Adoption and Impact Clinical practice Social care Medtech NICE New drugs Public health QOF indicators Quality standards CCGOIS indicators

34 NICE Guidance by Year

35 Adoption and Impact Support from NICE Adoption team (formerly known as HTAP) identifies ways to overcome potential barriers to the implementation of NICE guidance 10 resources published Impact team request, analyse and provide data to inform the scope, development and review of guidance measure the uptake of NICE guidance Resource Impact Assessment team produce commentaries and templates with indicative resource impact information for all NICE guidance

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37 Medical Technologies Guidance Address specific technologies notified to NICE by manufacturers. The case for adoption recommendations are based on the claimed advantages of introducing the specific technology compared with current management of the condition. This case is reviewed against the evidence submitted and expert advice. If the case for adoption is supported, it has been found to offer advantages to patients and the NHS.

38 Selection Criteria Claimed additional benefit to patients Claimed healthcare system benefit Patient population Disease impact Cost considerations Sustainability Is the technology likely to contribute to the sustainability agenda, e.g., less energy usage or less waste generation during production or clinical usage?

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41 Insights from the NHS The costing template identified savings by: reducing the cost of patient warming (device and equipment costs) reducing the number of surgical site infections In practice trusts demonstrated: a larger reduction in the use of forced air warming than those estimated in the costing template cost savings without including a reduction in surgical site infection rates. HOW?

42 Sustainability Reusable device with no consumables needed Eradication of need for purchase and disposal of single use blankets for forced air warming Reduction in electricity compared with forced air warming The Pennine Acute Hospitals NHS Trust projected a reduction in spending on disposable blankets of 27,131 in the first year They saved 56,000 in the first six months

43 Conclusion NICE guidance can support and promote the sustainability agenda This may not be automatically captured during the guidance development process and may not always be obvious But sometimes it is

44 Coalition for Sustainable Pharmaceuticals and Medical Devices (CSPM) Tom Penny, 19 th October 2015

45 NHS Carbon Footprint

46 CSPM Overview Formed in early 2012 Consortium of health related organisations Mechanism for driving change bringing parts of the system together and working collaboratively SDU acts as secretariat International reach

47 CSPM Members

48 Coalition Objectives Acting as the convenor of expertise related to sustainable pharmaceuticals and medicals devices and disseminate best practise throughout the healthcare system globally. Developing tools and guidelines to support the system in achieving more sustainable healthcare products and services through a holistic life cycle sustainability approach. Monitoring and updating existing tools and guidelines developed by the coalition to ensure their applicability (eg carbon footprint guidance).

49 Carbon Footprint Guidance Aimed to support consistent quantification of the carbon footprint of pharmaceutical products and medical devices Guidelines launched in November 2012, internationally focussed and freely available

50 Further Guidance Need to understand environmental impacts of services and how products are used Investigate the sustainability of new models of care and promote prevention

51 Care Pathways: Guidance on Appraising Sustainability Simon Aumônier Michael Collins 19 th October 2015 The world s leading sustainability consultancy The world s leading sustainability consultancy

52 What is the guidance? Freely available guidance allowing interested parties to investigate and understand the sustainability aspects of healthcare pathways globally Enable sustainability considerations to be more easily taken into account in a transforming global healthcare system Design new sustainable care pathways Optimise existing care pathways 2 The world s leading sustainability consultancy

53 How was it developed? INITIATED BY CSPM MEMBERS: CONVENING BODY AND AUTHOR: CSPM ADVISORY MEMBERS STAKEHOLDER EXPERT GROUP The world s leading sustainability consultancy

54 How was it developed? PROJECT MILESTONES Workshops with stakeholders to determine scope Collection of example data for each module to facilitate care pathway appraisals Two drafts of guidance documents Consultation with stakeholders & CSPM members DATA PROVIDERS Airedale Hospital NHS Foundation Trust: Frank Swinton. Barts Health NHS Trust: Fiona Daly. Cambridge University Hospitals NHS Foundation Trust: Richard Hales. Centre for Sustainable Healthcare: Frances Mortimer. Guy's and St Thomas' NHS Foundation Trust: William Holden. Hull and East Yorkshire Hospitals NHS Trust: Marc Beaumont. Leicester General Hospital: Bernie Stribling. Northampton General Hospital NHS Trust: Clare Topping. Royal College of Nursing: Mark Platt. South East Coast Ambulance Service NHS Foundation Trust: Julia Brown. North East Ambulance Service NHS Foundation Trust: Clare Swift. Northern Lincolnshire and Goole NHS Foundation Trust: Sally Yates and Johal Jug. St. George's Healthcare NHS Trust: Wilfred Carneiro. Sustainable Development Unit: Imogen Tennison and Sonia Roschnik. DATA COLLECTION Trucost The world s leading sustainability consultancy

55 Who can use it? patients policy makers and regulators healthcare providers suppliers sustainability practitioners To understand and improve the sustainability of health care and to inform the development of new models of care 5 The world s leading sustainability consultancy

56 What s included? Main Document Section 1: Introduction to care pathways guidance Section 2: Common principles applicable to all modules Section 3: Reporting recommendations Module Documents: specific guidance for a selection of distinct healthcare activities A care pathway is a complex intervention for the mutual decisionmaking and organisation of care processes for a well-defined group of patients during a well-defined period. A care pathway module describes one or more distinct health carerelated activities performed for, on behalf of, or by a patient. 6 The world s leading sustainability consultancy Care pathway modules are the building blocks which make up the total care pathway.

57 Steps to appraising a pathway Define the care pathway Define the unit of analysis Create a detailed map of the activities/modules required Complete a materiality assessment Appraise each module (using example data where appropriate) Add the modules together Interpret and report the findings GP visit x1 In patient x1 Surgery x1 Hospital bed day x3 Out patient x1 Care pathway 7 The world s leading sustainability consultancy

58 Modules GP Consultation Patient Travel Emergency Department Visit Inpatient Bed Day Surgical Procedure Self Management 8 What to include and how Consumables Equipment Pharmaceuticals Building energy, waste and waste Staff travel Patient and visitor travel Medical gases The world s leading sustainability consultancy Environmental Impacts GHG emissions Fresh water use Waste generated

59 Modules. Calculation steps: How to calculate impacts Activity Data: Generic data collected from Trusts Emission Factors Metrics: estimates of GHG, water & waste Priority Areas: Identifying hotspots & activities to improve sustainability 9 The world s leading sustainability consultancy

60 Module results Module Units GHG Fresh Waste emissions water use generated (kg CO 2 e) (m 3 ) (kg) GP Consultation per visit Patient Travel to GP per trip x to elective care per trip x emergency per trip Emergency Department per visit Inpatient Admission low intensity per day high intensity per day Surgical Procedure per surgery The world s leading sustainability consultancy

61 Module hotspots: where to target 11 The world s leading sustainability consultancy

62 What s next? Case studies Develop guidance for more modules Expand to address more impacts (social, environmental and financial) 12 The world s leading sustainability consultancy

63 Questions? Simon Aumônier Principal Partner E simon.aumonier@erm.com Michael Collins Technical Director E michael.collins@erm.com The world s leading sustainability consultancy

64 High Dose Haemodialysis: Towards a more Clinically Effective & Sustainable Care Pathway Julie Aspin Sustainability Manager EMEA Region Catherine Holton Home HD Product Manager Margaret Enos Product Stewardship Manager October 19 th 2015 UK/MG76/

65 Kidney Failure and End Stage Renal Disease Increasing rates of obesity and an ageing UK population mean the number of kidney failure patients is increasing by around 4.5 per cent each year 1 Around 41,000 people are affected by kidney failure in the UK with more than half this number receiving dialysis 2 Conventional Haemodialysis (HD) is an established therapy for individuals with end-stage renal disease 3 1. Kidney Disease : Key Facts and Figures NHS Kidney Care September NHS Choices Dialysis 1/10/ Accessed October 30 th Pauly P et al 2009 Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients NDT 24:

66 Increasing the frequency, along with the duration, of haemodialysis could improve patient outcomes compared to conventional Haemodialysis High Dose HD: No consecutive days without dialysis 1 For SDHD, a minimum of 5 treatment days per week A weekly minimal standard Kt/V urea of Several retrospective, observational studies indicate a survival benefit with High Dose HD compared with conventional haemodialysis Foley RN et al. N Engl J Med 2011; 365: , 2. Chertow G et al. N Engl J Med 2010; 363: Blagg CR, et al. Hemodialysis Int. 2006;10: Kjellstrand CM, et al. Nephrol Dial Transplant. 2008;23: Johanson KL, et al. Kidney Int. 2009;76: Marshall MR, et al. Am J Kidney Dis. 2011:58: Nesrallah GE, et al. J Am Soc Nephrol. 2012;23: Weinhandl ED, et al. J Am Soc Nephrol. 2012;23:

67 Towards a more Sustainable Pathway: IMPROVED PATIENT OUTCOME High Dose Haemodialysis for better survival rates 4

68 Although High Dose HD can be Performed In-Centre, additional benefits may be recognised in the Home Flexible dialysis schedule Less travel to and from centre More time for family and daily activities More time available for work or school Less nursing resource use National Health Service. Dialysis advantages and disadvantages. Jul, Available at: 5

69 Towards a more Sustainable Pathway: IMPROVED PATIENT OUTCOME High Dose Haemodialysis for better survival rates + IMPROVED PATIENT QUALITY OF LIFE 6

70 Vivia Haemodialysis System To be launched in 2015/16 in 4 European countries Key Feature - designed to make High Dose Haemodialysis accessible to more patients at home Patient usability/patient friendly features Has the flexibility to meet patient needs e.g. can transition from SDHD to NHD one day to the next without making any changes to the machine or its disposables Connected remotely via Sharesource to give the clinic access to the treatment data Auto-cleaning and disinfection allows various consumables, that would typically be discarded after a standard therapy, to be used across multiple treatments Built in water purification system streamlines the process for delivering therapy 7

71 Understanding the Carbon Footprint of Treatment with Vivia Product or Pathway in Renal Care? Our study assessed the cradleto-grave therapy, including the consumables, electricity and water use during treatment, patient and staff travel, and waste disposal Manufacturing of the HD machines was excluded (used for many treatments throughout its lifetime) Energy, water Materials/ chemicals Primary packaging materials Treatment profile: 3 hours per day for 5.5 days per week System boundary Dialysate solution Electricity Water Tubing sets Wastewater treatment T Use phase (patient home) Dialyzer T T Non-hazardous waste recycling, landfill, and incineration Water treatment supplies Consumables Doctor Maintenance Secondary packaging materials Production waste 8

72 Quantifying the technological advancement of Vivia Quantified by: Utilising life cycle thinking to scope the therapy into a yearly carbon footprint Develop a calculator to allow modelling of various treatment regimes for three different machines: Modelled various treatment regimes in GaBi 6 Software Device Name Manufacturer Type of Machine Vivia Baxter HHD - Competitor HHD Arena Baxter ICHD Baxter deconstructed supplies into individual constituents, measured or calculated the energy and water usage to obtain primary data for all 3 machines 9

73 Carbon Impact Analysis for treatment with Baxter ICHD machine vs. Vivia across different treatment regimes 5,000 4,000 kg CO2-Equiv. per year 3,000 2,000 1,000 Waste Treatment Patient and Staff Travel Treament Tap Water Treatment Electricity Consumables Distribution Consumables Production 0 Data on file VIVIA VIVIA ARENA at Home ARENA at Home Short Daily HD Nocturnal HD CHD ARENA In- Center 10

74 Summary of Results Emissions related to consumables consistently account for the largest contribution to the overall carbon footprint of haemodialysis therapy Removing patient transport from the haemodialysis treatment pathway removes over 1 tonne of CO2/patient/year Technological advances to redesign machines for the right environment can play a role in reducing environmental footprint there are carbon footprint reductions of around 1/3 when machines specifically designed for home-use are used for SDHD or NHD, instead of repurposed in-centre machines Energy use of the device is important, but simplistic procurement criteria focusing on particular environmental impacts can sometimes miss the bigger picture 11

75 Towards a more Sustainable Pathway: IMPROVED PATIENT OUTCOME High Dose Haemodialysis for better survival rates IMPROVED PATIENT QUALITY OF LIFE + + REDUCED CARBON FOOTPRINT Innovation that reduces the environmental impact of treatment = A more Sustainable way of delivering Haemodialysis 12

76 Questions? Presentation References: Kidney Disease : Key Facts and Figures NHS Kidney Care September 2010 NHS Choices Dialysis 1/10/ Accessed October 30 th 2014 Pauly P et al 2009 Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients NDT 24: Foley RN et al. N Engl J Med 365: , 2011 Chertow G et al. N Engl J Med 363: , 2010 Blagg C et al. Haemodialysis International. 2006; 10; 71-4, Kjellstrand CM et al. Nephrol. Dial. Transplant. 2008: 23: , Johansen KL et al. Kidney Int. 2009: 76:984-90, Marshall M et al. Am J Kidney Dis. 2011; 58:782-93, Nesrallah G et al. J Am Soc. Nephrol. 2012:23 Weinhandl E et al. J Am Soc Nephrol. 2012:23 National Health Service. Dialysis advantages and disadvantages. Jul, Available at: Data on file 13

77 Why care pathways are interesting Guidance launch Anne Gadegaard, Programme director 19 October 2015

78 Novo Nordisk - a focused, biotech-based healthcare company Sustainable Care Pathways - Guidance Launch 19 October Key facts A focused health care company with leading positions in diabetes care, haemophilia care, growth hormone therapy and hormone replacement therapy Significant growth opportunities driven by diabetes pandemic, matched by global presence, broad product portfolio and strong R&D pipeline Headquartered in Denmark, more than 41,000 employees in 75 countries, with products marketed in 180 countries Serves more than 24.4 million people with its diabetes care products Global leader in diabetes care Global insulin market share value: 27% North America: Market share 37% Europe: Market share 46% International Operations: Market share 47% Japan & Korea: Market share 52% China: Market share 55% Values-based management, guided by the Novo Nordisk Way and the Triple Bottom Line business principle Global/regional headquarter Manufacturing R&D facility Source: IMS Health, IMS MIDAS Customized Insights, November 2014

79 Sustainable Care Pathways - Guidance Launch 19 October Few patients achieve desired outcomes Novo Nordisk has embraced Rule of Halves (ROH) theory to help advance awareness and understanding of diabetes prevalence, and the need for better screening and treatment to ultimately help more patients achieve desired outcomes

80 Sustainable Care Pathways - Guidance Launch 19 October Case study: Introduction Type 2 Diabetes Management Care Pathway Two scenarios have been investigated comparing good management of type 2 diabetes (considered as maintaining a glycated haemoglobin level, HbA1c, of 6.5%) poor management (considered as maintaining a glycated haemoglobin level, HbA1c, of 8.4%) for the lifetime of the patient Illustration of the overall diabetes care pathway Lifelong risk of diabetes complications such as renal failure, cardiovascular diseases, vision lose, foot ulcer and amputations. Complications contribute to an earlier death and decrease in quality of life Complications are correlated with known risk factors such as blood glucose levels, BMI and blood pressure End of life Cardiovascular complication such as stroke or MI Unhealing ulcer and potential amputation Diabetic ulcer Background retinopathy Neuropathy Epidemiological facts Today Illustrative example (1) Diabetes UK, Diabetes: Facts and Stats, April2014.pdf, March 2014NN

81 Sustainable Care Pathways - Guidance Launch 19 October Case study: Conclusion Type 2 Diabetes Management Care Pathway The GHG emissions associated with good management are 1,740 kg CO 2 e for the lifetime of the patient the poor management scenario has a total lifetime cost of 1,787 kg CO 2 e By 2025, an estimated nearly 5 million people in the UK will have type 2 diabetes (1) and extrapolating the findings, good management of diabetes will have an estimated GHG impact of 640,000 tonnes CO 2 e per year (1) Diabetes UK, Diabetes: Facts and Stats, April2014.pdf, March 2014NN

82 Sustainable Care Pathways - Guidance Launch 19 October Case study: Conclusion Type 2 Diabetes Management Care Pathway

83 Sustainable Care Pathways - Guidance Launch 19 October

84 For more information: novonordisk.com/sustainability twitter.com/novonordisktbl