Oldham Doing It D ifferently

1. OldhamDoing It Differently Dr Hugh Sturgess Director, Pennine MSK Partnership

2. Context • New White Paper • Root and branch reform of NHS in England • Unprecedented financial challenge for NHS • Deep seated failings in the NHS • Model of Care • System of Care

4. What’s wrong with the system? • System of Care • “Disintegration!” • Micro-commissioning complex pathways • Perverse incentives – PbR • KPIs process driven not population level improvement or patient experience • No effective performance management of care

5. Variation in MSK Spend

6. Programme Budget Commissioning • Different from standard approach • Commission with the lead accountable provider for defined programmes of care with a defined budget • Commissioners have population quality based KPIs • Lead accountable provider shares responsibility for care co-ordination, quality and performance management across the entire pathway

7. One thing I have always found is that you have got to start with the customer experience and work backwards to the technology. Steve Jobs 1955-2011

8. Patients want more involvement 9

9. Analysis: Satisfaction with Total Knee Replacement (NJR) • Satisfaction questions were completed by 8095 patients • Overall -81.8% were satisfied -11.2% were unsure -7.0% were not satisfied • The OKS varied according to patient satisfaction (p<0.001) Source: National Joint Registry

11. Challenges • Lack of faith in new system • Lack of interest/support from grass root GPs • Dismantle existing systems • Financial instability • Threat of competition • Ageing population, more expensive treatments, increasing co-morbidities and LTCs • Lack of integrated care • Much spoken of – hardly ever delivered • Need to shift investment from Acute trusts to community and primary care

12. Oldham

13. Pennine MSK Partnership • Primary Care based organisation commissioned by NHS Oldham to provide non admitted care in rheumatology, orthopaedics and chronic pain • Consultant led – provide 97% rheumatology and take patients to point of listing in Orthopaedics • From May 2011 control £23m programme budget for MSK using prime vendor model • Psychological medicine for chronic pain • 11,000 new referrals a year • Deliver traditional hospital based services from community – biologics and infusions • GP and Specialist training • Research

14. Primary care holistic assessment and care Highly specialised, intensive, episodic hospital care Referral triage SUBCONTRACTING • Hub functions: • Referral triage • Skilling up 1’ care • Specialist Assessment • Specialist integrated care • Shared Decision Making • Personal Health Planning • Supported Self Care • Patient & carer support • Voluntary sector provision • PATHWAY MANAGEMENT Referral COMMUNITY MULTIDISCIPLINARY SPECIALIST SERVICE (Pathway Hub) Prime contractor

15. NHS Oldham ProgrammeBudget • MSK - £23m - Pennine MSK 1stMay 2011 • Primary Care • Local enhanced services • Community Care • Pennine MSK • Physiotherapy, podiatry • Secondary Care • All activity included

16. Outcomes Of ProgrammeBudget • We are incentivised to performance manage the entire pathway • Invest in Shared Decision Making and Self Management • Work with primary care to reduce variation • Work with secondary care to ensure best practice is followed • Work with commissioner – high value care within budget

17. Delivering Integration • Commissioner will focus on clinical outcomes rather than process metric • Patients at the centre of our redesign • Work with third sector • Use self management and self referral were clinically appropriate

18. Challenges and Opportunities • Acute Trust attitude • Change in commissioning • Financial constraints • GP support • Initial suspicion • Wider support as triage spreads to all referrals • Clinician support

19. Knee Pathway (O/A)

20. Shared Decision Making • Tested and Implemented the AQuA model past 2 years • Looked at impact of implementing SDM on patient reported outcomes for those who have had knee arthroplasty, year before implementation compared to the two years since • Already know SDM results in patient expectations being more realistic • High dissatisfaction in knee arthroplasty (19% of patient ambivalent about or regret surgery) • Joint project with NHS England

21. Shared Decision Making Implementation • Developed and trialed the NHS patient decision aids • Staff training • Organisation changes – standard board reports, staff induction, measuring decisional conflict • Patient empowerment – Ask three questions • AQuA collaborative • All patients: • Given A3Q leaflets • Signposted to PDAs • All front line staff trained in SDM, many in Motivational Interviewing too

22. Better Health Outcomes • Used Patient Reported Outcome Measures (PROMs) data on EQ-5D index to show: • Oldham’s knee replacement patients received an average health gain of 0.27 in 2009/10 and 0.35 by 2011/12. • A statistically and clinically significant increase in Oldham’s patients health outcomes. • The England average health gain was 0.30 throughout the period. • Period of improvement matches the introduction of SDM. • Involving patients in decision to treat appears to lead to better outcomes. • Treated increasingly sicker patients in Oldham, but restored to same good health level. • Improvement delivered within financial constraints in period with: • Arthroscopies growing at 8% in Oldham compared to 12% nationally. • Musculoskeletal spend per head decreasing by £10 in Oldham compared to an increase of £10 nationally.

23. Pennine MSK Impact Reducing per capita cost whilst maintaining quality

24. Pennine MSK Impact Reducing per capita cost whilst maintaining quality

25. Thank You Dr Hugh Sturgess Tel: 0161 628 3628 Mob: 0780 893 7788 E-mail: hugh.sturgess@nhs.net