Clinical Directors Forum

1. Clinical Directors Forum Donal O’Donoghue National Clinical Director

2. The Challenges • For the NHS • For Renal Medicine • For you as Clinical Directors

3. During the recession, government expenditure has continued to grow whilst receipts have fallen: Expenditure • Highest spending since 1982–83 • Lowest tax burden since 1960–61 • Highest borrowing since WWII £154bn borrowing last year Receipts

4. The Macro Challenge • The Nicholson challenge • The cost of liberation • No decisions about me without me • Quality, Innovation, Productivity and Prevention

5. Change in real current spending The challenge is immense: “Quality, Innovation, Productivity and Prevention (QIPP) productivity gains… will release up to £20 billion more funding into frontline services for patients over the four years [2011/12 to 2014/15].” (The Operating Framework for the NHS in England: 2011/12, December 2010) “But this will not protect the NHS from the need to secure efficiency savings and to control pay and prices in the NHS. If we can secure those efficiency savings, we can reinvest them in the NHS to deliver improving outcomes for the public.” (Secretary of State, Today, May 2010)

6. Focus on quality retained following the change of government… “Building on Lord Darzi’s work, the Government will now establish improvement in quality and healthcare outcomes as the primary purpose of all NHS- funded care” NICE Quality Standards, Quality Accounts, CQUIN, measuring for quality improvement, the National Quality Board are all key features of the new system

7. Equity and Excellence: Liberating the NHS set out a vision of a NHS that achieves amongst the best outcomes of any health service in the world. To achieve this, it outlined two major shifts: • A move away from centrally-driven process targets which get in the way of patient care; • A relentless focus on delivering the outcomes that matter most to people “All too often, the NHS has been hamstrung by a focus on nationally determined process targets which have had a distorting effect on clinical priorities, disempowered healthcare professionals and stifled innovation. We need to recalibrate the whole of the NHS system so it focuses on what really matters to patients and what we know motivates healthcare professionals – the delivery of better health outcomes.” Transparency in Outcomes- a framework for the NHS July 2010 But, an important shift in focus towards outcomes…

8. GOAL: Aligned outcomes frameworks for the NHS, public health and adult social care

9. The NHS Outcomes Framework will set direction and provide enhanced accountability The framework will be organised around 5 national outcome goals / domains covering the breadth of NHS activity How EFFECTIVE the care provided by the NHS is What the patient EXPERIENCE is like How SAFE the care provided is These will help the public and Secretary of State for Health to track: Domain 1 Preventing people from dying prematurely Effectiveness Domain 2 Enhancing quality of life for people with long-term conditions Domain 3 Helping people to recover from episodes of ill health or following injury Domain 4 Ensuring people have a positive experience of care Patient experience Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Safety

10. THE NEW QUALITY LANDSCAPE: How will the NCB deliver the NHS Outcomes Framework? • How to make change happen in the new system will feel very different. • Even though many of the levers remain, top down performance management of providers or commissions won’t be a feature of the new system. • There will be noNHS Headquarters - this is not the role of the NHSCB. • The focus on outcomes will require a far more sophisticated accountability model than we have had in the past. • Unlike process measures where it is easier to make black and white judgements about performance, outcome measures are far more complex to understand and interpret - this is a good thing as it will require real understanding of the issues • There will be a temptation to pull every available lever in an attempt to affect change – the reforms, however, are about liberating the intrinsic motivators of staff to deliver high quality care and better outcomes

11. The QIPP programme is supporting the NHS to meet the challenge Areas covered by Quality, Innovation, Productivity and Prevention (QIPP) programme Characteristics of a sustainable system: Supporting commissioners to commission for quality and efficiency – e.g. through improved clinical pathways, decommissioning poor value care Care closer to home Earlier intervention Fewer acute beds Provider efficiency – supporting providers to respond to the commissioning changes and efficiency pressures by transforming their businesses More standardisation Empowered patients Reduced unit costs Shaping national policy and using system levers to support and drive change e.g. primary care contracting & commissioning

12. Commissioning and pathways • Back Office Efficiency and Optimal Management • Procurement • Clinical Support Rationalisation (Pathology) • Productive Care • Medicines Use and Procurement • Safe Care System enablers Thirteen national QIPP workstreams will help local organisations respond to this challenge: • Right Care • Long Term Conditions • Urgent Care • End of Life Care Provider efficiency • Primary Care Contracting and Commissioning • Technology and Digital Vision • Workforce

14. The Speciality Challenge • The kidney care quality landscape • Renal QIPP • Integrated Care and AWP • Planning and uncertainty

15. NICE quality standard for CKD • Testing for CKD • Progression • Referral • BP control • Anaemia management • AKI risk management • Personalised information • AV fistula • Immunisation • HCAIs reduced • Transport for HD • Pre-emptive transplants • Care planning • Conservative kidney care

16. CQUINs The Commissioning of Quality and Innovation (CQUIN) payment framework are one way to achieve quality: The renal CQUINS cover acute kidney injury and home dialysis. The indicators of quality that have been chosen are: • Percentage of emergency admissions to have both 1. physiological scoring performed to identify patients at high risk of clinical deterioration (eg MEWS score) and 2. senior review (consultant or equivalent within 12 hours of admission). • Percentage of emergency admissions with a major risk factor for AKI to have both: 1. medication review and 2. serum creatinine re-checked within 24 hours of admission. • Percentage of patients requiring maintenance dialysis to be receiving home haemodialysis, peritoneal dialysis or assisted automated peritoneal dialysis.

19. Dialysis transport savings year after Sept 2009

20. Impact Quality: Patient complaints reduced 12 patients came off ambulance transport Productivity: • Number of journeys reduced by approx 33% • Number of patients requiring transport reduced from 51% to 34% Savings: • Cost savings in one kidney centre: £158,224 • Potential National savings: £25,500,000 • Transport costs reduced • Overall Service improvement

21. Chronic kidney disease: e-consultation Provided by: Bradford Teaching Hospitals NHS Foundation Trust NHS Evidence assessment of the degree to which this particular case study meets the criteria is represented in the evidence summary graphic:

22. Giving intravenous iron in patients homes and community hospitals Provided by: Royal Cornwall Hospitals Trust QIPP Evidence provides users with practical case studies that address the quality and productivity challenge in health and social care. All examples submitted are evaluated by NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria of savings, quality, evidence and implementability; each criterion is given a score which are then combined to give an overall score. The overall score is used to identify the best examples, which are then shown on NHS Evidence as ‘recommended’ or ‘highly’ recommended’.

23. Integrated Care:

24. AWP – Any Willing Provider …

25. Planning …

26. %HHD prevalence in dialysis popn 2008 Variation in Home Haemodialysis: Adapted from Renal Registry 12th Annual Report 2009

27. Shared Decision Making: “is a fundamental part of care planning and promotes the best choice in what otherwise can be a complex and overwhelming situation.” The care team communicates to the patient personalised information about the options, outcomes, probabilities and scientific uncertainties of the various treatments. The patient communicates his or her values and relative importance he or she places on the potential benefits and harms.

28. The Front Line Challenge • How will Best Practice Tariff Work? • Organising complex non-RRT Care • Activating Patients • Motivating and energising staff

29. Timely Vascular Access Standard 3“All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

30. The haemodialysis tariff covers a session of dialysis, defined as each session of dialysis treatment on a given day for each patient:

31. The peritoneal dialysis tariff prices cover a day of treatment:

32. Assisted APD - Now • There is currently no capacity to differentiate between APD and assisted APD in the new chapter LD HRG. • Therefore both aAPD and APD activity will result in the generation of an APD HRG with its associated National Tariff. • For the next 12 months it will be necessary to agree locally the commissioning and re-imbursement for the ASSISTANCE portion of the costs, and a means of communicating this activity.

33. Assisted APD – proposed HRG solution • The items in the current NRD which define the current HRG include separately; • Modality (CAPD, CCPD, Haemodialysis) • Supervision (Hospital, Satellite, Home, Shared) • The supervision is currently used to differentiate Home from Satellite and Hospital HD in HRG. • In the future it is proposed to use the currently un-used “Shared” supervision code to differentiate • Assisted APD (CCPD+Shared) • Self administered APD (CCPD+Home)

34. Assisted APD – HRG timescale • A request will be made in May 2011 to revise the current HRG to include aAPD. • The modest change requested, and the existing items in the NRD make it likely to be a quick modification. • In preparation providers can collect data on aAPD using the future (CCPD+shared) scheme now if they wish. • The current HRG grouper ignores supervision if the modality is CCPD so it will still result in the same APD HRG, but will allow immediate transition to the new HRG when these are released.

35. Elements required to collect data • The ideal is • A close to real-time record of individual HD treatment sessions for all unit HD patients which includes the access used for the individual treatment session, and the dialysis location (hospital or satellite). • An electronic treatment prescription which a patient will be self administering if doing a home therapy (CAPD, CCPD, HHD) containing a minimum of modality and the number of delivered treatments per week. • An electronic record of a patients blood borne virus status (mimimum = positivity to one or more of HepBsAg, HepCAb, HIV test) for all unit HD patients. • An electronic record of the patients age (<19 v.s >=19yrs).

36. Data flow NRD Source extracted from renal unit clinical computer system .csv file passed through local grouper to convert codes to HRG Finance divide activity by PCT Provider invoice for activity by HRG Finance also provide patient level Data as part of contract for assurance PCT pay provider for activity

37. Data flow NRD Source extracted from renal unit clinical computer system ICD-10 and OPCS Source extracted from hospital PAS .csv file passed through local grouper to convert codes to HRG Finance divide activity by PCT Provider invoice for activity by HRG Finance also provide patient level Data as part of contract for assurance PCT pay provider for activity

38. Data flow NRD Source extracted from renal unit clinical computer system ICD-10 and OPCS Source extracted from hospital PAS .csv file passed through local grouper to convert codes to HRG Finance divide activity by PCT NRD data remain in the grouper output file Provider invoice for activity by HRG aAPD identified using NRD codes rather than HRG Finance also provide patient level Data as part of contract for assurance Invoice for aAPD PCT pay provider for activity

39. Data flow NRD Source extracted from renal unit clinical computer system ICD-10 and OPCS Source extracted from hospital PAS Data submitted to SUS for grouping .csv file passed through local grouper to convert codes to HRG Provider and commissioner both review same activity data in SUS Finance divide activity by PCT Provider invoice for activity by HRG Finance also provide patient level Data as part of contract for assurance PCT pay provider for activity

40. Outpatient attendance tariffs:

41. Community Health System Health Care Organisation Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes Chronic Care Model

42. www.renalpatientview.org

44. "If there is one lesson to be learnt, it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks that matter".