Will You Be Working
Like This in 2014?
Dr. John Navein
Director
The Modernising Healthcare Partnership
Unplanned
Medical
Medical
Surgery
Diagnostics
ITU
Minors
Outpatients
A&E
Minors Emergency A&E
Money April 2003
Primary
Care Trust
(70% of NHS
Budget)
50-100
Practices
Acute Trust
It’s Not the Technology!
•Quality
•Service
•Clinical Networks
Delivering the
NHS Plan •Integrated Care
•Seamless
Next Steps on Investment
Next steps on return
•Standards
•Resources
Doing what we do -
only better
NHS
o Estimated 850,000 adverse events in NHS
hospitals (range 300K – 1.4M)
£2Bn in direct costs alone; half avoidable
Contributory cause in 11% of admissions
o 25% OPD tests have been ordered in
the previous 30/7 by the GP
Internal audit Arrowe Parke Hospital
o 35-50% of top 6 path tests of no clinical
value
Harvard Medical School 2002
o 20% radiology studies are of no clinical
value
Audit Commission AHP Radiology 2002
Learning
Clinical Decision Support
Software (CDSS)
o ETP is nice but Medication Management
Systems could:
Reduce medication errors by 85%
Reduces emergency admissions by 10%
An extra £1bn on the budget
o Ordercomms is nice too but CDSS could
Reduce radiology load by 20%
Chempath by 35% (250,000,000 tests)
Modernising Healthcare
Managing Outpatients
Modernising Healthcare
Electronic Referrals
Who needs a letter?
Modernising Healthcare
e-Referrals & e-Booking
o GPSIs/nurse specialists can manage 50-90%
of routine referrals
Tier 2 / CDSS can reduce referrals by 50%
o 70% of MOPD (& 85% of dermatology) can
be done by e-mail
o FTF = 27 Minutes; S&F = 3 minutes
o Probably referrals by 20% but costs by
20%
o Maine
Modernising Healthcare
“Ask a Doc”
Ophthalmology?
Ophthalmology
o 50% of OPD is retinopathy & glaucoma
MLP model applies
o Network of DTCs will do the cataracts
Major chunk of the surgery
o Are ophthalmology depts.viable?
Chambers?
Local networks commissioned/run by PCTs
o Same principle applies
ENT, neurology, rheumatology etc. etc.
Modernising Healthcare
Unplanned
Medical
Medical
Surgery
Diagnostics
ITU
Minors
Outpatients
A&E
Minors Emergency A&E
Unplanned
Medical
Medical
Surgery
Diagnostics
ITU
Minors
Outpatients
A&E
Minors Emergency A&E
Unplanned
Medical
Medical
Surgery
Diagnostics
ITU
Outpatients
A&E
Minors Emergency A&E
Unplanned
Medical
Medical
Surgery
Diagnostics
ITU
A&E
Minors Emergency A&E
Care of the
Elderly
Modernising Healthcare
Percentage of those admitted as inpatients by cumulative days
spent as inpatients
1.00
5% of inpatients account for 42% of overall inpatient days.
Cumulative percentage of inpatient days
0.90
0.80
0.70 10% of inpatients account for 55% of overall inpatient days.
0.60
0.50
0.40
50% of inpatients account for 10% of overall inpatient days.
0.30
0.20
0.10
0.00
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
Source: Analysis of British Household Panel Survey
Percentage of inpatients
Source Chris Ham DOH
In Walsall,
0.53% of the population
account for
56% elderly bed days
&
46% emergency admissions
Safe and Secure at
Home
Falls
o 1/3 of over 65s will
fall at least once
o Falls prevention
programmes reduce
falls by 50%
o 5-10% of those who
fall suffer injury
o 134,000 admits p.a.
o Hip protectors
reduce injuries by ½
Medication Reminders
•Poor Compliance 10% admissions
•Medication Reminders
•Improve compliance from 34 to 94%
•Reduce readmissions for CHF by 45%
Modernising Healthcare
Modernising Healthcare
Integrated Chronic
Disease Management
&
Evercare
Tier 3
Highly complex patients
Intensive (Secondary Expertise – some
or Case delivered in hospital)
Management
Tier 2
Specialist
More complex problems
Care
Management
(Specialist nurses or GPSI’s)
Tier 1
70-80% of patients
Usual Care (Self care supported by
with GP + practice nurse)
Support
Removing the Seam!
o Integrated Care delivers:
CHF admissions by 25%
New York 1998
LOS from 11 to 6 days in COPD
Edinburgh 2002
asthma admissions by 25%
Cochrane Review 2002
access to cardiac rehab from 23% to 70%
20 prevention e.g. N. Chol. 28% to 75%
Cornwall 2003
Removes delayed discharges
o “Ruthless” case management
o Supernurses (Advanced Primary Nurses)
SpR level, Autonomous, Prescribing
Caseload of 50 - 80 patients
Coordinating care - in reach to the hospital
Focused on care of the elderly – not specialty
o Technology Support
Joint record
Direct input by APNs
Hospital Assessment Tool (HAT)
Automatic Notification of Admission (next morning!)
o Informed supported patients in their own home
Home monitoring
But it’s better with IT
Remote
Monitoring
Reduces admission for:
o CHF by 25%
o COPD by 20%
Changes the diagnosis in:
o 37% of COPD patients
Virtual
Visiting
o 50% of same day
calls can be
managed by phone
o Safe and secure
o Video (POTS) works
e.g. drawing up
insulin
Community
Wide
Records
Community Wide Records
o Community wide patient record
Breaks the practice / patient link
Supports integrated care – needs ICPs
Enables clinical networks (GPSIs)
Quality data can be entered anywhere
No duplication of effort
o Care can be delivered anywhere
Other practices or in the home
Access (both ways) in A&E
Virtual case conferences – simultaneous access
E-Mail referrals - 70% MOPD can be done this way
Modernising Healthcare
o Potential Impact
Veteran’s Affairs reduced bed days by 50% in 5 yrs
Kaiser Permanente uses 1/3 of beds than the NHS
Evercare (US evaluation)
• Reduced admissions by 50%
• Overall cost down 7%
• 97% patient satisfaction
Hospital
at Home
Modernising Healthcare
? Broadband Home Video
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Some ideas
o Cystic Fibrosis
o Bone Marrow Transplants
o Managing Leukaemia
o Palliative care at home
Modernising Healthcare
Modernising Healthcare
Medical
Surgery
Diagnostics
ITU
A&E
Minors
Medical
Surgery
Diagnostics
ITU
A&E
Minors
Radiology Modernising Healthcare
Radiology Networks
o PCTs commission radiology separately
o Specialty radiology read at specialist
centres
CT scans in Boston
o Separate taking images from reading
Chambers
o Only in-patient radiology remains in
the hospital
Modernising Healthcare
Medical
Surgery
ITU
A&E
NHS
Modernising Healthcare
2014?
o Directors.
o Integrated with the core business of
the NHS.
o No more IT departments
HIS
Outsourced
o Worth your rations
Modernising Healthcare
john@navein.co.uk
Modernising Healthcare