Get documents about "Commissioning
Shared by: HC120831221338
-
Stats
- views:
- 12
- posted:
- 8/31/2012
- language:
- Unknown
- pages:
- 63
Document Sample
DHF
Presentations between 2004 an d2009
+44(0)1423 506 848
+44(0)789 907 4881
Kent House
42 Duchy Rd
Harrogate www.directhealthfirst.com
HG1 2ER
Diffusion of MRI Units, 2000
0.4
nd
Pola 1.5
ary
Hung 1.7
lic
epub
Cz ech R ce
2
Gree 4.6
UK
4.9 MRIs per million population
n
Spai 5.4
a
Kore 6.2
any
Germ 6.6
ark
Denm 7.5
It aly
7.9
den
Swe 8.1
US
9.9
nd
Finla 12.9
rland
S wit z e
0 5 10 15
•Source: OECD Health Data, 2003
Cost of Waiting for Elective Surgery(OECD, Working Paper no.6,
2003)
Deterioration in condition, death at the extreme
Loss of utility from delay
Rise in the cost of total treatment
Example:
· A study of patients waiting for varicose vein surgery in the UK found
‘considerable deterioration’ in their condition while waiting for surgery (Sarin et
al, 1993)
Opportunity Costs
856.8 work days lost each year in the UK due to sickness,
Statutory Sick Pay & Incapacity Benefit: In England, 5-
10% of the patients on elective waiting lists are on sick
leave from work
1,047,890 people waiting for NHS in-patient treatment,
June 2000.
Out-patient treatment (hospital tests, specialist
consultations) 13 week wait lists for 308,760 people (of
which 128,532 were waiting over 26 weeks).
What is day surgery?
Ambulatory care.
Out-patient care.
Short-stay.
Minimally invasive surgery.
Diagnostic procedures.
Minor injuries.
Non-surgical interventions.
Prices and Costs e.g. ENT (figures available in 2002)
HRG code C22
Septoplasty
£366/ £905/ £2302
HRG code C24
Bilateral dissection tonsillectomy
£250/ £853/ £4676
(50%) possible as day cases:
Lasar prostatectomy
Trans cervical resection endometrium (TCRE)
Eyelid surgery inc tarsoplasty, blepharoplasty
Hallux valgus ("bunion") operations
Arthroscopic menisectomy
Scope’ shoulder surgery (subacromial decomp)
Subcutaneous mastectomy
Rhinoplasty
Dentoalveolar surgery
Tympanoplasty
(50%) possible as day cases:
Laparoscopic cholecystectomy
interval appendicectomy
Laparoscopic herniorrhaphy
Thoracoscopic sympathectomy
Submandibular gland excision
Partial thyroidectomy
Superficial parotidectomy
Breast cancer wide axillary clearance
Haemorrhoidectomy
Urethrotomy
Bladder neck incision
Possible as day cases:
Tonsillectomy in children
Correction squint
Bat ears/minor plastic procedures
SMR
Reduction nasal fractures
Cataract extraction
Laparoscopy sterilisation
Termination pregnancy
TUR/laser/diathermy/limited resection bladder Ts
Pilonidal sinus excision and closure
Waste from unplanned admissions
GE
PERCENTA OF UNPLANNED STAY-INS
25
20
% Stay-ins
15
10
5
0
All Units
Pharmacological spend as % of total health spend
UK 16.1
France 16.8
Germany 12.3
USA 9.4
OTC and non-prescription drugs as % of total drugs
UK 20
France 31
Germany 35
USA 32
Admissions per 1000 patients
UK 21.4
France 20.3
Germany 19.6
Average LOS
UK 5
France 5.6
Germany 11
Hospital Beds per 1000 population
UK 2.4
France 4.3
Germany 7.0
Bed Occupancy
UK 82
France 76
Germany 77
“if you’re a fit young man who needs a
knee operation, you don’t want to go into
a general hospital and lie next to
somebody who has a bed-sore and MRSA”
Hospital Doctor (09-09-2004) NHS Improvement Plan:
Part Three, Treatment Centres are not a threat
DHF
Case Costing
ASC’s NHS TC’s
CASE COSTING DECIDES WHETHER OR NO WAY TO CASE COST
NOT YOU DO A PROCEDURE
NEVER BEEN A NEED
COST/CASE (BY CPT or DRG,
SPECIALTY,CONSULTANT) NO SYSTEM IN PLACE
SUPPLY MANAGER
IT SYSTEM SUPPORT
DETAILED INVENTORY SYSTEM
EDUCATE STAFF AND CONSULTANTS
HAVE TO CONTINUALLY WORK TO
DRIVE DOWN COSTS
DHF
Govt’s Target
18 weeks to include
·OP
·Dx
·WL
DHF
Wait Times
Without Wait Time With Wait Time
Austria Australia
Belgium Canada
France Italy
Germany Finland
Japan Denmark
Luxembourg Ireland
Switzerland Netherlands
US New Zealand
Norway
Spain
Sweden
UK
DHF
Procedure Rates: Knee
/100 000 (OECD 2003) 114
120
100
80 64 62
60
40
20
0
UK Avg. Wait Avg. No Wait
Drivers
Waiting times, lists & capacity
Choice, Access and Quality
Contestability, Plurality and VFM
DHF
PPP
Services
FM
Capacity
PFI Growth
Performance Management
& KPIs
KPIs
SUIs
Outcome measures
DHF
Procedure v Patient Year
Price by procedure Price by patient year
Low volumes High volumes
High price Low Price
Narrow spread of price Wide spread of price
High Consistency of Resource Unpredictable Resource
Large populations Sub populations
Specified Intervention only Choice of Interventions
Interventions always needed Value avoiding interventions
Elective Either Way CDM
Total hip Squint Asthma
Cataract Chemotherapy Psoriasis
Cholecystectomy Club foot Rheumatoid Arthritis
Herniorrha Radiotherapy Excema
C.A.D Reconstruction Depression
T.O.P. Phy Hair lip Schizophrenia
Pain blocks Extreme obesity Thyroid dysfunction
Dental Incontinence Dialysis
Chronic pain Angina
Osteo Arthritis
Chronic pulmonary
disease
CSS v CPS
The CSS contains everything that should help us specify our procurement safely for
the NHS
The CPS only contains that which we consider essential to the ITT and which will
deliver a VFM bid
Input and process
specifications
So the sponsor can integrate ISTC care with the rest of the health economy.
· e.g. what is expected from the NHS may differ between one cholecystectomy
package (with a very limited follow up) and another.
Input and process specifications
Ministers will find it hard to defend untoward events in the absence of process
specifications or standards
Provider can easily offer a strong argument that he was not at fault for a poor
outcome (by citing biological variability)
Input and process specifications
Some procedures require specific data for national registers and these
have to be specified
· e.g. NCEPOD
· Cataract National Dataset
· e.g. National Joint Registry
Outcomes
The difficulty with outcome(s)
is that the results
should be attributable
to the treatment
Measures
KPIs
· 25 ISTCs
· NHS TCs
Outcome Measures
· NHS TCs
· ISTCs
Outline
Current NHS organisation
Aspects of the NHS
Fears of the NHS
Opportunities in the NHS
Politics of the NHS
History
Churches & Charities
Poor Houses and other reforms to 1911
Lloyd George and the panel
1942 to 1948 : The NHS
1968 to 1989 reforms
Mrs Thatcher & Waiting times 1992 April
Mr Blair & Plurality
Waiting Lists
1992 24 months (+ 6months)
2002-2004…9 Months for
treatment
2002… 900K (to 150K)
2008 … 18 weeks total
Early (2002) Capacity Predictions
7,000,000
6,500,000
FFCEs 6,000,000
5,500,000
5,000,000
4,500,000
4,000,000
1996/97 1998/99 2000/01 2002/03 2004/05
PM’s Target
18 weeks to include
· O.P 4/52,
·Diagnostics 4/52
·treatment 8weeks……?
Differences...
Spot Prices
Speciality to Procedure Information, Refining
Procedures’ Descriptions (severity, co morbidity, and
case mix)
Patient Care Pathways
Clinical Engagement in real costings & interfaces
Financial Flows anticipated
Fears: commoditisation of health
Contract Failure & VFM
Delivery Failure :
Impact on - NHS viability
- Private Practice: volume
-prioritisation
Poor Quality
Fear of Overcapacity
PCTs (allowing lists to go up again)
Acute Trusts
SHAs
DH
Risk to NHS estate and base
Challenge to National strategy
Fear of clinical incompatibility
Personal habit
Agreed team practice
/S Agreed local customs
P/S Nationwide custom
P/S Nationwide best practice
P/S International best practice
P/S Robust evidence practice
/S Legal requirement
Credentialing
•People •GMC
•Specialist Register
•Training
•Buildings, equipment,
•Facilities consumables
•Organisation •HCC
•systems, information, registration
Status of US Industry:
Shift from Inpatient to Outpatient
35000
Annual Number of Surgeries
30000
25000
(in Thousands)
20000
15000
10000
5000
0
1984 1986 1988 1990 1992 1994 1996 1998 2000
Total Total
Hospital Outpatient
Inpatient Surgeries
Surgeries
ISTC Programme
TCs Patient Flow Diagram
New Provider Assessments (Outpatients)
+
- (£A)
diagnostics
Diagnostics
(direct access) OP Consultation OP Follow-up
A B C D
New Provider Surgery (FCEs)
(£S)
Essential OP follow-
+ diagnostics
- up as required Discharge to NHS
GP Consultation
with Patient - GP
- Intermediate
Care
Pre-op Surgery & Acute
Assessment Recovery Inpatient - Subsequent
Follow-up ? necessary care
E
NHS OP
Consultation
(and waiting
list)
VFM
Delivered quickly Grow
capacity
TCs
Maintain quality Improve access
On or Off In their buildings
NHS property
NHS Trusts
& PCTs
With or without
Near or
their staff
far away
Movable refurbished
Buildings
leased (modular)
Joint Service Reviews
actions agreed at previous meetings
routine data, identification of any problem areas, and agreed
actions
ad hoc reports and the results of any investigations,
identification of problem areas, and agreed actions
figures for the ISTCs concerned, compared with other ISTCs;
all findings from reviews of random case records
presentation by the provider to the sponsor of the results of
their clinical audit
Triggers for review
Source of data Anomaly Example
Routine Absolute Patients waiting longer than contracted maximum
reports statistical
Routine Relative Procedure time in the highest decile of all comparable
reports statistical providers; visual acuity following cataract surgery in
lowest decile of all comparable providers
Ad hoc reports Significant Unplanned transfer of patient to NHS provider
event
Ad hoc reports Complaints Patient had not understood proposed treatment when
giving consent to surgical treatment
Review ----- -----
randomly from
case records
Consequences of review
No problem No penalty, but may be other
detected consequence as per contract
A Provider to take remedial action within
specified timescale; possibly increased
level of monitoring
B Failure points, proportionate to
issue(s)
C Financial penalties
D Contract termination
Perceptions of quality risk
National govt.
Local Govt.
Providers (new territories)
Investors (due diligence)
Professions (mixed interests)
Media
Public
Opportunities
Acute Capacity for NHS
Other capacity for NHS
· Diagnostics (radio, pact, physiological, endoscopy)
· LTC (diabetes)
· Primary Care (e.g. CWICs)
· Chlamydia etc
· Mental Health
· LD
· Care of Elderly
Chambers
· Surgeons
· Physicians
· Other clinical/Health/Well being
· Sa a provider, as a FM
Two’s company,
Virtuous contract
£
Payer Provider
Happiness Service
Client
Three’s a crowd
Two third
party payers
Govt
£ control £
£
Payer Provider
happiness services
Client
Inpatient versus Day Surgery: US
50000
40000
30000
20000
10000
0
81
84
87
90
93
96
99
E
E
02
05
19
19
19
19
19
19
19
20
20
Outpatient Surgeries Inpatient Surgeries
Source: SMG Marketing
Freestanding Ambulatory Surgery Centres
in the United States
7,000,000 3500
3174
6,000,000 2707 3000
2425
5,000,000 2500
6,180,108
4,000,000 2000
5,264,759
3,000,000 1500
4,278,314
2,000,000 1000
1,000,000 500
0 0
1996 1998 2000
Volume Facilities
Types of Surgery Centres in the U.S.
Hospital owned
Joint Venture (Hospital & Physicians)
Physician Owned
Management Companies with or without physician ownership
Driving Forces behind the
“Surgery Centre Movement”
Physicians / Surgeons
Hospitals
Government / Insurance Industry
Patients
Designing the Process
“When schemes are laid in advance, it is surprising how often the circumstances
fit in with them”
Sir William Osler
Risk Classification
Surgical Surgical Surgical Surgical Surgical
Category Category Category Category Category
1 2 3 4 5
Anaesthesia
Class
1
Anaesthesia
Class
2
Anaesthesia
Class
3
Anaesthesia
Class
4
The Johns Hopkins Risk Classification System
Pre-Op Testing: a sample matrix for
minimally invasive surgery
Is patient healthy & <75
(no hospitalization or major changes in last 6 months)
YES NOT healthy NO, healthy but > 75
NO TESTING selecltive testing
EKG within 6 months
EKG within 1 month: Na+,K+,Bun/Cr, Glucose
h/o Cardiac, Diabetes (Electrolyte Panel):
h/o Diabetes, Renal Disease,
Diurectic use
CBC w/ platelets: Liver Function Tests:
h/o anemia, recent blood loss, rarely required
(potential for sign blood loss)
Blood Type: CXR:
miscarriages rarely required
