Commissioning for value

30 March 2015

CCGs know that they need to do things differently, demonstrate that they add value for patients and play their part in a sustainable NHS. Camden CCG has embraced Michael Porter’s concept of “value”, defined as improved outcomes for every pound spent. We have applied this to every area of our commissioning programme.

An example of how we are doing this is our work around the frail, elderly population. This was identified as one of the CCG’s initial key priorities. The CCG found that elderly people with complex health and social care needs frequently experienced fragmented services that were difficult for them and their carers to navigate. This poorly coordinated care increased the clinical risks in handovers and led to a high rate of admissions and readmissions to hospital that are costly, with limited improvement in outcomes. The CCG’s aim is to deliver integrated services to all patients with complex and chronic mental and physical problems, including the frail and elderly, which improve the coordination and continuity of care for patients.

Bringing together patients and clinicians, we identified that the outcome most important to this population of patients (adopted as our system measure of success) was “number of days spent at home”. We invited providers across health and social care to co-produce with commissioners a model to deliver services that achieved improvements against this outcome. This model focused on the identification of “at risk” patients; care planning and multi-disciplinary team (MDT) management at practice and, in the most complex cases, at borough level was introduced to ensure that all organisations were working towards the same goal. The model is underpinned by clinical governance across the pathway, shared clinical records across health and social care through the Camden Integrated Digital record and the continual measurement and evaluation of system-wide data.

The service commenced in April 2013 and has been a considerable success. 857 patients have been added to the register (92 of whom have care plans). 73 per cent of the most complex patients (212) managed by the borough MDT now spend increased time at home, which has resulted in a 40 per cent reduction in all hospital use. There is evidence from the Nuffield Foundation identifying that hospital admissions reduced for all patients over 75 in Camden. This suggests there is an even wider benefit to be gained from delivering care differently.

36 per cent of those managed by the MDT have dementia. Linked to this work has been increased identification of dementia (prevalence up from 0.29 per cent in 2010/11 to 0.36 per cent in 2013/14 – an additional 253 patients) and investment in memory services and dementia “champions”.

We have applied the same approach, identification of those at risk, standardising pathways, improving quality of services and integrating services around patients’ needs, to a range of areas and demonstrated reproducible improvements in outcomes and reduced costs.

For example, integrated services for children with complex (including mental health) needs and disabilities have achieved 75 per cent of outcomes and a reduction in costs of 35 per cent through less use of high cost settings and out of borough placements. We have undertaken steps to improve the health of our children and prevent future illness. This includes significantly increased childhood immunisations (2nd MMR 51 per cent in 2009 to 89 per cent in 2014), increased school health checks (74 per cent in 2011/12 to 93 per cent in 2012/13), investment in activity parks and a transitions service for 19-25 year olds.

Another priority is care for patients with long-term conditions where early identification is a key factor. Standardising pathways of care through providing education for GPs and support from specialists, along with integrating models of care, have identified 1,000 more people with hypertension and increased by 9 per cent the number of people with atrial fibrillation now receiving treatment. The integrated diabetes community service has resulted in over 1,000 more people being added to practice diabetes registers and reduced diabetes emergency admissions by 7.4 per cent from April 2013 to April 2014. Emerging data suggests patients registered with long-term conditions in primary care are 63 per cent less likely to have non-elective admissions in the six months after being placed on a register compared to the six months before.

Most encouraging of all is data from both GP patient survey (HSCIC) and EQ5D data that shows an increase (60 per cent in 2011/12 to 65.5 per cent 2013/14) in the number of people who feel supported to manage their long-term condition since the CCG started. These are numbers that are falling elsewhere – both nationally and in London – and support the approach that Camden CCG has taken towards commissioning for value.

Dr Caz Sayer, Chair, NHS Camden Clinical Commissioning Group

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