Will You Be Working Like This in 2014?

1. Will You Be Working Like This in 2014? Dr. John Navein Director The Modernising Healthcare Partnership

3. Minors UnplannedMedical Do 10% of the Work Use 80% of the Money Medical Surgery Diagnostics ITU Outpatients Minors EmergencyA&E A&E

4. Money April 2003 Primary Care Trust (70% of NHS Budget) 50-100 Practices Acute Trust

5. And it's certainly nothing to do with !*"*!ing electronic records It’s Not the Technology!

6. Delivering the NHS Plan Next Steps on Investment Next steps on return • Quality • Service • Clinical Networks • Integrated Care • Seamless • Standards • Resources

7. Doing what we do - only better

8. NHS • 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 • 25% OPD tests have been ordered in the previous 30/7 by the GP Internal audit Arrowe Parke Hospital • 35-50% of top 6 path tests of no clinical value Harvard Medical School 2002 • 20% radiology studies are of no clinical value Audit Commission AHP Radiology 2002

9. Learning

10. Clinical Decision Support Software (CDSS) • ETP is nice but Medication Management Systems could: • Reduce medication errors by 85% • Reduces emergency admissions by 10% • An extra £1bn on the budget • Ordercomms is nice too but CDSS could • Reduce radiology load by 20% • Chempath by 35% (250,000,000 tests)

11. Managing Outpatients

12. Electronic Referrals

13. Who needs a letter?

14. e-Referrals & e-Booking • GPSIs/nurse specialists can manage 50-90% of routine referrals • Tier 2 / CDSS can reduce referrals by 50% • 70% of MOPD (& 85% of dermatology) can be done by e-mail • FTF = 27 Minutes; S&F = 3 minutes • Probably  referrals by 20% but  costs by 20% • Maine

15. “Ask a Doc”

16. ?

17. Ophthalmology?

18. Ophthalmology • 50% of OPD is retinopathy & glaucoma • MLP model applies • Network of DTCs will do the cataracts • Major chunk of the surgery • Are ophthalmology depts.viable? • Chambers? • Local networks commissioned/run by PCTs • Same principle applies • ENT, neurology, rheumatology etc. etc.

19. Minors UnplannedMedical Medical Surgery Diagnostics ITU Outpatients Minors EmergencyA&E A&E

20. Minors UnplannedMedical Medical Surgery Diagnostics ITU Outpatients Minors EmergencyA&E A&E

21. UnplannedMedical Medical Surgery Diagnostics ITU Outpatients Minors EmergencyA&E A&E

22. UnplannedMedical Medical Surgery Diagnostics ITU Minors EmergencyA&E A&E

23. Care of the Elderly

24. Source Chris Ham DOH

25. In Walsall, 0.53% of the population account for 56% elderly bed days & 46% emergency admissions

26. Safe and Secure at Home

27. 1/3 of over 65s will fall at least once Falls prevention programmes reduce falls by 50% 5-10% of those who fall suffer injury 134,000 admits p.a. Hip protectors reduce injuries by ½ Falls

28. Medication Reminders • Poor Compliance  10% admissions • Medication Reminders • Improve compliance from 34 to 94% • Reduce readmissions for CHF by 45%

30. Integrated Chronic Disease Management&Evercare

31. Tier 3 Highly complex patients (Secondary Expertise – some delivered in hospital) Intensive or Case Management Tier 2 More complex problems (Specialist nurses or GPSI’s) Specialist Care Management Tier 1 70-80% of patients (Self care supported by GP + practice nurse) Usual Care with Support

32. Removing the Seam! • 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

33. “Ruthless” case management • 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 • Technology Support • Joint record • Direct input by APNs • Hospital Assessment Tool (HAT) • Automatic Notification of Admission (next morning!) • Informed supported patients in their own home • Home monitoring

34. But it’s better with IT

35. Remote Monitoring Reduces admission for: • CHF by 25% • COPD by 20% Changes the diagnosis in: • 37% of COPD patients

36. Virtual Visiting • 50% of same day calls can be managed by phone • Safe and secure • Video (POTS) works • e.g. drawing up insulin

37. Community Wide Records

38. Community Wide Records • 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 • 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

39. 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

40. Hospital at Home

41. ? Broadband Home Video

42. Some ideas • Cystic Fibrosis  • Bone Marrow Transplants  • Managing Leukaemia  • Palliative care at home 

44. Medical Surgery Diagnostics ITU Minors A&E

45. Medical Surgery Diagnostics ITU Minors A&E

46. Radiology

48. Radiology Networks • PCTs commission radiology separately • Specialty radiology read at specialist centres • CT scans in Boston • Separate taking images from reading • Chambers • Only in-patient radiology remains in the hospital

49. Medical Surgery ITU A&E

50. NHS