Getting it Right First Time Dr Rhydian Phillips GIRFT Policy & Implementation Director NHS Improvement July 2017
NHS: The Challenges Increasing Demand Financial challenges Decrease in NHS bed 42 Increased health needs Demographic changes base since 1994. % 2010 – 60m • >65% patients admitted are Currently at 129,299 Growing 2017 – 66m 75 years of age or older population 2050 – 75m £2.45bn 15/16 Provider deficit • People living longer will c.£900m 16/17 Provisional expect to remain active aggregate net deficit Ageing population c.£1bn – Rising costs in NHS Increase in total By 2030, 33% of the UK litigation premium c.£1.7bn hospital 129% population will be over 60yrs old from 14/15 to 16/17 episodes and by 2031 there will be 15.3m Annual flow from people aged over 65yrs £1.4bn NHS to independent • Total hospital episodes: sector 7.9m in 1994 Increasing BMI 18.1m in 2014 The challenge of ensuring that savings initiatives are based on By 2050, 60% of men and 50% clinical evidence of women will be obese 2
NHS: The Challenges Unwarranted variation across trusts Variation in hip & knee deep infection rate within one 0.19% - city. If all trusts got to 0.19% this would save the NHS 4.49% £200-300m p.a, enough for 60,000 replacements Variation in Variation in one city £531 - 4% vs average cost of between cemented Cost of Rods post orthopaedic vs uncemented hip £2,803 98% £72 - surgery care replacements £1,066 Large variation in ortho surgeons doing small number of complex Three times as many 3x procedures: facet joint procedures 61% doing less than 11 – driving in one half of a city loan kit costs (£200k av. £760k compared to the other max per site) Some trusts have out of hours MRI provision for emergency conditions (e.g. cauda equina) but others do not, and some trust don’t provide blue light transport 3
Introducing GIRFT Improving medical care in the NHS while also identifying significant savings. • Led by frontline clinicians Innovative use of data sets to identify unwarranted variations in the way services who are expert in the areas are delivered they are reviewing Example data set for Productivity • Peer to peer engagement orthopaedics pilot: metrics helping clinicians to identify changes that will improve National Joint National Hip care and deliver Registry Fracture Database efficiencies, and to design Hospital Episode plans to implement those NHS Indicators Statistics changes • Support across all trusts and Patient Reported HSCIC STPs to drive locally Outcome Measures designed improvements and NHS Atlas of to share best practice across NHS Comparators Variation the country • Agreed savings targets : National data NHS Resolution sources c.£1.4bn per year by 2020-21, starting with between £240m and £420m in 2017-18 4 Arthritis Research Waiting times
GIRFT Outcomes Improved patient outcomes Re-empowered clinicians Increased functional Improved patient experience bed capacity Reduced flow of work to Improved patient safety independents Overall improvement in trust £ Significant taxpayer savings balance sheets • • reduced complications and reduction in procurement and readmissions loan kit costs • • reduced length of stay more productive workforce and • reduced litigation costs reduction in locum costs • better directed care pathways 5
GIRFT Orthopaedics Pilot: Emerging Lessons Scope to tackle many of these variations Huge variations in practice and outcomes : and drive improvements through adopting device and procedure selection, clinical best practice, reducing supplier costs and costs, infection rates, readmission rates, and generating savings (e.g. from reduced litigation rates. readmission and re-operation rates). Many of the answers are already out there No consensus on best While some issues can practice in areas without There is great appetite be addressed by NICE or formal professional from clinicians and individuals or within body guidance. This managers locally to adopt trusts, some are best provides a significant GIRFT practices. tackled across networks opportunity to drive of sites / trusts efficiency. 6
GIRFT Emerging Lessons Lower back pain surgery costs >£100m per annum with little evidence of efficacy Cemented: £650 Uncemented: £5,300 £7,000 No evidence that hip on right provides Obstetric litigation cost per birth £6,000 (5 years) better outcome for over 70s £5,000 N = 135, Range = £55 - £6896 Huge variation between trusts in litigation averages: £4,000 • General surgery: £17 - £477 £3,000 • Urology: £4 - £117 • England average £1398 Vascular: £1 - £6,353 £2,000 • Obs & Gynae: £55 - £6,896 £1,000 £0 And the impacts are already emerging…… 7
GIRFT Orthopaedics Pilot: estimated impact to date c.£50m 50,000 £4.4m 75% savings over two years beds freed up annually estimated savings p.a, from of trusts have renegotiated and improved quality of by reduced length of increased use of cemented hip the costs of implant stock care stay for hip & knee replacements for patients aged and reduced use of over 65 – reducing readmissions expensive ‘loan kit’ operations 2013-14 2015-16 Litigation 1,600 1,350 cases Litigation £215m £138m cost A pricing letter provides Litigation claims and the British Orthopaedic Association transparency of the prices associated costs have been used GIRFT principles in best different orthopaedic trust reduced significantly practice guidance to its members pay for prosthesis, aiding procurement 8
From pilot to national programme Clinical lead Clinical work Remaining work streams 18 700 16 visits already streams are will kick off in waves completed already underway between Jul 17 - Mar 18 Trusts can start to implement their changes once they receive their data packs GIRFT National Reports to Wave Start Date Workstreams Total be published during 2017-18: 1 2012 Orthopaedics 1 - General Surgery (July) 2 Jan 2015 General surgery, Spinal, Vascular, Neurosurgery 5 - Vascular Surgery Urology, Cardiothoracic, Paediatric surgery, Ophthalmology, 3 Jan 2016 12 - Urology ENT, Oral & Maxillofacial, Obstetrics & Gynaecology - Cranial Neurosurgery 4 Apr 2017 Emergency medicine, Cardiology, Dentistry 15 - Spinal Surgery 5 May 2017 Breast surgery, Diabetes/Endocrinology, Imaging/ Radiology 18 - ENT 6 Jul 2017 Anaesthetics/Perioperative, Intensive & Critical Care, Renal 21 - Oral & Maxillofacial 7 Sep 2017 Acute & General medicine, Stroke, Neurology 24 - Cardiothoracic Surgery 8 Nov 2017 Geriatrics, Respiratory, Dermatology, Trauma Surgery 28 - Paediatric Surgery 9 Jan 2018 Rheumatology, Pathology, Outpatients 31 - Obs & Gynae 10 Mar 2018 Gastroenterology, Mental Health, Plastic surgery 34 - Ophthalmology Implementation phase projected to last until spring 2021 9
Building a national programme structure • 34 National Reports on specialties co-badged by their national professional bodies • A national report each on litigation & clinically driven effective hospital management • Report & model approach on procurement • A GIRFT Implementation Plan for each trust • Collating data/plans at regional level of each STP and CCGs (working with RightCare) Monthly • A series of targeted best-practice campaigns to Oversight highlight key opportunities. Group • A rich database of GIRFT metrics across all including trusts and workstreams accessed via the NHSI GIRFT, NHSI, Model Hospital. NHSE/ • Developing approach to benefits measurement – financial and non-financial RightCare 10
Types of GIRFT recommended changes 11
GIRFT Implementation: local GIRFT Hubs will be set up by autumn, with clinical and 7 project delivery leads who will support trusts, commissioners STPs and ACCs to … Build and deliver implementation plans reflecting: 1. The variations highlighted in trusts’ data packs 2. The improvement priorities discussed in Clinical Lead visits 3. The recommendations set out in each National Report Provide concentrated Disseminate best additional resources practice across the for trusts that require country, matching up trusts intensive support, with trusts who might benefit from helping to pay for additional collaborating in selected GIRFT project managers areas of clinical practice Hubs will work to GIRFT P&I Director & NHSI Op Prod Regional Directors, who will ensure GIRFT delivery is fully embedded in NHSI Regional SMTs’ plans 12
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