Value Based Health Care at Aneurin Bevan University Health Board

Value Based Health Care in Aneurin Bevan University Health Board Achieving the outcomes that matter to people, being good stewards of the finite resources available and working together to do the right thing across the whole system.

“Success should be defined not by the number of patient reported outcome measures collected, but by the number of patients whose care and outcomes have improved as a direct result of the programme - we should not lose sight of this goal.�

Dr Gareth Roberts | Assistant Medical Director for Value Based Health Care

Table of Contents Forewords from NHS Wales

04

Forewords from Aneurin Bevan University Health Board

06

Our Health Board’s Values and Mission

07

Executive and Clinical Leads

08

Meet the Team

09

Costing Support

10

The Case for Change

11

Adele Cahill: A Reflection on our Journey

12

Concept

14

Measuring Value Based Health Care

15

Costing as an Enabler

19

Technology as an Enabler

20

The Programme: Live Projects

22

Overall Completion Rates

23

Our Journey

24

Case Studies

26 - 29

Scaling Up

30

Where next?

32

Lessons Learnt

33

Key Takeaway Messages

34

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”In redesigning the ways in which we deliver better and sustainable services we must not forget that one size will not fit all”

Forewords from NHS Wales Whether you live in Aberystwyth or Anglesey, Builth Wells or Barry you want to know that you will receive the same high quality health and care services. We have to design services that support the needs of patients and those caring for them, which operate without hindrance from the organisational boundaries that have traditionally defined the NHS in Wales. The budget for health and social care in Wales is over £9 billion and expectations and demands on services continue to increase, so we need to look at ways to work efficiently and safely, while meeting current demand and developing to meet future needs. Our priorities include developing closer links between health and social services, strengthened community provision and better organisation of general hospital and specialised services. ’A Healthier Wales’ as our long-term plan for health and social care sets an expectation that more care and services will move from hospitals into communities in an integrated way.

The NHS in Wales like all parts of the UK is facing on-going financial and service pressures. Combine this with the good news that more of us are living longer, albeit many with chronic conditions, this shows that we need to fundamentally change the way we do things to meet our needs over the coming years. In redesigning the ways in which we deliver better and sustainable services we must not forget that one size will not fit all, when we look for instance at how we provide healthcare to very rural areas, and the commitment to provide services in both Welsh and English. Despite the volume of care, we must ensure that care is person-centred and of the same standard across our country.

Dr Andrew Goodall | Director General NHS Wales Chief Executive

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They have a creative programme that has developed a common language between clinicians, managers, finance, patients, and is linked to their existing care pathway.

All healthcare systems want to be sure the services they provide deliver the best possible outcomes they can for their patients. To be able to measure your effectiveness, and what is good as well as bad is not an easy journey to set out on for any organisation but Aneurin Bevan University Health Board (ABUHB) has taken the bold step to want to compare itself not only within Wales and the United Kingdom but on a broader international stage. To do this has been a choice not a requirement and requires commitment, leadership and a genuine culture of wanting to do the right thing for the population you serve. It has been a pleasure to be part of this programme, bringing together clinicians, finance and managers who really have the energy and passion to want to make a difference for NHS Wales.

Aneurin Bevan University Health Board (ABUHB)’s programme considers a Value Based Health Care system across the population of Gwent. Value is evidenced by collecting outcomes and costs (minimum). Sheer scale is ambitious, unique, working with in a restrictive environment in an operational legacy system. They have a creative programme that has developed a common language between Clinicians, Managers, Finance, Patients, and is linked to existing care pathways for patients, reaching all levels across an integrated service. The approach within the Health Board is now being scaled at a National level, it is simple, effective, has proven methodology, which is applicable anywhere even low to middle income countries.

Professor Alan Brace | NHS Wales Finance Director

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Forewords from Aneurin Bevan University Health Board I have been Chair of Aneurin Bevan University Health Board for just over eighteen months and during that time I have been impressed with the excellent and innovative work that I have seen taking place across the organisation. I have been particularly impressed with the Health Board’s journey to become a Value Based Health Care system, ensuring that we are assessing the value that we provide to our population, through maximising the resources available to us. Its sheer scale is ambitious, our programme supports a number of key National policies and priorities not least, Prudent Healthcare, the Wellbeing of Future Generations Act and A Healthier Wales; our Plan for Health and Social Care. I am particularly keen to determine how enabling the use of technology to collect data and to manage care will improve services for the future and how the use of outome data, including patient reported outcomes will support and improve decision making in direct patient care.

Ann Lloyd CBE | Chair

The Health Board is keen to demonstrate how Value Based Health Care is driving positive change and improvement across so many of our clinical service areas.

The Health Board has a passion for improvement and wants to consistently demonstrate how it is putting people first and supporting individuals to lead and manage their own care. We are keen to develop ways in which people can manage their own health care and have flexible access to their clinical teams when they most need it. Modernising the way we organise and deliver care is essential to improving outcomes and patient experience, and delivering value.

Aneurin Bevan University Health Board is pioneering the implementation of value based healthcare and is at the forefront of collecting the information and data that we need to be able to enable us and our patients to make informed decisions – as a result, we will deliver the outcomes that matter to patients with the resources that are available to us. We are keen to share our progress and learning, and discuss how we can continue to develop value based healthcare even further as we believe it will help us deliver the best possible services that we can for our patients and our communities.

Judith Paget | Chief Executive Officer

Our Health Board’s Values and Mission

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As a Health Board we strive for excellence in all that we do and actively encourage a culture of support, respect, integrity and teamwork. This is balanced with always assessing and challenging services to strive for improvement to match, and where possible exceed national standards, learning from success and identifying where improvements are required.

This ambition is also driven by a commitment to working together and engaging with patients, communities, staff, partner organisations and government. We believe in putting people first, staff taking personal responsibility to safeguard patients, fostering a strong passion for improvement in delivery of services, and making sure that promoting pride in service delivery promotes improvements in patient experience.

Our values and plans have always had a strong focus on delivering safe and high quality services. We also strive to meet and exceed national targets associated with increasing demands on health services as populations increase and people live longer (making them more likely to need access to health services).

We are determined that our values developed over recent years are realised and sustained in spite of the challenges. We want to be open and transparent with our patients and the public we serve. We also want to listen to, and engage with our communities, patients, staff, and partners in planning and delivering services in an effective manner.

ABUHB IMTP 2019/20

Our Population We serve an estimated population of over 639,000, approximately 21% of the total Welsh population.

Our Budget We deliver healthcare services to people across Gwent with a budget of ÂŁ1.2 billion.

Our Employees We employ approximately 14,000 people. About 250 of them are consultants and 6,000 are nurses.

Our Work Last year, we performed around 55,000 operations and had 126,248 attendances at our A&E departments.

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Joint Executive Leads

Dr Paul Buss

Glyn Jones

Medical Director & Interim Director of ABCi

Director of Finance and Performance & Deputy CEO

The Health Board are increasingly recognised as one of the internationally leading examples of the practical implementation of Value Based Health Care.

European Value Based Health Care Prize 2018

Clinical Leads

Dr Gareth Roberts

Dr Dave Minton

Mr Kartik Hariharan

Dr Rob Letchford

Assistant Medical Director; Value Based Health Care

Assistant Medical Director; Value Based Health Care

Local Clinical Lead; Value Based Health Care

Senior Project Manager, Value Based Health Care

Consultant Nephrology

GP and NCN Clinical Lead

Consultant Othopaedic Surgeon

Physiotherapy Clinical Lead

Meet the team

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Adele Cahill

Daniel Davies

Tanya Davies

Assistant Director

Programme Manager

Programme Support Officer

Natalie Davies

Lowri Sira-Parfitt

Dan Davies

Seran Balko

Senior Project Manager

Senior Project Manager

Project Support Officer

Project Support Officer

Holly Townsend

Lisa Price

Caroline Bradfield

Team of Volunteers

Project Support Officer

Project Support Assistant

Project Support Assistant (Ophthalmology)

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Costing Support

Siân Jenkins

Simon Barrell

Caroline Hobbs

Assistant Director of Finance (Hospital and Corporate)

Business Partner Accountant (Business Intelligence & Value)

Head of Management Accountants and Costing

Zoe Hicks

Craig Davey

Mark Munday

Decision Support Accountant

Decision Support Accountant

Finance Support Officer

Joseph Moss

Fay Lewis

Lisa Andrews

Specialist Costing Analyst

Finance Manager PLICS

Specialist Costing Analyst

Work with you for a healthier future

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Care for you when you need us Aim for excellence in all that we do Aneurin Bevan University Health Board’s Vision

The Case for Change The Health Board commissions and delivers services based on a number of golden threads that are the principles that underpin the way in which we plan, deliver and improve services for our population. Our guiding principles are consistent and coherent with the Quadruple Aims and the 10 design principles – and the Value Based Health Care programme is a key enabler to deliver higher value for health and social care. It is a key priority for the Health Board and will provide an enhanced focus on efficiency, productivity with Value Based Health care in particular, supporting areas of work to reduce clinical variation, improve productivity and outpatient based projects including reduction in delayed follow ups.  The Value Based Health Care programme will underpin the methodology to enable the design and delivery of new models of care, to ensure Innovative and transformative ways of organising and delivering care around the patient and their carers. Redesigned models will be data and evidence driven, with a clear focus on patient outcomes.

In addressing the challenges facing Health and Care across NHS Wales Aneurin Bevan University Health Board has made a clear statement towards its ambition, to work with partners, improve the health and wellbeing of the population through services delivered closer to home and at the same time ensure safe, timely and efficient hospital care, in the most appropriate location, delivering the best possible outcomes to patients, by well trained staff who feel supported and valued.

The Health Board works across many communities, systems and services, with an ambition of improving the health and wellbeing of the population we serve which will only succeed if it reflects the needs of citizens and is aligned to the plans and priorities of partners.

The NHS in Wales faces a range of challenges: rising costs, an ageing population and increasing demand. Prudent Healthcare puts NHS Wales at the forefront of a growing international effort to get greater value from health systems. Our aim is to meet the needs of patients whilst avoiding waste.

ABUHB IMTP 2019/20

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Adele Cahill: A Reflection on our Journey Adele Cahill, Assistant Director for Value Based Health Care at Aneurin Bevan University Health Board, shares a reflection on the journey that value-based health care has made through our Health Board to date. The very initial goal was: to consider a Value Based approach across Aneurin Bevan in response to the challenges laid out by the Cabinet Secretary in support of Prudent Healthcare, Wellbeing of Future Generations Act and A Healthier Wales: our Plan for Health and Social Care’.

In the beginning In 2015 the Director of Finance and Medical Director set out to explore the feasibility and impact of measuring outcomes and costing patient pathways, and in doing so created a new clinical leadership role: an Assistant Medical Director wholly responsible for leading a Value Based Health Care approach across the Health Board namely Dr Sally Lewis. In 2016, in support of this venture I was fortunate to be appointed as the Assistant Director to provide the senior leadership and programme management arrangements.

A formal programme was launched following a successful strategic partnership arrangement with the International Consortium for Health Outcome Measurement (ICHOM), which would allow the systematic collection of validated outcome measures and enable the Health Board to understand how this data could be utilised to support direct care, reduce clinical variation and inform resource allocation for Value. A small pilot project was established working with the Parkinson’s Nurse Specialist to test the feasibility of collecting outcomes electronically with patients in a clinic environment. A low cost, low-tech solution was adopted, and through perseverance and clinical support with Executive buy-in we got the programme off the ground.

The technological solution adopted was never going to be sustainable or scaleable in the long term, and therefore in 2017 following a large procurement a contract was let with ICNH Dr-Doctor; this would allow outcomes to be systematically collected at scale across multiple condition areas, alongside the development of new functionality to help support the programme.

We hope that our journey book will help others to create a cultural shift in health care services by adopting a value-based approach in delivering the right care, to the right patient, at the right time, using the right resources.

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Scaling up The last 3 years have been a journey of discovery, with many ups and downs, many lessons learnt but overall great positivity, progress and clinical engagement. The programme continues to mature, and in 2017 funding was supported to secure a small team to support Directorates and Divisions to enable the systematic collection outcomes and costs.

We have seen a change in clinical leadership with Dr Gareth Roberts and Dr Dave Minton taking up the reins since April 2018. The work at Aneurin Bevan University Health Board has influenced Welsh National policy and increased the momentum around driving Value Based Health Care across the whole of the Nation, appointing Dr Sally Lewis as National Clinical Lead for Prudent and Value Based Health Care for Wales. Within a short space of time, with limited but a growing number of resources the team at the Health Board has embarked upon a hugely ambitious programme to collect outcomes, undertake detailed costing in order to evidence Value and use data driven evidence to reform services.

Where next?

We are realistic around the length of time it will take to capture significant levels of data to inform major service change, but we believe that we are beginning to demonstrate the benefits of the programme across a number of our clinical condition areas. Understanding the informatics and data analytics needed to support this should not be underestimated, we learnt a long hard lesson around this, but believe we now have this piece of the jigsaw. The final piece will be to implement the test of change as a result of the data to form our new models of care.

The Health Board and the Programme in particular has learnt so much on how this could be done at scale and at low cost which will be important if Value is to maintain its global traction across countries with finite health budgets, and in particular across lower middle income countries.

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Concept The Value Based Health Care Programme at Aneurin Bevan University Health Board predicates its definition of Value on the Michael Porter Value equation, by improving health outcomes for the same costs; and/or decreasing costs whilst maintaining outcomes; but also looks to ensure “allocative value” in that where practicable resources are shifted across the organisation. It therefore also seeks to apportion resource where it has greatest impact, in the context of local and regional financial mechanism, this will result in a replicable and sustainable model which could be transferred to all health economies.

Dr Sally Lewis | AMD for Value Based Health Care

Sir Muir Grey

Porter Model

Better Value Healthcare Triple Aim

Patient-relevant outcomes Costs per patient to achieve these outcomes

= Patient Value

Personal value

Technical value

Allocative value

Measure that effect the treatment and interventions from the individual’s perspective, especially functional outcomes, wellbeing and adverse effects of treatment.

Aneurin Bevan University Health Board’s definition of outcomes

Measuring Value Based Health Care “Mandatory measurement and reporting of results is perhaps the single most important step in reforming the health care system.”

Michael E. Porter Measuring Shared Value | 2012

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In order to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets.

We must be prepared to change our systems and processes and to invest for Value. We have a collective responsibility to spend wisely. In Wales at least, every pound spent on Health is less spent on education, leisure, green spaces and the arts, the very things which promote employment, health and well-being. Bringing clinicians and people closer to managers and allowing us to participate in resource allocation for Value is a much better way to incentivise us all to define and reduce low value activity.

Building the Foundations: Language and Culture The relationship between clinicians, finance and managers in the NHS has often been fraught with tension and misunderstanding, but arguably has never been more important than in the current environment. If we are to do the best with what we have for our patients it is essential that we work together closely. When we do not work together we can make the wrong decisions. Finance managers may seek to make cuts in the wrong places, failing to recognise the impact on patients. Equally the clinical focus may become too narrow, failing to see the bigger picture and the opportunity costs of some of their clinical decision making.

Clinicians, finance and managers in the NHS are united in their dedication to the service and much of the negativity comes from the same emotional reaction to extreme pressures in the system. We must spend more time together. Language is important. Words like ‘Value’, ‘efficiency’ and ‘cost improvement’ and ‘performance’ may provoke a cool response from a clinician who may interpret that safety and outcomes are being ignored. So what did we do?

• Focussed on a common purpose • Built trust and common understanding around the jargon and the data • Empathised with each others’ pressures, compromised and solved problems together to meet that common purpose

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What do we mean by value and outcomes?

What is a Patient Reported Experience Measure (PREM)?

A Patient Reported Experience Measure (PREM) is a set of questions that patients are asked to answer in order to provide the patient’s view on their experience whilst accessing health care. A PREM concentrates on the quality of service that the patient receives, rather than the outcome itself.

“I believe that having access to my data and outcomes is my right as a patient.”

What is a Patient Reported Outcome Measure (PROM)?

A Patient Reported Outcome Measure (PROM) is a set of questions that patients are asked to answer in order to get their view on their own health. The name is fairly self-explanatory, these are assessments completed by patients themselves. The purpose of completing a PROM is to get the patient’s own assessment of their health and health-related quality of life.

“Everyday life experiences should be factored in to our clinic visits. It’s important for patients to share what matters to them.”

The word ‘Value’ has many different meanings, dependant on who you are talking to, and what shoes they are wearing at the time, so it is important to emphasise that Value in healthcare does not mean ‘cheap’ or cost reduction in isolation. What it does mean is that we, as the stewards of precious resource, should influence the direction of that resource to where it creates the greatest improvements in patient outcomes and their experience of care. Therefore in order to measure value within a system we must systematically capture clinical and patient-reported outcome measures as well as costs.

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The Value Based Health Care programme at Aneurin Bevan University Health Board will create a care system that is able to be scaled and implemented at a National level across NHS Wales from both the perspective of people using it, and for the system itself. It is not surprising that the best outcomes are achieved at lower cost when we place an emphasis on prevention, timely diagnosis and the involvement of patients in managing their care and records.

Much of what we currently measure are not true outcomes but indicators, proxies or process measures often used as a benchmark of organisational performance. Our system of measurement must mature so that we are assessing the success of our healthcare against outcomes that matter to patients.

The importance of outcomes How do we know that patients are asked what matters to them and have collaborated with health and social care professionals to identify and achieve their health goals?

Building on the strategic partnerships with ICHOM and DrDoctor, Aneurin Bevan needed comparable expertise in costing complete pathways of care. The team combined the capability and expertise built up through PLICS (patient level information and costing systems) with time-driven activity based costing (TDABC). The Health Board has been pragmatic throughout, combining different costing methodologies based on the specifics of the pathway.

The team focussed on activities that could be seen and influenced, costing only the part of the pathway that the work of the clinical and patient pathway review had identified as having potential value. Although the costing team remains small, Aneurin Bevan has very deliberately invested in expertise and dedicated resources to support the delivery of value based healthcare work, finance and IT professionals are seen as a core part of the multidisciplinary team.

Component Parts of Outcome Measurement

Much of what we currently measure are not true outcomes but indicators, proxies or process measures often used as a benchmark of organisational performance.

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The Value Based Health Care programme is not like other change management programmes. It offers a different way of thinking, a unique approach that goes beyond reducing costs. The key to the programme’s success is that clinicians are in the driving seat: it is our clinical leaders who invite the Value Based Health Care team in to work together to review opportunities to improve services for patients.

Five Implementation Stages A five-stage implementation framework has been devised to guide our initiatives through from the concept to reality, these phases include pre-implementation, idea, delivery, review and sustainability. This framework offers indicative time-frames and sets out the practical steps required for a successful project. At each stage, participants focus on over-riding drivers: Why? What?

When? How? Who? and most importantly So what?

Programme Outputs The Value Based Health Care programme defines an output as the tangible or intangible ’item’ produced, created or delivered as a result of planned activity. These include, but are not limited to: 1. Use of standard ‘toolkits’ for each condition/disease areas where value-based health care is implemented; 2. Patient level and time-driven activity-based costing (or hybrid options); 3. Systematic collection of experience, outcomes and costs across cycle of care; 4. Detailed programme plans to support rollout and implementation; 5. Dashboards combining data at patient and cohort level for clinical and management use; 6. Plan, Do, Study, Act cycle with each phase of programmes; 7. Access to key functionality through the IT platform supported by Dr Doctor; 8. Local, national and international benchmarking using standard toolsets; 9. Access to national and international Communities of Practice.

It’s a hybrid model taking the best of standard methodologies to create a unique approach.

Daniel Davies | Programme Manager

Costing as an Enabler

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Costing is a key component of value based healthcare; we need to consider outcomes relative to cost as we only have a finite resource with which to maximise care for patients. Due to the enormous, complex systems within finance, organisations often have incomplete information to describe the cost to deliver the care they provide to patients. Costing provides pounds as a common currency to describe the use of resources across settings. Costing needs to be undertaken across the entire pathway and cycle of care in order to enable true value-based decisions to be taken.

How does the identification of cost benefit clinicians and service managers?

Working through each step in a patient’s pathway provides space for clinicians to consider and question each step taken to deliver patient care, and whether they all add value. Financial information raises the awareness of the costs of inputs that may not be understood or are sometimes otherwise taken for granted.

Having a better awareness of costs can alter people’s attitude towards budgetting - this often spreads beyond the original scope of the project or pathway and promotes improved stewardship of NHS resources.

Time Driven Activity Based Costing Time Driven Activity Based Costing is a method recommended by Harvard to support collection of costs for Value. As a bottom-up approach to costing, it is focussed on patient pathways (i.e. cycles of care) and identifies the direct costs of resources used per patient (e.g. staff, space, consumables & equipment). Time Driven Activity Based Costing documents the amount of time spent with each resource.

Scope and Map Pathway

Meet with staff at each stage

Cost and Model

Feedback and Test

So what?

Why use Time Driven Activity Based Costing?

Time Driven Activity Based Costing can be applied to both very simple or complex patient pathways; it enables analysis and comparison of cost information and pathways across multiple sites and organisations and allows us to quantify the impact of clinical variation across the pathway – warranted/unwarranted.

It promotes engagement and collaboration between clinical, operational and finance staff and focuses on ‘visible’ costs and so clinicians can better relate to their activities whilst allowing us to map a whole pathway across primary, secondary and community providers in areas where complete activity data sets are not always readily available. Time Driven Activity Based Costing can be easily aligned to patient outcome measures to understand ‘Value’, which allows us to better understand how we can shift resources within a pathway to eliminate nonvalue adding activities, maximise the use of capacity, ensure services are provided in an appropriate setting and, ultimately, improve outcomes for patients.

Using cost as a mechanism that accurately portrays clinical behaviour.

- Dr Paul Buss, Medical Director What is PLICS? Patient Level Information and Costing System (PLICS) is a nationally defined and guided method of costing. It is produced regularly across England and Wales, allowing for comparison and identification of variation both within and outside Aneurin Bevan University Health Board. It actually uses time driven principles to allocate costs. PLICS is a topdown approach to costing which produces fully absorbed costs that include indirect and overhead costs and it applies costs to all captured activity and therefore focuses on secondary care areas

What have we achieved so far?

Memory Assessment Service (Older Adult MH) A TDABC exercise was carried out to quantify differences between resources used across pathway steps in the five boroughs both before and after outcome collection commenced. Prior to outcome collection and service change, there was a 37% variation in pathway cost per patient between boroughs.

Tele-Dermatology Using TDABC, it was identified that it was more cost effective to change the pathway to send lesion patients to Medical Photography first to allow clinicians to review these images virtually and appropriately discharge or direct to an Outpatients appointment. This identified £150,000 of capacity that could be released to meet increasing demand when applied to all lesions.

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Technology as an Enabler To ensure that we are able to develop our Value Based Health Care approach at scale, we have to ensure that we utilise and future proof our approaches to the work. This is where the use of technology is crucial to our programme.

The technology that we have implemented not only enables ‘systematic collection’ of outcomes, but it analyses, calculates and presents this information back in a meaningful way that our clinicians can easily use to support direct care, better follow up management and longer term service re-design.

”Fantastic use of technology to keep appointment reminders at the front of your mind. Love being able to save directly to my electronic diary!”

Dr Doctor The Dr Doctor platform gives our patients the ability to view and manage upcoming appointments and view important information associated with their visit.

Examples include views of hospital map locations, additional information regarding the clinic and or condition that they have and signposting to relevant services that can help the patient.

Patients can access this through their smartphones and/or any other device connected to the internet.

By integrating PROMs data collection into this existing system, patients understand that responding is an integral part of their care: PROMs are not a satisfaction survey, the data is used by clinicians to empower patient care, enabling patient led discussions, inform shared goals and decision making.

It provides our clinicians with a holistic view of the patient and their symptoms which aid a more informed consultation and consideration to other factors ie. the things that matter to people.

Use of Data to Inform Service Change and New Models of Care

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Our Value Based Healthcare Programme acknowledges the amount of ‘rich’ information that it produces, The key to the success though is how this is actually used. To ensure a sustainable Value Based Health Care approach we have to make sure that the presentation and visualisation of this information back to our stakeholders (including patients), is easy to read and understand.

This is why the programme has taken a clinically led approach to its visualisation and presentation of the data and the information collected. However it is very apparent that outcome and costs alone cannot be used in isolation to support our clinical practice, service re-design or decision making. Therefore the programme has developed a strategy that enables the combination of Value Based Healthcare information to ‘other’ useful and ‘critical’ data sources, such as; clinical outcomes, demographics, admissions, falls etc.. All of which combined presents our clinicians, patients and partners with greater data driven evidence to improve care to the patients in Aneurin Bevan University Health Board.

“There is no point in collecting, measuring and presenting data or information, if you can’t understand and act upon it accordingly.’

Various Levels of Data Use

Big Data Research, artificial intelligence and machine learning and full outcome data analysis

Organisational Performance Patient safety, triangulation with other process data and benchmarking

Programme Level System-wide population data, inform resource allocation to meet population needs.

Service and Pathway Clinical variation and quality improvement

Direct Care Support shared decision making, shared goals, new models of care and triggers for key clinical decision point.

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The Programme: Live Projects The Value Based Health Care team are actively supporting eighteen condition areas across Aneurin Bevan University Health Board.

1

4

7

10

13

16

Cataracts Using outcome measures to redesign the service and triage patients to release capacity.

Psoriasis Using outcome measures to decide treatment options and understand patients’ quality of life.

Epilepsy Understanding the relationship between patients mood and medication to inform treatment options.

Pleural Disease Using outcome measures to understand what matters to patients with pleural effusion.

Urinary Flow Using outcome measures to triage patients based on clinical need.

Heart Failure Using outcome measures to enhance treatment options for patients and reduce time to optimsation.

2

5

8

11

14

17

Parkinsons Using outcomes to deliver an efficient and effective service based on patient symptoms.

Foot and Ankle Using outcome measures to understand what matters to patients.

Lung Cancer Using outcome measures to provide an evidence base for treatment options.

Myeloma Collecting outcome measures to understand the needs in Myeloma care and inform the national registry.

Hips and Knees Using outcomes to inform pre and post operative consultations using data to inform National registry.

ITU Using outcome measures to understand the impact on families and carers of patients.

3

6

9

12

15

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Inflamatory Bowel Disease Using a value based approach to manage demand and inform service change.

Pulmonary Rehabilitation Addressing variation across the Health Board by reallocating resources across the system.

Ankylosing Spondylitis Using outcome data to treat patients with the greatest need first and monitor stable patients through a flexible access approach.

Alcohol Liaison Service Using outcome data to evidence the impact of the service across the Health Board in order to sustain services.

MAS (Dementia) Using a value based approach to deliver an equitable service across the Health Board.

Adult Weight Management Using outcome data to evidence the impact of the service across the Health Board in order to sustain services.

Overall Completion Rates

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Remote collection of patient-reported outcome measures (PROMs), with support from clinical teams, is helping to achieve completion rates above 70%.

The Value Based Health Care programme is innovative in its approach, using technologically-driven methods in the pursuit of better patient outcomes and prudent use of resources. In keeping with this ethos, the programme invested in a digital platform (Dr-Doctor) to support the electronic collection of patient outcomes, linked to direct patient care. Not only does this alleviate the burden on staff, studies have found that remote data collection can be more effective than manual collection.

17,067

78%

50%

Sent

Completion Rate

Completed Remotely

We’ve sent out 17,067 Patient Recorded Outcome Measures since we started.

78% percent of the Patient Recorded Outcome Measures that we have sent out are completed and returned.

50% of the Patient Recorded Outcome Measures that have been completed are done so from the comfort of the patient’s home.

Please note that these performance statistics are based on cumulative collection and completions since the beginning of each project. Further information is available from the Value Based Health Care team.

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Our Journey

2016/2017 Implementation Build Change in Executive sponsorship Appointment of Assistant Director VBHC Appointment of project team GLOBE benchmarking with Cataracts/ICHOM National alliance with ICHOM for NHS Wales Procurement for VBHC platform: Dr Doctor

2014/2015 Idea Executive sponsorship Appointment of Assistant Medical Director Clinical Lead Understand theory Build relationships Clinical engagement

New condition areas: Dementia

2015/2016 Discovery Formal strategic alliance with ICHOM Pilot in one clinic a feasibility study: Parkinsons

1 Hospital

1 Clinic

1 CNS

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2017/2018 Acceleration Appointment of Programme Manager New condition areas: Cataracts Pulmonary Rehabilitation Psoriasis, Foot and Ankle Inflammatory Bowel Disease

2018/2019 140 Clinics

All Hospitals

80+ CNS

18 Condition Areas

Dedicated Programme Team

Scaling Up New condition areas: Myeloma Ankylosing Spondylitis Alcohol Liaison Service Epilepsy Lung Cancer Heart Failure Pleural Disease Urinary Flow Hips and Knees AWMS ITU

Case Study:

Inflammatory Bowel Disease

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Faced with rising demand, the inflammatory bowel disease (IBD) service used patient outcomes and experience data, along with clinical information and cost data to redesign the service to ensure the right patient is seen at the right time.

Patient data was collected remotely, with strong response rates and the data used to reconsider how services are delivered. This offered clinicians new insights into their patient population, enabling patients to be more involved in their care, optimised the use of outpatient clinic time, and presented opportunities to prioritise those in need due to flare-up of symptoms. In the process, the team saved time, whilst improving care.

The Background

What we did

Inflammatory Bowel Disease is a chronic condition, most often diagnosed in younger people, which requires monitoring and management over a lifetime. It therefore presents a significant demand on follow up services, 42% increase in 4 years, and puts pressure on referral to treatment times in gastroenterology clinics. Clinics frequently over run, placing pressure on staff and patient experience.

The IBD clinical leadership worked with the VBHC team to collect patient reported outcome measures (PROMs) from 268 patients over a 10-month period (September 2017June 2018). The remote PROMs completion rate achieved in IBD clinics has been >60% which is significantly higher than other diseases, reflecting a tech-savvy and enthusiastic patient population which are keen to be engaged with their care.

Cases can be complex: patients typically have two or more comorbidities, and symptoms can flare up unpredictably.

Patients appreciated being included in their care and found the PROMs questionnaire easy to complete. They valued the opportunity to ask questions on the electronic form which could then be discussed during consultations.

PROMS are enabling clinicians to focus on what matters to the individual. The exercise served to help clinical staff and patients prepare for appointments, maximising best use of the time available.

Prior to this initiative, there were no rapid access clinics for patients suffering sudden flare ups and minimal data to support patient management.

Key Benefits 28% of patients have a PROM score which is consistently above 70 for control of their IBD symptoms in the last six months. This implies that their symptoms are unchanged and under control. For some of these patients, a flexible access clinic appointment may be offered rather than a face-to-face clinic consultation.

Swapping some face to face consultations with flexible access appointments utilising clinical information and PROM data, the consultant is able to increase clinic capacity from 14 to 17 patients (equivalent to £5 or 15% per patient attendance). Released capacity is used to positively effecting referral to treatment targets by seeing new patients and to provide rapid access to those in need.

Takeaways »»The patient is actively involved in their care; they have an opportunity to take ownership of their care/health. »»Patients benefit from optimised care and are seen promptly when needed. »»Flexible access clinics avoid the need for unnecessary face- to-face clinics. »»Clinicians gain insight into patient outcomes and provide prompt care.

Case Study:

Dementia Analysing outcomes and cost data helps address variation across memory assessment services, improve patient care, and optimise staff time.

An initial examination of patient-level costing data revealed significant variation in practice and costs across the five boroughs of Gwent. The Memory Assessment Services (MAS) at ABUHB aimed to redesign dementia services to provide a consistent standard of care, driven by outcome measurement.

The Background The Older Adult Mental Health Directorate worked with the Value Based Health Care team to collect a minimum set of outcomes, along with time-driven activity-based costing.

The primary aim was to understand variation across memory assessment services in supporting dementia patients, and to introduce a single equitable pathway that is both efficient and effective for all patients. The new proposed model ensures a value based approach to dementia care, providing a lower-cost model with improved patient and clinical outcomes.

What we did

Key Benefits A broader improvement arising from sharing of best practice will apply across boroughs. Motivated by a desire for optimal patient care, clinicians and managers have embraced a collaborative way of working.

A preferred value based pathway has been identified and agreed by clinical teams and is in the process of being implemented. With minimal investment in health care support workers, new patient capacity has risen by 50% in 4 of the 5 boroughs, enabling us to meet rising demand until 2020. Where fully implemented diagnosis and waiting time targets are being met and cost variance across the 5 boroughs has reduced by 24%.

A two-year project was launched in April 2017 to collect costs, patient and clinical outcomes. Work began at the pilot site, Caerphilly, in May 2017, followed by the other four boroughs between October and December 2017. A comparative exercise on cost data was used to identify financial benefits between January 2017 and August 2018.

Longitudinal data collection will enable a better understanding of the effectiveness of medication (currently effective in only 60% cases) in the local population and will be used in direct care to inform clinical decision making and medication governance.

Takeaways

Use of a carer burden measure is expected to enable prevention strategies to prevent crisis which might otherwise lead to prolonged admissions.

»»Clinically led transformation on the basis of value; »»Questioning and changing ’locked’ clinical practices; »»Using lean methodology to address the gaps in a national shortage in medical staffing; »»Including patients and carers in the care process.

The key was getting everybody around the table for dialogue about variation between boroughs.

- Mike Fisher, Directorate Manager

Case Study:

Cataracts

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By focusing on outcomes and cost data, our cataracts service is reducing variation, increasing productivity and improving patient experiences while making our service more efficient.

Demand for cataract services is rising. Services need to be efficient to cope with demand and to ensure optimal service to patients.

A national costing exercise took place to understand the variation in cataract patient pathways across Wales. Our service collected ICHOM standard set Patient Reported Outcome Measures (PROMs) data from patients before and after cataract surgery. This information, combined with clinical outcomes and costing data, showed that some patients might be better served by an alternative pathway – improving their experience and outcomes, whilst saving time and money. This approach could become the basis of a new triage system, helping to deliver the right care to the right patient.

The Background Visual impairment affects 4% of the population. Cataracts represent the greatest demand (>50%) on ophthalmology services with around 6,000 referrals and 3,000 day surgery cataract operations per year. Approximately 70% of patients referred for surgery have the operation. This means up to 30% could be better served in an alternative pathway.

Against a backdrop of service delays and variation in outcomes, clinical and operational staff identified opportunities to improve efficiency and embarked on a change programme. In 2017, the cataracts service began working with ICHOM on the international GLOBE benchmarking exercise. We took this opportunity to develop a value based healthcare approach for cataract services.

Key Benefits If we can identify most of the 30% that do not have surgery and the 20% that do not improve using the PROM early in the process. These patients would be placed in an alternative more appropriate pathway,that can meet their needs at a lower cost. This would improve outcomes (more people with improved vision, less getting worse), increase capacity and flow, reduce RTT and the need to outsource cataracts operations.

What we did The team systematically collected PROMs and clinical outcome data for cataract operations at the health board using the ICHOM Standard Set. Information was collected before (in-clinic) and after surgery (by post). Using a Time-Driven Activity Based Costing (TDABC) approach, the cataract patient pathway was mapped and the cost of each pathway step calculated. The approach was then used in the rest of Wales to allow comparison of variation in the pathways across Wales. Clinicians led an outcome measure collection and analysis process to drive service changes and improve patient outcomes. This outcome data will be used to triage and indirect care.

Takeaways »»PROMS might be an important element of triage in ophthalmology, more data will be required to assess this. »»Pre-operative PROMS could enable triage to the most appropriate and high value pathway. »»This could improve patient outcomes and experience.

For every 10 patients on whom we do a full workup, we only operate on 7. A PROM could help us identify these patients earlier.

- Dr Chris Blyth, Clinical Lead, Ophthalmology

Case Study:

Heart Failure

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A consultant nurse working with the VBHC team is using PROMS and clinical data to rethink the patient pathway – optimising patient care while reducing pressure on services.

By rethinking historic practices, changing work plans and embracing IT solutions, the heart failure service reduced administrative and communication tasks, freeing up staff time and releasing service capacity.

The Background

What we did

Heart failure has a significant impact on quality of life, 50% of patients die within five years of diagnosis. There is increasing prevalence in our ageing population, leading to rising demand on unscheduled care (5% of acute admissions) and scheduled care (2% of total NHS budget).

We collected the ICHOM data set in clinic and remote.

The CNS use this data in direct patient care, informing and streamlining the consultation and improving patient centeredness.

Before embarking on this VBHC project, clinics were overbooked and often ran late, generating additional work to be completed outside OPD time. Outpatient clinic schedules were managed on an electronic booking system.

However, the non-clinic activity was not recorded and was therefore difficult to assess.

We have implemented NICE recommendations for follow up, customising appointment times to need. Extending NP appointments to provide education and facilitate patient activation, whilst reducing time and increasing frequency of Follow up appointments, delivering more rapid optimisation of medication.

We have ring fenced urgent appointments for those in acute

The service was unsustainable and not fit for purpose for current practice. Staff were firefighting and crisis managing, making it difficult to deliver evidencebased therapy to patients in a timely manner.

- Linda Edmunds, Nurse Consultant, Heart Failure

Key Benefits Reconfiguration of CNS work plans released capacity to enable the formation of t new community based clinics.

These clinics: »»provide an additional 11 appointment a week; »»and are equivalent to £11k per year of staff time; »»deliver care closer to home, halving travel time and distance; »»improve outcomes with shorter time to optimisation and improved quality of life.

deterioration, enabling us to see those with greatest need in a timely fashion.

Takeaways »»Pathway mapping facilitated reflection, discussion and change of ’routine’ practice; »»Teamwork and leadership are required; »»Changing the way we work can increase capacity, improve experience of staff and patients and improve outcomes.

We are excited about a future that allows us to be innovative in delivering new approaches to improve patient care. We will embrace prudent healthcare and embed a more efficient, sustainable service.

- Karen Hazel, Heart Failure Specialist Nurse

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Scaling Up The ultimate aim of any programme to collect and analyse patient outcome data must be to scale up across all clinical areas. If we are to do this comprehensively this involves collection across the whole system (as is needed to assess the true value of all components of a disease programme) and embedding into normal clinical practice. If this is seen as a stand-alone activity which is not incorporated into patient flows then it will not succeed as it will be seen as a meaningless activity for both patients and their clinicians. Many of the challenges associated with this activity will be common, such as anxieties around lack of time.

Integration

Synchronicity with existing processes

Integration with existing Patient Administration Systems (PAS) and Electronic Patient Record (EPR) is desirable wherever possible.

For outcome data capture to become a sustainable and meaningful exercise, the process by which it is gathered needs to become embedded in normal clinical practice. As well as incorporating into normal clinical flows, this means integrating also into the administrative processes of the health organisation, particularly the ways in which that organisation communicates with patients. This will avoid duplication of communication and lower the risk of over-burdening patients.

Response rates will be better if assessments are linked to the provision of other information which may be relevant to that individual’s circumstances such as disease-specific guidance or appointment reminders.

Any clinician will tell you that a single point of login is a must have - there is nothing more irritating than having to log in to multiple separate IT systems during a consultation. This is a point of failure. Equally, any requirement to duplicate data entry should be avoided wherever possible and integration should ideally allow self-population of data which already exists within PAS or EPR. Patients may well come to receive requests to complete outcomes questionnaires from a number of specialties simultaneously. Again, any unnecessary duplication should be avoided through integration of systems eg. The system should be ‘smart’ enough to recognise if a patient has already completed an EQ5D quality of life questionnaire, the system should recognise that there is no need for another form to be completed if within the agreed timeframe.

Attention must also be paid to ensuring the highest possible response rate of PROMs assessments where this is being done remotely. This is an example of where rapid PDSA cycles can be helpful in assessing why a return rate may be low, and taking steps to address this eg providing paper questionnaires where IT access is poor.

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Why and how outcome data is collected and utilised will also vary between clinical areas. For example in planned care specialties such as orthopaedics or urology, remote collection of outcomes via web links may be necessary in order to accommodate large volumes of patients or to drive the creation of new service models such as flexible access to outpatients. Alternatively in the management of chronic degenerative disease such as Parkinson’s or stroke, outcome data may be used immediately after capture to inform shared decision making about priorities, goals and treatments.

It is important to consider all possible factors having an impact on the level of functionality required from IT systems, whatever solution is deployed.

Point of capture

Access to the data

Once detailed thought has been given to why outcomes are being collected such as how the data will be used and the characteristics and size of the patient group involved, how the data should be collected will become clear. Here are some key considerations: 1. Number of patients to be assessed; 2. Type of service model – outpatient clinic, flexible access to outpatients, domiciliary/remote contact; 3. Access and ability to use information technology, not restricted to specific devices (desktop, phone or tablet); 4. Likely timescale over which data is to be collected; 5. What is the opportunity to collect data at different points across the patient pathway/interface between different sectors.

It is important that there is real time access to the data and that it is ‘owned’ in the first instance by the clinical teams. Key members of the MDT should be able to query the data easily – many software solutions offer short cuts for common queries but it also important that clinicians can generate their own questions through a ‘query wizard’.

Remote (web) access to patient outcome assessments is likely to be highly desirable in planned care specialties such as orthopaedics, where there is a very high volume of patients which may make face to face capture in clinic difficult or even unfeasible. This will also be the case where remote monitoring can generate new service models such as virtual outpatients and remote tracking of chronic disease which may guide patient contact with their health professional facilitated by patient initiated outcomes.

Interoperability with existing clinical informatics systems enhances these benefits. For example, if a patient with Parkinson’s disease is admitted to hospital, there would be instant access to their history and drugs, leading to safer and more rapid care such as through a reduction in delayed administration of essential medication.

What do patients want? Initial investigation with patients locally has highlighted the benefits of well presented data during the consultation. They said that it had enabled them to factor every day life experiences into their clinic visits – clinicians added that there was an opportunity to inform and make best use of a consultation by ranking patient priorities through the outcome capture process.

Patients were also keen to emphasise the need for good statistical information on the likely trajectory of their disease and how that could help them plan and make decisions about their care with their families. Therefore attention must be paid to presenting outcome data in a number of ways which are accessible to all.

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Where next?

Our aim is to continue to embed the Value Based Health Care approach as the core way of working by aligning clinicians, managers and finance professionals around a common purpose.

During the year 2019-2020, we will be implementing the Aneurin Bevan University Health Board value based health care approach into the following condition areas:

Dementia (Community Mental Health) Primary Care and Mental Health Children and Young People’s Mental Health Mental Health and Learning Disabilities Dementia (Inpatients) Prostate Cancer Stroke Chronic Obstructive Pulmonary Disease Colorectal Cancer We will also be enhancing the functionality of our technology to ensure that it is future-proof and fit for purpose.

The way that we share our learning and engage with our stakeholders is also important to us, so we will also be enhancing our communications strategy that will sit alongside our programme.

Lessons Learnt

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Getting started can be difficult and you’ll forever be learning as you progress. To help you on your journey, we’ve listed some of our most valuable lessons that we’ve learnt over the last three years.

Must have Executive buy-in and leadership.

Your sponsor must have influence to lead the programme.

Must have good clinical engagement. Clinicians are the stalwarts of your services.

Outpatients, nursing staff, Informatics, Information Governance and Business Intelligence are key enablers Don’t assume that everybody is IT literate.

Everything you do on the frontline needs to be intuitive.

Being clear on the WHY and issues to address.

Understand your problem before you try to find a solution.

Clarity on use of data and at what level - what do you want to be able to use your data for?

Start small and scale up - choose a condition area and get your processes right.

Doesn’t always need to be 100%, aim for ’good enough’. You don’t need to be able to do everything straight away - start with outcomes or costing and bring them together later as the project matures.

Don’t get hung up on the technology - it’s an enabler. Make your technology work for you.

One size doesn’t fit all. There is no blueprint for solving your problem - be flexible and adaptive.

Invest in the expertise, capability and infrastructure necessary to enable clinicians and patients working together to deliver improvements in care.

Costing, information and informatics are all part of the core multi-professional team.

High quality, consistent and continual communication with patients and clinical teams.

VBHC Programme | ABUHB

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Key takeaway messages

The expertise and commitment developed within the multi-professional team at Aneurin Bevan University Health Board is one of the distinctive features of the approach, and likely one of the factors that has been - and will be - critical to succesfully improving value.

The other notable features are: - Strong support from senior leadership from the beginning, including both the Medical Director and Director of Finance.

- Visible and dedicated clinical and managerial leadership accountable for delivering on value based healthcare.

- Define value with patients, carers, and clinical teams to start building value culture.

Get the relevant people around the table, share information and let them get on with it.

Heart Failure Clinician

Pragmatic approach to the development of Value Based Health Care capability, recognising that change takes time and effort, but that long-term success is dependent on having successful examples from which people can learn.

- Start by focussing on outcomes, but invest time and effort in costing and informatics expertise necessary to enable teams to act on outcomes information.

- Continually think about the patient perspective by asking and working with patients and responding to feedback.

King’s Health Partners

Continually refining approach by drawing on the expertise of people delivering and receiving health care.

’Nothing would please me more than if in the next couple of years clinicians right across our Health Board: nurses, therapists and doctors talk universally about the importance of value when they start talking about new projects.’ Dr Paul Buss | Medical Director at Aneurin Bevan University Health Board

Authors Adele Cahill Assistant Director for Value Based Health Care ABUHB

Dr Sally Lewis National Clinical Lead for Prudent and Value Based Health Care

Co-authors Daniel Davies Programme Manager for Value Based Health Care

Dr Rob Letchford Senior Project Manager for Value Based Health Care

Contributors Value Based Heath Care team Editor Dan Davies

Stay in touch Address 2nd Floor, Block C Mamhilad House Pontypool NP4 0YP

Visit aneurinbevanhb.wales.nhs.uk

Email ValueTeam.ABB@wales.nhs.uk

Tweet @VAbuhb

Š Value Based Health Care Programme | Aneurin Bevan University Health Board | 2019

Phone 01495 765 366