Better value in the NHS:

Lessons from the past and opportunities

for the future

Prof John Appleby

Chief Economist

The King’s Fund

www.kingsfund.org.uk/bettervalue

• Generic prescribing • Lengths of stay • Day case surgery

Percentage of primary care prescribed items by

generic/proprietary prescribing and dispensing: England,

1976/7 to 2013/14.

Estimated saving in 2013 total net ingredient cost due to

increases in generic prescribing and dispensing between

1976 and 2013

£7.1 bn

Saving by 2013/14 of increased

generic prescribing since 1976

Variation in generic prescribing by GP practice: England

2013/14

Trends in acute medical and surgical patient lengths of

stay: English NHS: 1974-2014

11% (Extra beds that would have been needed in 2013 if

no reduction in LOS since 1998)

61% (Increase in bed

throughput 1998-2013)

International comparisons of average length of stay (all

types of patient): OECD countries

+1.3 m

Proportion of all patient activity carries out as day

cases: England 1974-2014

Roll out of PbR

Two key lessons from the past 1. The drivers of change are multiple and overlapping

Common drivers:

› Health technology developments

› Clinical/managerial culture

› Patient pathway design

› Data and information

› Frontline support to enable change

› Financial incentives

› Financial pressures/support

2. Improvement takes time and occurs through a series of

small steps rather than giant leaps forward

Opportunities

for the future

Variations in clinical practice

By PCT/CCG*:

• Diagnosis of coronary heart disease ranges from 52 to 89%

• Diagnostic tests:1000-fold difference in rate GPs order blood glucose tests

• Prescribing practice: 25-fold difference number of anti-dementia drug prescriptions

• Management of chronic disease: patients with COPD who had review in past 15 months ranges from 77 to 87%

• Rates of clinical procedures: rate of elective tonsillectomy in children ranges from 145 to 424 per 100,000 <17 years

• Length of stay in hospital: 11-fold difference in elective breast surgery LoS

• Health outcomes: mortality rate from pneumonia in 75+ ranges from 4 to 11 per 100,000 population

Overuse

• Monitor estimated £0.2 – £0.6 a year potential saving from by stopping low-value elective procedures like knee washouts and tonsillectomies.

Overtreatment in hospitals

• NICE estimate that following their prescribing policy for antibiotics for respiratory tract infections would reduce prescribing by £3.7m

Overprescribing

• Eliminating inappropriate pathology testing could save the NHS £1 billion a year

Overdiagnosis and use of diagnostic

tests

Underuse

• In 2012/13 only 60 per cent of people with diabetes received all eight recommended care processes

Underuse of effective

interventions

•1 in 8 people over 35 has COPD but remains undiagnosed Underdiagnosis

•Between a third and half of drugs prescribed for long-term conditions are not taken as recommended

Medicines not taken properly

Misuse (preventable harm)

• Additional days in hospital as a result of adverse events are estimated to cost the NHS in England and Wales £1 billion each year

• Direct cost of falls in hospital estimated to be £15 million in 2007

Adverse events in hospital

• Estimate based on 10 GP practices found error rate of around 7%

Adverse events outside

hospital

Care of long-term conditions

Opportunities for: • Earlier detection and diagnosis • Involving patients in decision

about their care • Supporting patients to manage

their own health • Care co-ordination • Integrated approaches to mental

and physical health needs

Care of older people living with frailty and

complex needs

Opportunities for: • Avoiding preventable and

inappropriate hospital admissions

• Improving the patient flow within hospitals

• Better discharge and reablement

End of life care

Opportunities for: • Reducing time in hospital at the

end of life • Better care co-ordination • Training generalist staff in end-

of-life care

Agenda for action

Frame the productivity debate around

quality and outcomes

Hugh Alderwick Ruth Robertson Phoebe Dunn David Maguire

More information: www.kingsfund.org.uk/bettervalue

@jappleby123

www.kingsfund.org.uk