A citizens jury into fairness in NHS Commissioning. These are the presesntations fo the expert witnesses.

1. Oldham Health Commission into fairness

2. Keynote Speech Dr Ian Wilkinson

3. GPCC in Oldham: A strategy for an Accountable Care Organisation Dr Ian Wilkinson (Chair of Oldham GPCC) Denis Gizzi (Exec Director)

4. The current landscape

8. Responsibilities: Most health care pathways and programme budgets will be held by GP consortia – 70% of the current budget This will include; elective care, rehab care, urgent and emergency care (inc OOH), most community services, mental health and learning disability services. Consortia (will not) be responsible for primary medical services, or other family health such as dentistry, pharmacy, ophthalmics or national and regional specialist services (this will be the remit of the NHS Commissioning Board, with influence from GP consortia). Consortia will manage combined budgets (separate account from core practice accounts). Their duty will be NOT to overspend, to hold suppliers to account and to ‘hold to account to quality outcomes and contribution from general practice Promote equalities and work within productive partnerships with the local authority Duty to effectively engage patients and the public within the core commissioning role Bottom Line: deliver higher quality, regulated outcomes at lower macro cost and whilst enabling public ownership and informed choices. GP Consortia: Focus on new responsibilities

12. Our principles

13. How The NHS Works Ursula Hussain and Jade Czuba

14. Where Does All The Money Go? Steve Sutcliffe

15. The Financial Challenge Steve Sutcliffe

16. How Are Priorities Determined? Denis Gizzi

17. Triple aim – a tool for prioritisation and review IHI triple aim principles Improved capita cost control To improve care provided and the health experience of individuals To improve population health and via disease groups

18. Programme Budgets - A Rational Starting Point Managing the ‘Whole’ over Time The ‘IW’ Idea (the Oldham Chocolate Orange) GPCC will control the whole health care system and therefore the whole programme budgets in line with Government policy. In order to hold control and deliver efficiencies and enhanced quality of the whole ‘real’ budget, segments could be extracted and delegated authority allocated to clinical teams / clusters / firms to take clinical and management control over a specific clinical budget area. Each segment (or Programme Budget area) would be set a framework within which to operate. The GPCC consortia Board would retain macro accountability,potentially with a prime vendor Within the transition period, GPCC could take control over some ‘segments’ under delegated authority from the PCT Referenced within 17 Feb Nicholson letter Managing The ‘Segments’ over Time The segments represent individual programme budget areas linked to specific clinical domains such as MSK, Respiratory, CVD etc The idea is based on the concept of local ‘clinical firm’ leadership of segment areas using a common method. This would provide flexibility for all clinicians to engage.

19. Selecting programme and services for review

20. 7 stage health market analysis

21. Process following health market analysis

22. Making investment decisions

24. The Prioritisation Tool : Importance & Do-ability (+ ability to flex weighting due to macro forces) DO-ABILITY: 5 dimensions are assessed Patient & Public Engagement Health Economy Stakeholder Alignment Technology/Facilities/Workforce Impact on efficiency creation Market Capability IMPORTANCE: 5 dimensions are assessed Patient Benefit Clinical Benefit Reform/Strategic Direction Operational Imperative Financial Impact Economic impact & do-ability Flex weighting depending on financial scenarios AVOID ALTOGETHER IMPLEMENT IMMEDIATELY ASSESS IMPACT AND ACT DELIVER IF DESIRED

26. Next steps for GPCC

28. How will we know if GPCC have succeeded? -Critical Success Factors Objective Measure 1 Full commitment and engagement of every GP practice in consortia 360 degree feedback/informal networks /delivery of outcomes 2 Improvement in outcomes as per accountability schedules: - finance, patient and public engagement, governance standards, clinical outcomes Improvement in performance 3 Population with LTC have a health care plan % of patients with Persoanlised Care Plan 4 Strong relationships with the public and partner organisations 360 degree feedback 5 Robust product delivery platform in place to enable effective redesign Successful delivery of service change 6 Appropriate workforce in place Measurement against organisation framework 7 Established and recognised model of managing suppliers Internal knowledge and capability to manage supplier relationships 8 Robust contracting process Robust contracts and management processes with all providers

29. Health Inequalities in Oldham Mark Drury

30. The Wider Determinants of Health

31. Ill health does not happen by chance or through bad luck. Health is multidimensional and is influenced by many determinants, which may go unnoticed. The collective effect of poor housing, unemployment, social isolation, individual lifestyle factors and the environment in which we live, have enormous influences on health and wellbeing outcomes

33. Population

37. Lifestyle The main contributors to premature mortality in Oldham

42. QUESTIONS? Why do you think people from more deprived backgrounds adopt risky lifestyle behaviours Should people’s behaviours affect the treatment they receive from the health service?

43. Life Expectancy, Main Causes of Premature Death and Morbidity across Oldham

45. Please note: Denominators for life expectancy used 2001 and 2007 respectively mid year population estimates for wards. Trends in Male Life Expectancy The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for males. The highest life expectancy is currently better than the national average. The lowest is currently 7.7 years below the national average. The gap between the best and worst life expectancy is currently 10.1 years

46. Trends in Female Life Expectancy The dotted areas of the chart illustrate the gap between the lowest and highest ward level life expectancy for females. The highest life expectancy is currently better than the national average by 2.8 years. The lowest is currently 7.8 years below the national average. The gap locally between the best and worst life expectancy is 9.6 years

47. In people under 75 years

48. In people under 75 years

50. So What?... The case for working deliberately, to create more equal outcomes , rather than simply more equal opportunities to become ever more unequal, has two essential rationales – the practical and the moral . In those countries where health inequalities are greatest, overall health status of the population is lower . It is difficult to lower the coronary heart disease mortality of the population if only part of the population is experiencing improvement. Lowering health inequalities helps societies become more successful economically – drawing on the talents of all the citizens at a society’s disposal, rather just a section of them – and socially. More equal societies have less crime and less fear of crime. Inequalities in health that are potentially avoidable are unfair. Social justice is a reason for desiring a reduction in social inequalities in health. In Oldham there is a particular issue about health inequalities (and wider inequalities) between communities living side by side and social cohesion .

51. Opinion: what should fairness mean in the NHS? Martin Rathfelder

52. Andrea Fallon, Consultant in Public Health, NHS Oldham, 16.4.2011 .

55. Four essential questions … What should we be doing and why are we doing it? what rights and duties do we have to intervene, what outcomes do we seek and what is the evidence that it will work…(eg example of post bariatric surgery cosmetic surgery) Who should it be for, and what risks/costs are there to others? the boundary between restricting liberty for some to promote the health of others, and how fair will it be …. Who should decide? who should have the loudest voice …clinical, political, financial or public, patient How should we decide? what process should we use, are there precedents, and what legal obligations do we have in ensuring the ‘right’ process us followed.

63. Andrea Fallon, Consultant in Public Health, 16.4.2011

71. Cost-utility Where the type and volume of outcomes from two interventions aren’t the same then we look for a ‘common outcome currency ‘ – eg QALYs (quality adjusted life years) – eg whether to prioritise hip replacements, coronary bypass operations or kidney dialysis – although different procedures, we could try to look at how they compare in improving quality of life – hence using the QALYs measure.

73. QALYs and DALYs Quality adjusted life years (years of healthy life lived) and disability adjusted life years (years of healthy life lost) are two commonly used measures to identify the burden of disease on a population. However, these are value laden and subject to interpretation. Without treatment ‘a’ With treatment ‘a’ Estimated survival 5 years Estimated survival 10 years Est QALY weight (from patient data) 0.5 Est QALY weight (from patient data) 0.7 QALYS =5x0.5 = 2.5 10 x 0.7 = 7 QALY gain from treatment a = 7 – 2.5 = 4.5 QALYS

76. Meaningful Patient Involvement Mark Drury

79. Involvement Model Informing Consulting Negotiating Participating Goal Provide balanced and objective information to assist patients/ communities in understanding the problem/ solutions/ alternatives etc. Obtain community feedback on analysis, alternatives and/or decisions. Work directly with patients/ communities to ensure concerns and aspirations are consistently understood and considered. Genuine partnership with community/ patients in each aspect of decision making. Promise We will keep you informed. We will keep you informed, listen to you and feedback on how decisions were influenced. We will work with you to ensure that your concerns and aspirations are reflected and provide feedback on how decisions were influenced. We will look for your input in formulating solutions and incorporate your input into decision making to the maximum extent possible.

87. What matters to patients? Oldham Health Commission April 2011 Mandy Wearne Director Service Experience www.InspirationNW.co.uk

88. Putting the ‘S’ back in to the NHS!

96. Getting the basics right!

97. Get the basics right – don’t leave it to chance Ensure staff are competent, Don’t loose my notes, Keep the place clean Fit in to my life – not force me to fit in to yours Make the service easy to access, Give me convenient options, Don’t waste my time Treat me as a person – not a symptom Listen to me and take me seriously , Understand the wider context of my condition, Treat me with respect and dignity Work with me as a partner in my health – not just a recipient of care Encourage me to keep control of the process, Equip me to look after my own health Give me the support I need

108. Voting via SMS messaging Please TEXT the word ‘CARE’ followed by the number (1-8) to 60095 e.g. If Self Confidence your choice Text: CARE1 to 60095