Vascular Checks in Bolton
Industrially Scaled and
Systematically Applied
Dr Stephen Liversedge PEC Chair
Lynda Helsby Project Lead
Health Inequalities 2010
• Reduce deaths from heart
disease and stroke and related
diseases by 40% in people
under 75
Health Inequalities 2010
• Narrowing the Gap
• Males 74.6 years
• Females 79.0 years
•
•
•
•
2.3 year gap
2.1 year gap
Great Lever, Halliwell and Crompton
67.5 years
Bradshaw
82.2 years
Health Inequalities 2010
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•
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•
National Support Team visit
3 most ‘profitable’ areas to address
Existing cardiovascular disease
Diabetes
Prevention of cardiovascular disease
Health Inequalities 2010
• National Support Team visit
• Industrial scaling
• Systematically applied
Primary Prevention of
CHD
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•
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•
2006-2008 Incentive scheme
Improve your position by 10% or 20%
10 practices didn’t participate
Poor data in a further12 practices
74,769 target
31,518 assessed as at April 2007
Missing 43,251
Registers 15% to 25%
How were we doing?
Primary Prevention Scheme 2006 - 2008
100
90
Percent Assessed
80
70
60
50
40
30
20
10
0
2006
2007
2008
2009
2010
Date
2011
2012
2013
Primary Prevention of CHD
Logarithmic Incentivisation
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•
•
•
•
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•
30%
£ 1.00
40%
£ 1.50
50%
£ 2.00
60%
£ 3.00
70%
£ 4.50
80%
£ 6.50
90%
£ 9.00
100% £12.00
Logarithmic Incentivisation
Logarithmic Incentivisation
12.00
11.00
10.00
9.00
8.00
Payment
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
30%
40%
50%
60%
70%
Percent achieved
80%
90%
100%
Costs
• 286,000 population
• 88,660 need assessment (31% of list)
• 70% is 62,062 @ 4.50
• £279,275
• 80% is 70,925 @ 6.50
• £471,651
• 90% is 79,794 @ 9.00
• £789,960
• 100% is 88,660 @ 12.00
• £1,003,920
Work and Pay
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•
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•
How much?
31% of list
620 for each GP
80% achievement
– 496 patients
– £3224
• 90% achievement
– 558 patients
– £5022
Everyone must be involved Staff
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Project Manager
Health Trainers
Data Quality Facilitators
Practice Managers and reception staff
Practice Nurses
All GPs
All Primary Care Staff
And Secondary Care Staff
Everyone must be involved
–The Public
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Local Authority
The Bolton News
Local Radio - Tower FM
Work Places
Supermarkets
Pubs
Betting shops
Mosques
Practice Reports – Monthly
Audit
Primary Prevention Audit
Question
Month
Practice
Population
Diabetes
a
b
c
d
e
f
g
> 45 yrs
> 20%
<> CVD & RA in risk on Prev for No. on Hb1ac < BP <
Diabetes last 5 yrs PPR
PPR Register 7.5
150/90
CVD INCLUDES CHD, TIA, occ CVA, PVD
h
Chol <
5mmol
i
j
k
l
m
CKD Register
n
o
p
q
Exp CHD
Exp prev / No. on No on No. on No. BP . Chol < prev / No. egfr Exp prev
practice CHD reg CVD reg Asprin 150/90 5mmol practice < 60% / practice
Apr-08
4,810
1,558
1,174
149
124
92
109
103
123
172
125
146
121
74
May-08
4,827
1,546
1,204
155
124
93
107
107
122
189
154
154
129
73
Jun-08
4,838
1,550
1,273
175
127
95
107
109
124
192
156
149
129
72
Jul-08
4,862
1,560
1,324
236
128
96
111
107
121
189
154
147
128
70
Aug-08
4,889
1,572
1,343
240
129
100
118
107
121
190
153
150
133
70
Sep-08
4,934
1,574
1,364
241
130
102
116
104
121
191
155
153
132
71
Practice Trajectory
Lancashire & Partne - PPA_RA in last 5 yrs
Actual
Target
Trajectory
6,000
5,000
4,719
4,000
2,796
3,000
2,345
2,000
1,374
1,000
843
843
0
Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09
What is left to do?
Green
Ariff & Partners
1,840
1,259
581
3.20
182
Indigo
Umebuani
1,120
794
326
1.75
186
Yellow
Shri-Kant & Partner
1,599
1,226
373
2.00
187
Indigo
The Market Surgery
973
598
375
2.00
188
Yellow
Littlewood & Partners
2,640
1,694
946
5.00
189
Green
Silvert & Partners
3,735
2,429
1,306
6.50
201
Green
Agarwal & Partners
1,572
910
662
3.25
204
Indigo
Fletcher & Partners
3,739
2,552
1,187
5.80
205
Green
Barua
1,026
819
207
1.00
207
Indigo
Nagle & Partners
6,855
4,737
2,118
10.00
212
Yellow
Singh & Partners
1,341
900
441
2.00
221
Indigo
Dryburgh & Partners
4,367
2,945
1,422
6.00
237
Green
Lowe & Partners
2,098
1,375
723
3.00
241
Blue
Wall & Partners
3,196
1,863
1,333
5.50
242
Blue
Lynch & Partners
3,126
1,985
1,141
4.67
244
Blue
Phillips
1,675
1,166
509
2.00
255
Indigo
Lamb & Partners
3,438
2,118
1,320
5.00
264
Blue
Korlipara & Partner
2,637
1,376
1,261
4.20
300
Orange
Newgrosh
602
301
301
1.00
301
How are we doing?
100%
Bolton PCT Primary Prevention Audit
90%
80%
Percent of Patients Assessed
70%
60%
50%
40%
30%
20%
10%
0%
Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09
Results
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Preventing Heart Disease
Improved performance ‘Beyond QOF’
Better Diabetes, Hypertension, CKD registers
Better Primary Health Care Teams
Better Primary Prevention Registers
• 9,097 on register at 2007
• Currently 17,646 @ January 2009
• 24,000 expected on register…….eventually
Before
Primary Prevention Scheme 2006 - 2008
100
90
Percent Assessed
80
70
60
50
40
30
20
10
0
2006
2007
2008
2009
2010
Date
2011
2012
2013
After!
Primary Prevention Scheme 2006 - 2009
100
90
Percent Assessed
80
70
60
50
40
30
20
10
0
2006
2007
2008
2009
2010
Date
2011
2012
2013
Workstreams
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Information
Data Quality
Clinical Engagement
Outreach work
Health trainers
Marketing
Local Enhanced Scheme
Near Patient testing
Clinical Governance
Learning Points Information
• Regular reports vital for practice and project
team
• Adapt information depending on outcomes
• Interpretation of information is variable
• Project team must focus on information and
act accordingly
Learning Points - Data
Quality
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Assume nothing
Ensure searches are systematic
Support is necessary for running searches
Training requirements exposed
Capacity of Data Quality Facilitators
Learning Points - Clinical
Engagement
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Clinical Leadership is essential
Time to build relationships
Understand your Primary Care
Get a lead in each practice
Culture and ethos determines the success
Learning Points Outreach work
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Good marketing exercise
Well received everywhere
Data quality and transfer
Cost issue
Duplication
Targeted outreach the most effective
Learning Points - Health
Trainers
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Vital
Moveable resource
Adaptable
Flexible
Resilient
Enthusiastic
Learning Points - Marketing
• Branding – appealing,
recognised, catchy
• Launch event success
• Publicity
• Media involvement
• Banners
• Cost
Learning Points - Local
Enhanced Scheme
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Grab attention
Different - logarithmic incentivisation
Acknowledges work already done
Acknowledges it gets harder
No strings attached
Aims for 100%
Learning Points - Near
Patient Testing
• One stop shop
• Helps with needle
phobics
• Training /Quality
assurance issues
• Cost
• Laboratory support
Learning Points - Clinical
Governance
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Risk calculation tools
Management of risk register patients
Training
Support
NICE guidance
Final Learning Points 1
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Select your project team carefully
Shared ambition
Enthusiastic
Informed
Prepared to challenge
Prepared to support
Final Learning Points 2
Health Inequalities:
Deprivation No. of
Score
Practices
>40
14
% Achieved
30 – 40
18
73.7%
20 – 30
12
75.2%
<20
11
74.3%
79.4%
Final Learning Points 3
• The Last 20%
– Half (10%) mean to attend
– Busy…. and Well
– Work commitments
• Last 10%
– Ghosts
– Needle phobics
– 4 urban myths
– Leave me alone
Final Learning Points 4
• To do it this way you need
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Clinical Leader
Project Team
Incentive scheme
Peer group cluster analysis
Practice Visits
Health Trainers
Outreach
Publicity
• All equally important
Before
Primary Prevention Scheme 2006 - 2008
100
90
Percent Assessed
80
70
60
50
40
30
20
10
0
2006
2007
2008
2009
2010
Date
2011
2012
2013
After!
Primary Prevention Scheme 2006 - 2009
100
90
Percent Assessed
80
70
60
50
40
30
20
10
0
2006
2007
2008
2009
2010
Date
2011
2012
2013