North Wales Review: the Wanless Path

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North Wales Review the Wanless Path

• Chris Ham
• University of Birmingham
• 13 July 2005

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The Wanless Context (1)

• The Review of Health and Social Care in Wales
  (June 2003)
• A comprehensive and hard hitting analysis arguing
  for systematic change
• There is a pressing need for a review of the
  pattern of health and social care services a
  radical redesign is imperative

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The Wanless Context (2)

• There should be a strategic adjustment of
  services to focus them on prevention and early
  intervention
• The current configuration of services places an
  insupportable burden on the acute sector and its
  workforce
• Actions to reconfigure provisionare needed
  alongside a rebalancing of the system to meet
  need earlier in the care pathway

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The Wanless Context (3)

• More beds are not needed Wales has 37 more beds
  than England
• Hospital productivity should be improved to
  reduce variations in performance
• Beds in community hospitals should be used more
  effectively
• Delayed transfers need to be tackled

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The Wanless Context (4)

• Primary care and community services must be
  better resourced and staffed
• Many patients with long term conditions like
  diabetes could be cared for more effectively out
  of hospital
• Partnerships with LAs are essential e.g. to
  reduce delayed transfers and cut LOS
• A whole systems response is needed

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Moving forward

• Designed for Life sets out the 10 year strategy
  and vision
• Three regional networks will be developed across
  Wales
• There will be a continuing emphasis on prevention
  and public health
• Hospital reconfiguration will be taken forward in
  the context of a commitment to primary care and
  social care development

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World class health and social care

• What might this mean in practical terms?
• The Wanless prescription is for reconfiguration
  to achieve better use of hospital services
• Wanless and Designed for Life argue for clinical
  and service integration
• Where are there examples that might inform the
  North Wales Review?

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The example of Kaiser Permanente

• KP is a long established health care organisation
• Its values are as close to those of the NHS as
  you will find in the US
• Analysis shows that for the over 65 population,
  KP uses only one third of the bed days as the NHS
• The following data have been standardised to make
  comparisons like for like, as far as possible

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OrthopaedicsBeds days per 100,000 aged over 65
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CHDBed days per 100,000 aged over 65
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RespiratoryBeds days per 100,000 aged over 65
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OtherBed days per 100,000 aged over 65
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Hip Fracture
Inpatient Length of Stay Distribution
NHS IP LoS
Kaiser IP LoS
NHS IP LoS
Kaiser IP LoS
35
30
25
20
Average Inpateint Length of Stay
15
10
5
0
M 85
F 00-04
F 10-14
F 20-24
F 30-34
F 40-44
F 50-54
F 60-64
F 70-74
F 80-84
M 05-09
M 15-19
M 25-29
M 35-39
M 45-49
M 55-59
M 65-69
M 75-79
Sex/Age Band
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Stroke
Inpatient Length of Stay Distribution
NHS IP LoS
Kaiser IP LoS
NHS IP LoS
Kaiser IP LoS
45
40
35
30
25
Average Inpateint Length of Stay
20
15
10
5
0
M 85
F 00-04
F 10-14
F 20-24
F 30-34
F 40-44
F 50-54
F 60-64
F 70-74
F 80-84
M 05-09
M 15-19
M 25-29
M 35-39
M 45-49
M 55-59
M 65-69
M 75-79
Sex/Age Band
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How does KP achieve these results?

• Many factors contribute there is no single
  bullet
• KP is an integrated health care organisation
• The primary care/secondary care divide does not
  exist
• Physicians work in a system of multispecialty
  group practice

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A focus on chronic diseases

• KP gives high priority to the prevention and
  treatment of chronic diseases
• It aims to keep its members healthy and seeks to
  avoid admission
• Its view is that unplanned admissions are a sign
  of system failure
• Upstream prevention and active chronic disease
  management are emphasised

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Levels of care related to risk

• Self care and self management support for all
  members who can benefit (level 1)
• Disease management support through doctors and
  especially nurses (level 2)
• Intensive case management for members with more
  complex conditions and co-morbidities (level 3)
• Underpinned by prevention and health promotion

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Hospital utilisation

• KPs lengths of stay are much shorter than those
  of the NHS
• Discharged is planned before admission or on
  admission
• Care pathways and protocols are used extensively
• Step down facilities support acute hospitals
  skilled nursing facilities

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Implications (1)

• KPs performance illustrates what world class
  means
• Hospital treatment is expensive and not always
  safe
• The NHS has considerable scope for reducing bed
  day use
• This means a series of linked interventions care
  pathways, discharge planning, better use of
  community hospitals, etc

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Implications (2)

• Community hospitals may be an under utilised
  resource
• Skilled nursing facilities are essential in
  reducing bed day use
• Active rehabilitation and nursing characterise
  these nursing facilities
• Home care support is also essential to facilitate
  discharge

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Implications (3)

• The workforce is a critical resource
• Discharge planners are used extensively (1/25
  beds)
• Nurses deliver much of chronic disease management
• AHPs deliver rehabilitation and other support
• Hospitalists (general physicians) manage care in
  the inpatient environment

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Clinical and service integration

• KP is a well integrated system
• The NHS suffers from fragmentation between
  primary and secondary care
• The problems of acute hospitals cannot be solved
  just within hospitals
• Primary care and social care have a major
  contribution

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Taking this forward

• The NHS cannot become KP overnight
• But KPs experience shows what the future might
  begin to look like
• NHS pilots in England have started to adapt some
  of Kaisers techniques
• NHS Wales may be even better placed because the
  policy context is more conducive to an integrated
  approach

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Following up

• C Ham et al Hospital bed utilisation in the NHS,
  Kaiser Permanente, and the US Medicare programme
  analysis of routine data' BMJ, 2003 327 1257-60
• C Ham Lost in Translation? Health Systems in the
  US and the UK Social Policy and Administration,
  2005, 392, 192-209
• D Lawrence From chaos to care, Perseus
  Publishing, 2002.
• c.j.ham_at_bham.ac.uk