Health CommitteeWritten evidence from Accenture (LTC 90)

Accenture welcomes the opportunity to respond to the Health Committee’s call for written evidence. With a global Health practice comprising over 15,000 professionals, we work with 35 Trusts in England, 23 of the 25 Health companies in the Fortune Global 500, and public, private and community health providers in in Brazil, Finland, France, Germany, Italy, Norway, Spain, The Netherlands, US, Canada, Australia and Singapore.

Summary

The NHS is under pressure to deliver high quality care and significant savings, whilst at the same time dealing with increasing populations of patients with long-term conditions.

To address this, a transformation is needed in the way health and care services deal with chronically ill patients.

We believe that this requires a comprehensive response that combines integration of services across the health sector with proven, patient-centric health management interventions.

There are strong examples of the impact such an approach can have on improving patient outcomes and significantly reducing costs, and we have detailed a number of national and international examples below.

To enable the implementation of this model quickly and at scale, integration and health management needs to be prioritised by commissioners, collaboration is needed across health and social care, and technology needs to be harnessed to enable effective integration.

The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness

The imperative for service transformation is clear

1. The NHS is experiencing increasing pressure on resources. Trusts are serving a growing population of patients with complex and long-term conditions, a group who are already costing the NHS in excess of £70bn every year, 70% of the total health and care budget.1

2. In addition, the recent Francis Report led to increased scrutiny of the quality of care received, rightly leading to a renewed focus on patient outcomes, and this is happening at the same time that Trusts are seeking substantial savings. We concur with the general consensus that in order to address these competing challenges, service transformation is needed, principally through vastly improved integration of health and care services.

3. Yet despite this consensus, the urgency for change, and a growing evidence base for the impact integrated care and health management can have,2 the delivery of this model of care in the NHS has not happened at scale.

4. We believe, based on our experience both in the NHS and globally, that there is scope to vary the current mix of services. We believe that integrated health and care services can become the standard in the NHS, but several issues restricting implementation need to be addressed in order to achieve this.

Recommendations for enabling at scale delivery of integrated care

5. There are a number of financial, structural and design challenges that are currently making implementation difficult. Addressing these would enable the delivery of integrated care at significantly greater scale and pace.

5.1Putting integration and health management at the top of the investment agenda

Removing disincentives to investment: the tariff structure for the acute sector disincentivises investment in preventative activity. Income is generated from the treatments delivered within an acute setting, but consideration should be given to how hospitals can be rewarded for preventing those admissions.

Incentivising cross-agency collaboration: the benefits of integration and health management accrue across health and care organisations, but to release these benefits investment in services and infrastructure is needed. Our experience to date shows that whilst there is agreement amongst health organisations on the value of integrating services, organisations are unclear who should be taking ownership of delivering it. However, with the establishment of Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards (H&WBs), and with integration a key priority for NHS England,3 this presents an opportunity to drive the agenda forward. Commissioners need to work together to invest in integrated care as a priority, with CCGs recognising that commissioning community health management solutions will significantly increase patient outcomes and relieve pressure on the acute sector.

5.2Identifying excellence in integrated care and enabling delivery at scale

Identifying an evidence-based pathway for integrated care: there are currently multiple, small-scale projects piloting different models of integrated care.4 Whilst there is clear value in testing different approaches and any model must take into account local needs, in order to achieve a significant increase in the scale and pace of implementation commissioners need a shared vision of what excellence in integrated care looks like. The development of a clear, evidence-based pathway for non-acute treatment of patients with long-term conditions would provide the confidence for commissioners to press ahead with procuring services.

Enabling scale and value for money: identifying excellence in integrated care pathways would also enable commissioners to join together to co-commission the necessary infrastructure, thereby harnessing the benefits of scale: cost reduction and a larger population to measure outcomes.

5.3Enabling integration through technology:

Delivering on one patient one record: a key challenge for professionals working across the health and care sector is access to patient information. This is particularly important for vulnerable patients with multiple chronic conditions. Electronic Medical Record systems should be compatible across health providers, from acute to community, in order to ensure patients receive the right treatment at the right time—avoiding unnecessary hospital admissions and lengthy stays resulting from a lack of awareness of a patient’s medical history.

6. Health providers around the world are facing the challenge of increasing populations with long-term health conditions and are therefore examining new solutions to re-design services in a patient-centric and cost-effective manner. We believe that international examples can usefully inform the delivery of services in England, and that these models could readily be replicated by the NHS. To illustrate this, we have provided a case study of our work in Valencia.

Valencia, Spain: Adapting Existing Care Models to Better Manage Chronic Conditions and their Impact on Public Health

7. Accenture has been working in partnership with La Fe University Hospital to implement an 18 month clinical trial to redesign the care of patients with multiple, complex chronic diseases. 60% of spending goes to only 4.5% of patients and the vast majority is spent on acute treatment. La Fe’s aim is to assess how health services can be redesigned in a safe and cost-effective manner to (i) avoid patients entering the acute setting in the first place,5 and (ii) reducing length of stay in the acute setting by proactively supporting their treatment via non-clinical measures.

8. To reduce unnecessary hospital visits, we implemented a case management function to remind patients of appointments and support them in following their treatment plans, and established a helpline for patients to contact us by phone to discuss questions or concerns.

9. To further drive down admissions, we are working with the hospital, using advanced Analytics, to predict which patients are most likely to have acute episodes. These patients are then targeted for enrolment in the case management programme and receive continuous support and proactive management of their symptoms in the community. This significantly reduces the chance of an exacerbation of chronic disease symptoms leading to costly acute episodes.

10. Preliminary results in Valencia are promising showing a reduction in A&E visits from 5 to 0.9 and preventable inpatient days by 70–80%. These care improvements for chronic patients also contribute to significant cost savings of around €18,000 to €5,000 (per patient pa). The figures are indicative and preliminary at this point and we will provide the figures to the Committee when they become available.

11. This model could easily be replicated in England. Case management already exists in community healthcare, administered by district nurses working with a case management model. Cambridge University Hospital (CUH) so far is the only acute hospital to have implemented it with strong results (see below).

12. Technology and health analytics (already used across the UK public sector) would further “future-proof” the system by identifying patients at high risk of future acute episodes, reducing hospital admissions and delivering better patient outcomes at considerably less cost.

Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions

13. There are a number of examples of effective integration to treat long-term conditions, however the approach has been fragmented, with different areas implementing different elements.

14. We believe that to have the biggest impact the approach should be two-fold:

Comprehensive integration and coordination of activities between health and care providers in the primary, acute, community and social care setting.

End-to-end health management that treats the patient not the condition.

15. The diagram below demonstrates the different actors and interventions needed to deliver truly effective integrated care:

Illustrating the Model: Treating Diabetes through Integrated Care

16. Diabetes is a good example of a long-term health condition placing undue and increasing pressure on NHS resources. Effective health management means patients can live full, active lives, requiring minimal intervention from health and care services, whilst failure to appropriately manage the condition can lead to traumatic and costly procedures such as limb amputation.

17. Accenture conducted some preliminary analysis on diabetes trends in Wiltshire and found that between 2010 and 2025 the population living with diabetes is estimated to increase by 68%. Spend per registered patient with diabetes in the region has increased by 17% in the last five years, and projections show this will continue to increase. Wiltshire, clearly, is not unique: the challenge is a national one.

18. The provision of proactive health management is therefore urgently needed, and we believe that combining the following examples of integrated care and health management tools could lead to a dramatic improvement in patient outcomes and reduction in cost.

Examples of effective service integration of different actors

19. Integration from an acute perspective:

Cambridge University Hospital (CUH), UK—Right patient, right place, right time across the care continuum

19.1The problem: CUH wanted to reduce the length of stay (LOS) of patients to improve the patient throughput and experience, and reduce cost.6 This included preventing unnecessary delays to the discharge of patients with on-going care needs. A key challenge to achieving this was insufficient collaboration between the Trust and adult social care providers.

19.2The solution: Accenture worked with CUH on a wide range of measures but the two most relevant for the Committee are the introduction of case management and the set-up of a single point of access to coordinate all discharge activities across several health and care providers.

Case managers (specially trained nurses) were introduced across wards in Medicine and Surgery. Patients had a dedicated case manager responsible for ensuring they were at the right place at the right time, speeding up the LOS and improving collaboration between health professionals, patients and their families.

A joint vision of integration between the Trust and community care providers was developed to minimise discharge delays. This led to the secondment of around 50 social care staff into an integrated CUH-based team. We also developed and agreed admission and discharge criteria for lower levels of care in line with global best practice guidance, profiled the existing community bed base and implemented process and pathways across acute and community providers.

19.3The outcome: Implementation of this integrated care model reduced section 5 admissions by three days, led to LOS reduction of one day in surgery for patients with no on-going care needs and reduced outliers by 40%.7Overall the benefit of case management led to reduction of 47,000 bed days over the course of one year, equating to around £5.5 million of cost savings.8 There were also significant improvements in patient experience, as well as in the satisfaction levels of healthcare staff.

20. Integration from a community perspective:

Large Cleveland-based research hospital system, US—Community-based patient navigators supporting chronically ill diabetes patients in the community9

20.1The problem: Research in the US found that unmanaged diabetes costs approximately 21% more than managed diabetes, in large part due to the higher levels of inpatient treatment.

20.2The solution: Accenture worked with the hospital to implement a Patient Navigation Program (PNP). The PNP used non-medical “lay” staff in the community to help clinical staff to ensure chronically ill patients received continuous support outside the hospital setting. Patients were profiled and segmented and personalised interventions developed to target the particular needs of each group.

20.3The Outcome: Patients are more compliant with their care plans after enrolment in the program, contributing to a decrease in no-show/cancellation. Whilst the annual cost to patients for unmanaged diabetes is $14,210, this was reduced to $11,744 after the introduction of the patient navigators.

Integration across different actors needs to be complemented with big data, analytics, technology and changing services

21. Integrating health and care services is a vital component to responding to the growing issue of chronic diseases. However, alone it is not sufficient to drive improvements in patient outcomes and required cost reductions. To achieve this, integration needs to be combined with evidence-based health management interventions that are supported by big data, technology and analytics.

22. Working with clinicians, nurses and healthcare providers, Accenture has developed a suite of interventions that have been proven to deliver improved patient and financial outcomes. These include:

22.1.Predictive analytics: spotting the most at risk patients and treating them before episodes become acute;

22.2Case management and integrated discharge: improving cross-agency collaboration, increasing patient throughput and experience, and reducing cost;

22.3Wellness management: Health coaching programmes engaging patients in positive motivation and behaviour modifications, and wellness screening and outreach campaigns; and

22.4On-going education and monitoring: Telemonitoring and remote follow-up, for example using cutting edge TEKI technology,10 tailored to patients with long-term conditions.

23. There are multiple local and international examples of effective integration across health and care services which treat and manage long-term conditions. By addressing the barriers to implementing these models at scale, the NHS can deliver better outcomes for patients at significantly less cost.

13 May 2013

1 Jeremy Hunt, Secretary of State for Health, Will we rise to the challenge of an ageing society?, 25th April 2013

2 3 million lives; Whole system demonstrator; Torbay (Kings Fund)

3 NHS England, Putting Patients First: the NHS Business Plan for 2013/14-2015/16, April 2013

4 Department of Health, Integrated Care Pilots, 12 March 2012

5 Reduction in unplanned, predictable visits due to exacerbation of chronic disease symptoms

6 Reduced length of stay (elective and non-elective) for patients requiring post-acute lower levels of care across all specialities; Reduced length of stay for patients (elective and non-elective) with no post-acute on-going care needs

7 October 2012-March 2013 measured against October 2011-March 2012

8 CUH calculates bed days at a cost of £125/day. Using the Kings Fund figure of £250, the cost saving comes up to £12m annually.

9 For further information on Patient Navigators see: http://www.accenture.com/us-en/Pages/insight-patient-navigation-most-important-healthcare-job-summary.aspx

10 For a short video detailing the innovative technology deployed in the Basque Country to connect clinicians and patients, including using patients’ televisions via TEKI technology, see http://www.accenture.com/us-en/Pages/success-basque-country-managing-increased-chronicity.aspx

Prepared 3rd July 2014