Implementing High Value Care in Europe Health system NHS

Context The (NHS) Wales delivers universal for 3.1 million Welsh residents with a 2019 budget of £7 billion (€8.2 billion). In 2014, the Welsh Minister for Health and Social Services launched a policy called Prudent Health care, focusing on co-production with patients, equity, reducing over-medicalisation and unwarranted variation in care. Subsequently, high value care has become a vehicle for delivering Prudent Health care under the overarching policy of ‘A Healthier Wales’ 1 . To implement this plan, NHS Wales created a national HVC team led by Dr. Sally Lewis, with the ambition “to improve the health outcomes that matter most to the people in Wales”.

Achievements In 2017, NHS Wales developed a portal for standardised Data Resource – an interoperability hub with an open PROM collection for 31 care pathways, with application programming interface (API) – as well as questionnaires available in English and validated Welsh national disease reporting dashboards to increase translations. Aneurin Bevan University Health Board transparency with Welsh citizens by letting them compare (ABUHB) has been a pioneer in collecting PROMS for over providers and outcomes. Lastly, NHS Wales has signed Implementing20 conditions Value-Based with a 77% response Health rateCare through in Europe the use outcome-based contracts where life science vendors of smartphones. NHS Wales is also building the National receive payments when target outcomes are met. Health system NHS Wales

Implementation 2. Internal forces 3. Scorecard Context • Government mandate • PROMs, CROMs (ICHOM) Through dialogue with practitioners and medical • National VBHC team • Cost (TDABC) The Nationalassociations, Health NHS Service Wales reaches (NHS) clinical Wales consensus delivers on universal • Seven health boards • PREMs outcome sets and PROM tools, often using ICHOM health care for 3.1 million Welsh residents with a 2019 budget 9. External collaborations standard sets for specific conditions. Costs are measured • ICHOM 4. Data platform of £7 billion (€8.2 billion). In 2014, the Welsh Minister for R G E N C • OECD I O • National Data Resource R R either with TDABC or, at , with patient level E D N I T N • Outcome-based contracts R G • In-house development Health and Social Services launched a policy called Prudent A costing. To accelerate HVC implementation across seven with Medtronic P Health care,Welsh focusing health boards, on co-production the national HVC team with works patients, to equity, I

M 1. Condition

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P N R I O Health system level R reducing over-medicalisation and unwarranted variation in A support local teams in embedding HVC activity. V 8. Learning community P 5. Benchmarks I N M G O care. Subsequently,“The plan-then-do value-based approach is obsolete health – even care dangerous” has 2,become • Seven health boards C • National comparisons • Finance Academy • Outcome and cost a vehiclesays for Professor delivering Alan Brace, Prudent NHS Wales’ Health Director care of Finance. under the reports REWARDING overarching“Today’s policy successful of ‘organisationsA Healthier close Wales’ the strategy-to-[120]. To implement this plan,implementation NHS Wales gapcreated with a new a national approach bestVBHC described team as led by Dr. ‘Decide-Do/Refine-Do’2. This agile test-and-learn approach 7. Incentives 6. Investments Sally Lewis, with the ambition “to improve the health outcomes • Outcome-based procurement • Data analysts fuels NHS Wales’ entrepreneurial implementation at health • Clinical efficiency and savings • National Data Resource that mattersystem most level. to the people in Wales.” • National / regional VBHC teams

Achievements - HVC Implementation Matrix Data platform PAGE 1 OF 2 In 2017, NHS Wales developed a portal for standardised PROM collection for 31 care pathways, with questionnaires In terms of digital transformation, NHS Wales is developing available in English and validated Welsh translations. Aneurin the National Data Resource (NDR) – a multi-provider Bevan University Health Board (ABUHB) has been a pioneer in benchmarking hub that enables open reporting, research, collecting PROMS for over 20 conditions with a 77% response as well as clinical and operational support across Wales[122]. rate through the use of smartphones. NHS Wales is also Cost-effective solutions are developed in-house to improve building the National Data Resource – an interoperability data visualisation for patients and caregivers. With national hub with an open application programming interface (API) – terminology standards, “The NDR is a set of national and local as well as national disease reporting dashboards to increase servers holding and linking data produced by Welsh health care transparency with Welsh citizens by letting them compare organisations, with strict information governance standards providers and outcomes. Lastly, NHS Wales has signed and a federated approach”, said Helen Thomas, Director outcome-based contracts where life science vendors receive of Information. payments when target outcomes are met. Learning community Implementation NHS Wales is developing a VBHC learning community at Through dialogue with practitioners and medical national and regional levels through various initiatives. For associations, NHS Wales reaches clinical consensus on example, it has developed a year-long programme across outcome sets and PROM tools, often using ICHOM standard the seven health boards – the Finance Academy – where sets for specific conditions. Costs are measured either finance and clinical participants work in pairs to devise and with TDABC or, at hospitals, with patient level costing. implement value-based projects locally. Another example is To accelerate VBHC implementation across seven Welsh the national costing exercise, which analyses the variation health boards, the national VBHC team works to support in cataract patient pathways across Wales. In 2018, health local teams in embedding VBHC activity. “The plan-then-do boards collected PROM data (ICHOM cataract standard set) approach is obsolete – even dangerous”[121], says Professor from patients before and after cataract surgery. Using a Alan Brace, NHS Wales’ Director of Finance. “Today’s TDABC approach, the cataract patient pathway was mapped successful organisations close the strategy-to-implementation and the cost of each step calculated (£615 per surgery on gap with a new approach best described as ‘Decide-Do/Refine- average). Approximately 70% of patients referred for surgery Do’[121]. This agile test-and-learn approach fuels NHS Wales’ have the operation. “If we can identify early in the process entrepreneurial implementation at health system level. most of the 30% that do not have surgery and the 20% that do not improve after surgery, these patients would be placed in an alternative pathway that can meet their needs with improved outcomes at a lower cost”, asserts Dr. Chris Blyth, Clinical Lead, Ophthalmology. The key learning is that pre-operative PROMs could enable earlier triage to the most appropriate and high value pathway[23].

48 Data platform Learning community (cont’)

In terms of digital transformation, NHS Wales is Approximately 70% of patients referred for surgery have developing the National Data Resource (NDR) – a the operation. “If we can identify early in the process most multi-provider benchmarking hub that enables open of the 30% that do not have surgery and the 20% that do not reporting, research, as well as clinical and operational improve after surgery, these patients would be placed in an support across Wales3. Cost-effective solutions are alternative pathway that can meet their needs with improved developed in-house to improve data visualisation for outcomes at a lower cost”, asserts Dr. Chris Blyth, Clinical patients and caregivers. With national terminology Lead, Ophthalmology. The key learning is that pre- standards, “The NDR is a set of national and local servers operative PROMs could enable earlier triage to the most holding and linking data produced by Welsh health care appropriate and high value pathway4. organisations, with strict information governance standards and a federated approach”, said Helen Thomas, Director of Information. External collaborations

NHS Wales negotiated with Medtronic a first value-based Learning community contract in colorectal cancer, using a new care cycle based on enhanced recovery after surgery (ERAS). Reduced NHS Wales is developing a HVC learning community at length of stay and cost per bed days are the two process national and regional levels through various initiatives. indicators measured, with the payment to Medtronic For example, it has developed a year-long programme being a percentage of the savings generated. The second across the seven health boards – the Finance Academy outcome-based contract was for Medtronic’s sacral – where finance and clinical participants work in pairs to nerve stimulation technology to treat faecal incontinence. devise and implement value-based projects locally. This agreement involves an outcome-based payment Another example is the national costing exercise, which model where the company is paid 12 months following analyses the variation in cataract patient pathways implantation if it meets pre-agreed parameters upon across Wales. In 2018, health boards collected PROM benchmarks. “Given the societal costs for this chronic data (ICHOM cataract standard set) from patients before disease, the expected savings between current and new and after cataract surgery. Using a TDABC approach, the care cycles are £38,000 (€45,000) per patient”, estimates cataract patient pathway was mapped and the cost of Adele Cahill, National Lead Value-Based Procurement5. each step calculated (£615 per surgery on average).

Highlights

NHS Wales is developing a nationwide HVC plan to 1. Chief Medical Officer for Wales Annual Report 2019. Valuing our health. measure patient outcomes and analyse them through a 2. Markins, M., Five Ways the Best Companies Close the Strategy- centralised data platform. PROMs are expected to be Execution Gap. Harvard Business Review, November 2017. applied for triage in order to orient patients towards 3. Interview with Helen Thomas, Director of Health Informatics at NHS Wales, on August 11, 2019. appropriate and high value care pathways. NHS Wales 4. Blyth C., et al., Using outcome data and costs to demonstrate ‘Value’ rolls out its implementation roadmap through HVC in our Cataract Service: reducing variation & using outcomes to support direct care and triage. Poster presented during the ICHOM training at the crossroads of financial and medical conference 2019 Rotterdam expertise to disseminate a cultural shift at health 5. Interview with Adele Cahill, National Lead Value-Based Procurement, system level. NHS Wales on August 12, 2019.

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