The Business Case Difficulties of OPAT in Wales Brendan Healy

1. The Business Case Difficulties of OPAT in Wales Brendan Healy

2. The business case difficulties of OPAT in Wales Brendan Healy

3. OPAT in Wales • “I wouldn’t start from here”

4. The Problems • In Wales hospitals are not paid by activity • Freeing up beds, increasing efficiency and increasing activity all cost money • The only way to save money is close beds / lose staff • Bed pressures engender interest but only temporarily • A service already exists

5. Current Service • Acute response team • Deliver antibiotics, clexane, blood transfusions etc • Antibiotics prescribed (by anyone) for a duration specified at outset

6. Other services • A7 day unit for administration of biologics • TPN team

7. Options • Develop a new service • Use existing service and provide support, advice, patient review etc.

8. Current Service • Generic service • Large team • 24/7 service • Responsive to need • Cheap • Microbiology lead service • Decreased expertise in any one area • Governance issues • No review of patients during treatment • Expensive (relatively)

9. Two attempts to date • Full business case with all costs listed etc => business case panel => Very interesting but too expensive and currently no money • Following presentation => spend to save bid

10. Selling the service

11. Improved patient satisfaction Decreased Hospital acquired infection including C. diff Reduced length of stay / Admission avoidance Prevents social / psychological problems associated with admission Allows choice of therapy to suit individual needs Reduced bed pressure Improved efficiency of resource use including impact on waiting times Reduced hospital staff workload Benefits of OPATPatient Hospital

12. Cost of C diff • 21.3 days longer stay • £4,000 / case • (Treatment, Investigations, Hotel costs etc) • 1996 Wilcox

13. Benefits contd • Efficient use of inpatient resources • Increase clinical inpatient capacity • Reduce hospital staff workload • Nurse lead = efficient use of resources

14. Does OPAT save money? • Cost effective • Cost savings in the form of bed days • True cost saving if beds closed • Cost saving depends on commissioning

15. Does OPAT save money?

16. Patient-led NHS (March 2005) Designed for life Delivering Higher Standards 2008-11 Waiting times Access Patient satisfaction Patient choice Strategies Targets

17. UHW • Acute Response Team • < 2 weeks IV antibiotics required • Audit of 3 months data • September – November 2009

18. SSTI

19. SSTI • Total number of visits 828 • Total number of IV antibiotics delivered 1382 • ID/Micro input reduce to 273 visits • Saving 555 visits • Total visits cellulitis 247 • ID Micro input reduce to (average 5 day) 168 • Saving 82 visits

20. Chest Infection

21. Chest Infection • Total number of visits 233 • ID/Micro input 102 • Saving 121 • Total saving 3 months 758 • Total saving / year 3032

22. Plan for UHW • Rapid review of patients admitted with cellulitis for early discharge and management in the community when safe to do so. • Review of orthopaedic joint infections with a view to managing them in the community with regular review in clinic • Review of other patients requiring courses of IV antibiotics for management in the community – e.g. Infectious endocarditis, resistant UTI. • Provision of early review of in-patients to obtain appropriate access for management in the community (a frequent problem is suitable access not achieved early enough during the in patient stay and therefore unable to gain access later on when it is required)

23. Are there suitable patients in UHW to increase throughput? • Orthopaedic • >2 weeks • RMJ - 15 infected revision knees a year, 15 cases of chronic osteomyelitis per year • 1 patient per Orthopaedic consultant per year - 30 patients.

24. Proposal • Start small • Improve efficiency of current service • Treat 15 orthopaedic patients in first year

25. Estimated Savings • Drug budget Savings (cellulitis): • Based on BNF prices • Cost per day for conventional therapy £23.32 • Cost for IV ceftriaxone £10.17 • Total saving (3 months) £3574.73 • Total saving (1 year) £14,298.92 • Bed Day Saving (Orthopaedics): • 750 bed days at £180/bed day £135,000 / year • Total £149,298.92

26. Costs of Project • What is required? • Clinic Coordinator £8,000 • Medical Records £6,000 • Consultant Session £7,000 • Training in IV line insertion No cost • Total £21,000

27. True Cost of Project • Drug budget Savings (cellulitis): • £14,298.92 • Bed Day Saving (Orthopaedics): • £135,000 / year • Clinic Coordinator £8,000 • Medical Records £6,000 • Consultant Session £7,000

28. OPAT vs Acute Response Team • Specialist service vs Whole organisation service • ART reduces silo’s • Beware “Empire Building”

29. Potential for ART • IV fluids at home • Reduce hospital admissions for D&V • Reduce hospital outbreaks of D&V

30. Potential for Wales • Improved efficiency of service • Improved management of infection • Better patient satisfaction

31. Conclusion • OPAT saves money after a fashion • Improves efficiency of service • Improves quality of service • Increases patient choice and satisfaction • Not one size fits all

32. Outcome • Spend to save bid => too cheap but will fund internally => no money => submit a business case / carry out a pilot within SPA time

33. Third attempt • Full business case • Find time to start the service and then bid for more money / funding

34. Summary • Commissioning - in Wales hospitals are not paid by activity • A service already exists • Bed pressures are temporary • Hard to convince management that savings are real – they only see the bottom line • Current economic climate • Don’t give up!