What is a “Deep Dive” pack?

1. What is a “Deep Dive” pack? CCGs have received a bespoke Commissioning for Value insights pack. These packs, sometimes referred to a Level 1 packs, analyse data on spend and outcomes at a Programme Budget level across a wide range of programmes. Those packs identified candidate programmes which offered the most value in return for improvement work – they answered the question of - where to look. Having selected one or more programmes to analyse in more detail – a Deep Dive pack would examine pathways in more detail to identify opportunities for improvements - What to change. The structure and content of Deep Dive packs has evolved through work done by Right Care and Yorkshire and Humber PHO (now PHE Knowledge and Intelligence Team) working CCGs in Derbyshire and Yorkshire and Humber. This anonymised example is taken from the work done by YHPHO. The structure of a pack is not fixed and immutable but it is based on a tried and tested successful approach. This exemplar will give you a tangible feel for what a Deep Dive pack would look like for your locality and your priority programmes. 1

2. Commissioning for Value Focus PackCCG: XXX CCGFocus area: Cardiovascular pathway Draft Version 5.0 January 2013

3. Contents • Background and context • Aims of the packs • Packs as part of transformation process • Methodology • Analysis methods • Analysis • Summary messages • Analysis by pathway stage • Practice level variation • Secondary care quality • Bringing it all together • Next Steps • Annexes • Annex 1: Detailed indicator spine charts • Annex 2: CCG Benchmarks • Annex 3: Data sources • Annex 4: What works Contents

4. Aim of the packs • In September 2012, YHPHO produced Commissioning for Value Intelligence Packs for every CCG in Yorkshire and Humber. These packs identified programme areas which offered potential opportunities for improving outcome, quality and efficiency at local level. • The packs included an offer to work with CCGs to develop this Focus Pack or ‘deep dive’ looking at an agreed programme area to understand variation across the pathway including GP practice benchmarking, working with local BI teams to identify opportunities for improvement together with the best evidence on what works. • This work forms part of the health intelligence to support commissioning workstream which has been funded since 2009/10 by PCT Chief Executives in Y&H. • In 2013/14 YHPHO’s specialist intelligence services will be part of the CSU business intelligence offer. • Further support is available to use and explore the intelligence in this pack – contact sue.baughan@york.ac.uk or jake.abbas@york.ac.uk. Background

5. How these packs support service improvement Background

6. Methodology used to produce this pack Methodology

7. Summary: Prevention and Prevalence Prevention • 4/5 indicators are below the average of the top 40% benchmark group • If the CCG reached the average of the top 40% in its benchmark group, 1,978 fewer people with a long term condition would smoke • The CCG is in the highest quintile for binge drinking. This is based on a PCT modelled estimate from the Health Survey for England. If the estimate is correct then 20,161 fewer people would binge drink if the CCG reduced its rate to the benchmark average for the top 40%. The CCG may want to triangulate this with other indicators, for example alcohol related admissions Prevalence • 9/10 indicators are above the average of the 40% benchmark group • For CHD, stroke and hypertension the observed prevalence can be compared with that expected given the characteristics of XXX CCG’s population. For CHD the expected to observed ratio exceeds that of the 40% benchmark group. • For stroke a further 83 cases and for hypertension a further 3,492 would need to be observed to achieve the expected to observed ratio of the 40% benchmark group. Summary

8. Summary: Management in primary care • 18/22 indicators are below the average of the top 40% benchmark group • QOF indicators have been used but excepted patients have not been included in the denominator • There are no indicators in the bottom quintile compared to the benchmark group • There are three primary care management indicators where over 150 patients would benefit if the CCG moved to the average of the top 40% benchmark group • % CHD patients treated with a beta-blocker (182 more people) • % CHD patients who have had a flu immunisation (202 more people) • % hypertension patients with a record of BP <=150/90 (371 more people) • £1.2 million reduced prescribing spend in primary care if CCG reduced to average of the 40% benchmark group Summary

9. Summary: Management in secondary care and end of life care Management in secondary care • 60/66 indicators are below the average in the top 40% benchmark group • CVD, and within that classification, CHD and heart failure emergency admissions are all high (bottom quintile) compared to the benchmark group • Although the rate of elective CHD admissions is relatively low, the cost of admission is relatively high (£270k more than average of top 40% benchmark group). • LOS for CHD elective (280 bed days higher), stroke (over 3000 bed days higher) and angiography (over 1000 bed days higher) are all relatively high when compared to the average of the top 40% benchmark. End of life care • An additional 78 people would die at home if the CCG rate matched that of the top 40% benchmark group Summary

10. Where does the CCG compare poorly against its benchmark group?Analysis by pathway stage (1) Prevention Prevalence / diagnosis Management in Primary Care

11. Where does the CCG compare poorly against its benchmark group?Analysis by pathway stage (2) \ Management in Secondary Care Social Care End of life Care 11

12. Where to focus: Understanding practice variation • Practices have been compared against other practices within their practice cluster for all the indicators where data is available at practice level • This information is presented here to form the basis of a discussion between the PHO, Business Intelligence in the CSU and the CCG about how further analysis could support practices in reducing unexplained practice variation • The number of indicators where the practice is in the bottom quintile for the practice cluster has been compared on the next slide and the opportunities for the practices with the highest number of indicators in the bottom quintile has been quantified on the subsequent slide • Practices will have less influence on management in secondary care than they do on management in primary care and this should be taken into account in the way CCGs interpret the information on practice variation Analysis

13. Where to focus: Understanding practice variation Number of CVD indicators in the bottom quintile of the practice cluster Analysis Note, some of the data are based on small numbers. Statistical significance has not been tested and should not be inferred. The data are presented to identify potential areas of improvements rather than providing a definitive comparison of performance.

14. Where to focus: Top 3 GP practices with CVD indicators in the bottom quintile of the practice cluster and opportunities* in brackets Analysis • * If they were to equal the practice cluster average • Note, X practice does not have a practice cluster assigned to it and has been compared to the national average. Some of the secondary care opportunities calculated for this practice are greater than the number of original admissions due to small numbers and comparison to the national average.

15. Bringing it all together – Where to focus, what could work, who should we speak to Analysis Next step is to move from intelligence to action CCG needs to identify from the summary slides where to focus and what could work and which CCG may be an exemplar to follow This table illustrates this approach Annex 4 sets out more examples of ‘what works’ evidence included in the NHS Atlases of Variation

16. Other local intelligence to add in……… CCGs should consider what local intelligence is available to further triangulate with the intelligence in this pack. This may include: • Practice variation analyses • Up to date intelligence from secondary care • Analysis from Acute Trust quality dashboard or other provider data • Contract monitoring data • Local prescribing data Analysis

17. Annexes

18. Annex 1: Spine Charts Minimum value in cluster Maximum value in cluster Annexes Key: Prevention Worse outcome Better outcome Prevalence Lower prevalence / Better outcome Higher prevalence / Worse outcome

19. Annex 1: Spine Charts Annexes Primary Care Better outcome / Lower spend Worse outcome / Higher spend

20. Annex 1: Spine Charts Secondary Care Worse outcome / Higher spend Better outcome / Lower spend Annexes

21. Annex 1: Spine Charts Secondary Care continued Better outcome / Lower spend Worse outcome / Higher spend Annexes

22. Annex 1: Spine charts Social care / End of Life Annexes Worse outcome / Higher spend Better outcome / Lower spend

23. Annex 2: Interim CCG cluster classification NHS XXX CCG is in cluster 5. Annexes

24. Annex 3: Full indicator list Annexes

25. Annex 3: Full indicator list (continued) Annexes

26. Annex 3: Full indicator list (continued) Annexes

27. Annex 3: Full indicator list (continued) Annexes