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Investing in Healthcare: breaking down the silos

Brussels, 16 October 2013
With the endorsement of the Lithuanian Presidency of the Council of the EU In partnership with the European Economic and Social Committee Co-chaired by Antonyia Parvanova MEP & Gianni Pittella, Vice-President, EP

Social Return on Investment:

The results of the Early Intervention Clinic in Spain. The concept of the Fit for Work Early Intervention framework In Europe.

Professor Paul Emery and Professor Juan Jover

Rheumatic and Musculoskeletal Diseases

More than 200 diseases

Joints Connective Tissue Spine Soft tissue Bone

High Disease Burden

High incidence and prevalence Chronic course High use of Health System resources High impact in quality of life: Pain and Disability

Burden of diseases in Canada, 2000

http://www.phac-aspc.gc.ca/ph-sp/preveco-01-eng.php#fig1 Adapted from IHE, 2008; data from the Public Health Agency of Canada

Spains National Budget. 2005

Temporary Work Disability Subsidies an Other Economic Benefits of Social Security 10.000.000.000 euros

20% Musculoskeletal Temporary Work Disability

The complexity of Work Disability

Occupational Process
- Economic Activity - Employers - Unions - Occupational Health

Health System Process

- Individual factors - Collective - Public Health - Health Care System
- Primary Care - Specialized Care - Inspection

Administrative Process
Social Security Institute - Compensation - Laws - Control - Fraud - Inspection

TWD

What if?

PWD

MSD-TWD Program (98-01)

Inclusion: 12 months Control TWD initiation due to MSDs (13.000 nonselected episodes) Intervention Three health districts in Madrid Randomized study Voluntary program Patients maintained their group Intention to treat analysis Follow-up: 12 months Results Days of TWD Patients with PWD Direct Costs Indirect Costs Cost/efficacy Cost/benefit Early Intervention Protocolized clinical management Patient Education Self-management Administrative Duties

Research: a clinical approach to MSD-WD

39 % reduction of TWD duration (days)

% of patients back to work

100

50% reduction of PWD (cases) Increased patient satisfaction Positive Economic evaluation Decreased and indirect costs Control direct Intervention Benefit/cost at two years: 11 euros Extension of the Program (1998-2004)

25

50

75

> 38.000 processes >1 million days off-work saved

0 0

30

60

90

120 150 180 210 240 270 300 330 360

Days

Scientific Publications

Diagnostic concordance between primary care physicians and rheumatologists in patients with work disability related to musculoskeletal disorders. Candelas G, Absolo L, Len L, Lajas C, Loza E, Revenga M, Bachiller J, Collado P, Richi P, Blanco M, Jover JA.

Rheum Int . 2011 Dec; 31(12) 1549-54

Prognostic Factors for Long-Term Disability Due to Musculoskeletal Disorders

LYDIA ABSOLO, LETICIA LEN, LORETO CARMONA, CRISTINA LAJAS, GLORIA CANDELAS, MARGARITA BLANCO, AND JUAN A. JOVER1

Rheum Int . 2012 Dec; 32(12)3831-9

Dissemination and Partnerships

Policy Makers and Administrators
Senate
Ministry of Health Autonomous Communities

National Rheumatic and Musculoskeletal Diseases Strategy TWD Early Intervention Programs

Social Security and Labour

Nat. Institute of Social Security Employers, Unions, Occ. Health

Health Professional Body

Spanish Society of Rheumatology

Primary Care Societies

NHS Inspection Services

Dissemination and Partnerships

Policy Makers and Administrators
Senate
Ministry of Health Autonomous Communities FfW early intervention clinics

Social Security and Labour

Nat. Institute of Social Security Employers, Unions, Occ. Health

Health Professional Body

Reumatology Units

Primary Care
NHS Inspection Services

FfW Early Intervention Clinics

Efficacy 32%

Efficacy 27%

FfW EIC Concept

Health Service Research

TWD

Access

Health Care Reengineering

Health Results

Very early

Specific and Specialized

Decreased TWD-PWD

FfW Early Intervention European Task Force

Professor Paul Emery

European Early Intervention for RMDs Task Force Working Group

Chaired by Professor Paul Emery and Professor Juan Jover
Membership applies to European clinicians committed and interested in developing early intervention programmes/clinics in their country for people with RMDs Secretariat: Patient Central contracted by The Work Foundation Current Membership: Professor Emery (UK), Professor Jover (Spain), Professor Matucci (Italy), Professor Faustino (Portugal), Professor Fitzgerald (Ireland), Dr Steve Brennan (UK)

Task Force Purpose and short-term objectives

Support the production and expert endorsement of material that allows the development of early intervention for RMDS:
Produce Evidence Base (in short-term based on Spanish early intervention programme with input in longer term from UK model) Clinical and financial analysis of Jover data: Key principles, learnings and outcomes

Collation and analysis of data and activity from wider Spanish Early Intervention Programme

Early Intervention Toolkit

For clinicians interested in setting up EI clinics:
The rationale for early intervention key principles

How to set-up early intervention clinics lessons from Spain and UK

Further elements to be informed by:
- The Working Groups meeting at EULAR 2014 - Follow-up from Summit and FfW ambassadors their needs

Early Intervention Clinic Principles

Rapid referral
Rapid assessment

Expert assessment:
Confirm diagnosis Confirm appropriate management Simple intervention for 90% of patients referred Patient education and engagement Early discharge to return to work

Model: Early Intervention for RA

Early intervention now established as effective in preventing disability and work loss
Early arthritis clinics routine Ambition remission-induction Disease prevention now on agenda

Effect of RA Disease Duration on Inflammation and Function

Inflammation Function

Severity

Time Interventions
Emery P. Ann Rheum Dis. 1995;54:944

Early Intervention: UK

Introduction
Project to demonstrate early intervention reduces work disability in musculoskeletal patients demonstrate early intervention improves patient outcomes and increases patient satisfaction deliver unique UK data on early intervention and work disability to drive a cost-effectiveness model

deliver a model for treating high volume musculoskeletal problems and associated work disability

Enhancing the MSK Service: Leeds

Current Service Leeds Musculoskeletal Service receives 25,000 referrals per year; 90% are seen by physiotherapists. Accessed by three CCGs (450 GPs in Leeds)
6-8 weeks waiting time to see a physiotherapist

No strict criteria or protocols relating to referral based on GP judgement

Enhancing the MSK Service: Leeds

Enhanced service Rapid confirmation of diagnosis (within 5 days of being signed off sick)
Rapid assessment and initiation of appropriate management (within 5 days of being signed off sick from work) Earlier and structured initiation of patient education, selfmanagement/coping strategies plan

Provision of simple, psychological assessment

The small numbers who may need further specialist assessment and investigations will get earlier referral

Discharge plan based on fit for work status or permanent disability

Enhancing the MSK Service in Leeds

GP Refers on first issue of unfit to work certificate (Med 3) Level 1 Cohort Randomised 1,500 750 Education, Self management, basic investigations 4-6 weeks ( 2 ) Return to work Permanent Disability

Control Group=750

Level 2 Formal Rehabilitation Diagnostics 4-8 weeks ( 3 )

Return to work Permanent Disability

Level 3
Diagnostics Onward Specialist Referral

Return to work Permanent Disability

Enhancing the MSK Service in Leeds

Local-Buy In and Project Steering Group Service Enhancement Project Steering Group formed (supported by the Director of Public Health, Dr Ian Cameron). A process of stakeholder engagement undertaken to identify and confirm support and contribution of the necessary collaborators to deliver project
Managerial Representatives of Leeds Community Health Care Trust

Transformational Lead for 3 CCGs in Leeds Dr Chris Mills Clinical Lead: Dr Steve Brennan Academic Lead: Professor Paul Emery Project Lead: Rhonda Siddall

Project Phases

Phase I: Configuring an enhanced service

Phase II: Delivering an enhanced service

Phase III: Assessing the value of an enhanced service

Phase IV: Producing the service enhancement model template + communicating the results

Phase II: Delivering an enhanced service

Service Model: 6 dedicated clinics per week over 2-3 sites owned by Leeds Community Healthcare Trust Clinics run by MSK Physician Steve Brennan (Leeds Community Healthcare Trust)
IT and Administrative Support Provided by Leeds Community Healthcare Trust Service Data System compatible with GP system (System 1) via a shared access agreement

Phase III: Assessing the value of an enhanced service

Project Period: 18 months
Number of Patients: 750 (compared to control group of 750; control managed by GPs)

Process:
- Data Capture: Integrated System 1 - Interrogation and Analysis: done by Leeds Community Healthcare Trust and Dr Steve Brennan

Outcomes Assessed:
Impact on temporary work disability (TD) Impact on permanent work disability (PD) Patient Satisfaction Impact on onward referral and investigation costs

Thank you for attending the Fit for Work Summit 2013.
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