The Business Case for Quality

1. Gerry Marr Chief Executive The Business Case for Quality

2. 76.2% of GDP c £44K for each economically active person in the UK 36.5% of GDP Multiplied by 5 in 2 years & represents 12.4% of GDP Calculated using latest data from National Statistics c £17K for each economically active person in the UK

3. Scottish Parliament Finance Committee -Report On Strategic Budget Scrutiny June 2009 • The Centre for Public Policy for Regions (CPPR) Risk Analysis • “By 2013-14 the (Scottish) Budget will be between roughly £2 billion and £4 billion lower in real terms than at its peak in 2009-10. • That represents a 7 to 13 per cent real terms cut over that four to five-year period.” • In the period forward to 2017-18 it expects “a return to positive, but very low, real-terms growth of perhaps around 1 per cent.” • This compares with its estimate of an average of 6 per cent per year growth in the Scottish budget over the first six or seven years of devolution.

4. The Balance of Quality and Cost

6. Efficiency is a dimension Quality. It can be safer care, more timely and can offer better patient experience.

7. The Healthcare Quality Strategy for Scotland • Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. • Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. • Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

8. Action Groups

10. Quality & Efficiency – Two sides of the coin “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.”

11. “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets” Aim, Objectives & Scope • Framework objectives: • Quality is not compromised; • NHSScotland will achieve financial balance over the SR10 period; • NHS Boards are supported in achieving efficiency targets and improving services; and • Central co-ordination of support, monitoring, benefits realisation and challenge will be available to NHS Boards. • Three Framework themes: • Support – supporting our workforce; • Enablers – identifying, sharing, sustaining good practice; • Cost reductions – reducing variation, waste and harm.

12. Efficiency and Productivity Framework “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.” Focussed Approach: • Work-streams identified and links made to QAB and Delivery Groups • Portfolio Board established to identify priority projects • Return on Investment • Collective approach to implementation of what works. How? • Support – supporting our workforce through engagement, partnership and placing quality at the centre. • Cost reductions – using the data to identifypotential based on variability of care • Enablers – identifying, testing sharing and sustaining good practice.

13. Work-streams: Reducing Variation, Waste and Harm • Primary Care & Community • Patient Flow & Acute Services • Workforce Productivity • Evidence Based Care • Prescribing, Procurement & • Shared Services • Service Redesign & Innovation Service Redesign

14. How is this different from traditional cost-cutting? • Requires process literacy and redesign • Holds quality the same or improves it • Needs different ways to categorize costs and transparency • Can unite people in a cause to control health care costs

15. Content / Quality of Care1,2 Technical quality worse No more elective surgery More hospital stays, visits, specialist use, tests Health Outcomes1,2 Slightly higher mortality No better function Physician’s perceptions5 Worse communication among physicians Greater difficulty ensuring continuity of care Greater difficulty providing high quality care Greater perception of scarcity Patient-perceived quality1,3 Lower satisfaction with hospital care Worse access to primary care The Paradox of PlentyWhat do higher spending regions -- and systems -- get? Trends over time4 Greater growth in per-capita resource use Lower gains in survival (following AMI) (1) Ann Intern Med: 2003; 138: 273-298 (2) Health Affairs web exclusives, October 7, 2004 (3) Health Affairs, web exclusives, Nov 16, 2005 (4) Health Affairs web exclusives, Feb 7, 2006 (5) Ann Intern Med: 2006; 144: 641-649

16. Integrating Finance and Quality

17. 84% 61% 41% 24% 9% Healthcare demand is growing A new Ninewells Hospital by 2031! NHS Tayside +148 beds 2016 +517 beds 2031

18. Evidence of Waste in Healthcare Systems

19. Six Categories of Waste (Muda) • Delay: idle time spent waiting for something, such as utilisation reviews, insurer payments, test results, patient bed assignments, OR prep, medical appointments. • Re-work: performing the same task a second time, such as re-testing, re-scheduling, re-filing of lost claim forms, re-writing of patient demographic data, multiple bed moves. • Overproduction: manufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, surplus medications, excessive levels of paperwork. Cont. 

20. Six Categories of Waste (Muda) • Movement: unnecessary transport of people, products or information, such as requiring patients to see a primary care provider before seeing a specialist who is clearly needed. • Defects: design of goods that do not meet customer needs, such as medication errors, wrong side surgery, poor clinical outcomes. • Waste of Spirit and Skill: failure to address the many hassles in our daily work, hunting and gathering, re-calling, the same things every day

21. Increase Capacity of Outpatient Clinics? Are there significant Outpatient Capacity losses? 25.0 20.0 Opportunity? 15.0 New % Return 10.0 5.0 0.0 Discharged AWAITING TEST REFD OTHER DNA-Total Could Not Wait - FA REFER TO OTHER RESULT CLIN/HOSP HOSP 46% of New Outpatient appointments are being wasted!

22. Evidence of Clinical Variation in Healthcare Systems

23. Are there significant variations in hospital expenditure by GP practice?

24. Are there significant variations in prescribing practices?

25. Are there significant variations in clinical practices in prescribing medicines? Variation by Defined Daily Dose per 1000 patients

26. Map 2 Cancer inpatient expenditure per 1000 population by PCT

27. Map 4: Percentage of people with diabetes receiving nine key care processes by PCT

28. Map 7: Mental health expenditure per 1000 population by PCT

29. Map 21: Rate of provision of hip replacement per 1000 people in need by local authority

30. Improving Quality and Reducing Costs Our Choice Surviving – the 5% Thrive – the 95%

31. Triple Aim Health of the Population Best Value for Money Experience of Care

32. The Inequalities Challenge • Reducing failure demand • 40% of public spending is driven by demand created by preventable negative outcomes in individual and community lives (National Community Planning Group) • (Such demand can only be maintained by sustaining the high growth of the last decade!) • The most deprived 100 areas exhibit consistent, interacting and mutually reinforcing negative outcomes across all aspects of life (The Scottish Index of Multiple Deprivation) • Children achieve 25% of that achieved in least deprived areas • 20% adults prescribed anxiolytics and antidepressants • 3 in every 10 adults admitted as an emergency (life expectancy 10 years less) • Crime 8 times higher than the average • Ref : Making Better Places: Making Places Better)

33. Inequalities – what we need to do • Reduce Failure Demand • A substantial amount of Scottish public expenditure is driven by failure demand • Prevention of Early Intervention • The solution to this is to stop theses negative outcomes occurring or reducing their impact on peoples lives • Localisation and Integration of Public Services • The complexity of these issues is the driver for integration • A Change of Approach as well as Focus and Locus • Public services cannot ‘do’ positive outcomes to people or communities. At their best, they can support them to pursue and achieve positive outcomes in their own lives Ref: Making Better Places, Making Places Better

34. 2009 - 2011 TACTICAL STRATEGIC PRODUCTIVITY & EFFICIENCY SERVICE OPTIMISATION CRES TRANSFORMATION DEALING WITH THE 5% SPENDING THE 95% BETTER

35. 2010 - 2013 TACTICAL STRATEGIC PRODUCTIVITY & EFFICIENCY SERVICE OPTIMISATION CRES TRANSFORMATION DEALING WITH THE 5% SPENDING THE 95% BETTER

36. The Leadership ChallengeWe need to deliver on our statutory responsibilities as well as our ‘contract’ with Government for services which meet the dimensions of quality.But we also need to create capacity and capability within the system to realise the potential for reducing unwarranted variation, waste an harm as well as negative outcomes for our communities.The simple truth is that it is these resources that will realise our ability to transform our public services.

37. There Is No Recession In Innovation “Fortunes are NOT made in the boom times...That is merely the collection period.  Fortunes are made in depressions or lean times when the wise man overhauls his mind, his methods, his resources, and gets in training for the race to come." George Wood Bacon