Creating a cost effective and sustainable health system using an evidence base Health Workforce 2025 Anne Kolbe ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD Chair, New Zealand National Health Committee

Declarations of Interest Vocationally registered paediatric surgeon Chair, National Health Committee Director, Pharmaceutical Management Agency (PHARMAC)

National Health Committee Section 11 advisory Committee responsible for providing the Minister of Health with recommendations on: Which technologies should be publicly funded in New Zealand To what level and where technology should be provided How new technology should be introduced and old technology removed

Today … Challenges - why we need to change! Health, wellness and independence - prosperity Vote Health GDP and GNP Burden of disease Technology - goods and services Capital, back office and IT infrastructure Workforce

Today … Opportunities Evidence - data, information and knowledge Models of care Explicit prioritisation Enablers Values based relationships Innovative macro level thinking Business / clinical partnership Collaboration and teamwork Leadership

Leadership values Honesty Integrity Openness Passion Diligence Perseverance Courage Resilience Humility Concern for others Commitment to service

Leadership competencies Know oneself Understand the business Horizon scan, develop and maintain the “collective” vision, position the business De-construct and manage complexity See opportunities not problems

Leadership competencies Embrace innovation Take risks and learn from mistakes and allow others to do the same Listen, empathize and learn! Delegate and facilitate the actions of others Build and nurture teams Recognize and celebrate success

Working together! Astute leaders foster co-operation, collaboration, networks and partnerships

What are we trying to achieve? Safe, quality health, wellbeing and independence outcomes for individual patients and populations Live within our means - value for money and affordability Sustainability

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012 Sustainability Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debt.

Source: OECD Health Data, 2012

Growth in core Crown health spending has outstripped national income … Core Crown health expenditure per capita and GDP per capita indexed real growth Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012

Vote Health 12/13: NZ$14 billion Source: New Zealand Treasury 2012

LEGATUM INSTITUTE | THE 2013 LEGATUM PROSPERITY INDEXTM

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012 Why is health care spending increasing? Demographics - in part Non demographics - may be as important! Income growth - expectations Technology - widening scope to treat Lower productivity growth than the rest of the economy - health care is labour intensive

Consider … Our systems have developed to manage acute life threatening conditions. Care is episodic and reactive Emphasis on hospitals and doctor lead care organised around medical specialties Patients often seen as passive rather than active contributors to their own care

Increasing population of people with Long Term Conditions (LTC) COPD, diabetes, CVD, dementia and some cancers Most of these people have >1 LTC Many are over 65 years LTC are a potent driver of ambulatory care sensitive admissions and costs But the world has changed …

Trends in Age-Standardized Death rates for the Six leading Causes of Death in the United States, 1970 – Jemal A, Ward E et al (2005). Trends in the Leading Causes of Death in the United States, Journal of the American Medical Association 295 (10):

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012

NHS 3.6 m (21.9%) of ED attendances require admission 37% increase in 10 years 65% are older (>65 years) - frail, dementia, complex needs Utilise 51,000 ABD (70% of total available ABD) 33% fewer, general and acute beds Ave LOS now increasing for patients >85 years Evidence of fractured care, breakdown in out of hours care, medical workforce crisis, capital and IT limitations RCP 2012

Just in case you think … Australia 12 chronic conditions accounted for 1.5m (21.8%) of hospital separations Stroke COPD CHD Diabetes Average LOS days AIHW New Zealand 21% increase in acute medical discharges (225,000) Chest Pain 3.6% GI 3.5% Respiratory Infections 3.5% Cellulitis 3.0% Circulatory Disorders 2.5% COPD 2.5% Abominal pain 2.5% Neonatal 2.8% NZ Ministry of Health 2012

The challenge is to adapt the system to the changing burden of disease in the face of expanding technology options and constrained resources

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future Wellington, December 2012 So what are the implications for strategic policy? Encourage active healthy populations - minimize needs and costs Early identification of diseases Quality and cost effective management of disease in the community - health and social sector Ensure the workforce, IT infrastructure, capital investment and funding streams are developed and aligned to enable the changing models of care

NHC approach … Evidence based, assessment and prioritisation of non-drug technologies with a focus on models of care Four domains Clinical safety and effectiveness Societal and ethical Economic Feasibility of adoption 11 decision making criteria A4R framework

NHC Programme Budget 12/13 Source; NHC Executive analysis 2013

Source; NHC Business Plan 2013

NHC Tiered Business Approach to Work Plans Sector Engagement and Participation Source; NHC Business Plan 2013

NHC Programme Budget 12/13 Source; NHC Executive analysis 2013

Tier 1 Strategic Overview Respiratory Disease in New Zealand $265m public casemix hospital discharges 10 disease states within respiratory disease prevalence, incidence, health outcomes, health utilisation and cost Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care Source: NHC Respiratory Disease in New Zealand

Source; NHC Executive analysis 2013

Source:2013 NHC Executive analysis of /12 NMDS and 2010 National Mortality Collection Burden of Respiratory Disease

Source: NZBDS 2013 DALY Breakdown by Percentage Death Breakdown by Percentage

Incident Diseases: Efficiency Gains Required to Reach $5 million 2013 NHC Executive Analysis of 2011/12 NMDS

Source; NCH Decision Making Paper 2013

Tier 2 COPD: A Pathway to Prioritisation Source: OECD Data 2011

NHC Programme Budget 12/13 Source; NHC Executive analysis 2013

Renal Sympathetic Nerve Ablation Estimated prevalence of resistant hypertension Australia n= 260,000 New Zealand n= 97,000 Costs Index admission A$11,000 Medical management A$1,200 “Back of the envelope” budget impact … Australia >A$3 billion New Zealand A$1 billion So where does this intervention fit in a model of care for refractory hypertension and what is the appropriate target population? Isler M et al. Lancet 2010; 376: Krum H. Hypertension 2011; 57: HealthPACT 2013

TAVI for Aortic Stenosis Application; NHS per million population? Comparator; sAVRepl Approximate costs index admission + 2years FU care sAVRepl A$25,000 TAVI A$63,000 Questions How to identify the population most able to benefit? Substitution or Addition financial methodology?

So …

Success … Long run game - there are no simple solutions or quick wins! The changes are complex, multifaceted and need to occur at all levels “Big picture” strategy - involves action Evaluation, evaluation, evaluation … and constant tweaking! Consistent and persistent national leadership

…before writing the prescription for the health workforce of the future it will be important to consider the best business strategy for the delivery of health care into the future!