The Business Case for Quality Gerry Marr Chief Executive

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

Budget “Building Britain’s Future” Overall UK Public Expenditure £5bn additional “value for money” savings” in 2010/11 Up to £9bn additional recurring savings by 2013/14 Real terms growth of 0.7% between 2011/12 and 2013/14

Scottish Parliament Finance Committee - Report On Strategic Budget Scrutiny June 2009 The Centre for Public Policy for Regions (CPPR) Risk Analysis “By the (Scottish) Budget will be between roughly £2 billion and £4 billion lower in real terms than at its peak in That represents a 7 to 13 per cent real terms cut over that four to five-year period.” In the period forward to 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.

The Balance of Quality and Cost

Responding to what patients want and need

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.

Action Groups SafeEffectivePerson-centredInfrastructure Acute SPSPChildren and families Ethos and leadership Measurement Paediatric SPSPPopulation healthEquality and mutuality E-health Mental health SPSPReshaping careEnablement and self-management Communications Primary care SPSPExperience and outcomes QI Hub HAIEffective practitioner Education and workforce development Governance Physical environment

Aim, Objectives & Scope Three Framework themes: Support – supporting our workforce. Enablers – identifying, sharing, sustaining good practice. Cost reductions – reducing variation, waste and harm. 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. “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.”

Tackling Variation – high cost, high volume services

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

The paradox of plenty What do higher spending regions -- and systems -- get? Technical quality worse No more elective surgery More hospital stays, visits, specialist use, tests Content / Quality of Care 1,2 Slightly higher mortality No better function Health Outcomes 1,2 Worse communication among physicians Greater difficulty ensuring continuity of care Greater difficulty providing high quality care Greater perception of scarcity Physician’s perceptions 5 Patient-perceived quality 1,3 Lower satisfaction with hospital care Worse access to primary care Trends over time 4 Greater growth in per-capita resource use Lower gains in survival (following AMI) (1) Ann Intern Med: 2003; 138: (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:

Thriving In The New Environment Aims: How much? By When? “Big Dot” clinical aims 1-3% waste reduction per year, year on year Improve Safety Engage Patients Improve Efficiency Leadership Reduce medical errors and harm Reduce “never events” Chronic conditions self-management Prevention and wellness (start with your staff) Transparency for high-performing providers Shared decision making New models for medically complex patients Palliative care improvement Reduce artificial variation (LOS, use rates, readmissions, etc.) Eliminate “flow faults” Set a goal of reducing waste by 1-3% of operating expense budget for I year, year on year Create a culture of getting value for money Adopt a proactive approach to errors and harm to reduce malpractice claims and costs Engage the Board

Integrating Finance and Quality Context FinancialWaste DemographicHarm Safety & QualityVariation

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

Older peoples services – why reform? Tayside estimated 65+ Bed Day cost £63M per annum 10% reduction represents a £6.3m annual saving Demographics – 84% growth by 2031

= Constraint GP feedback Tayside Whole System Model - Imbalance = Queue Before Activity = Target Challenge = Trend in Volume = Known Issue = Suspected Issue Q T Areas of Imbalance: 1.Queues in the system Referral to 1 st Appointment Admission queues post Decision to admit (Ward 15) Awaiting inpatient beds in the Community 2.Performance Vs. Target Utilisation of some community beds 18 week RTT Internal targets on Turnaround 3.Trends Increasing trend in GP referrals up 12% Urgent & Emergency admissions up 7% 4.Constraints Average Length of Stay in Community Hospitals is 21 days Availability of data T T acute receiving ward (Med/Surg) out-patient Q routine discharge complex discharge Q T Q C Q Q C

Evidence of Waste in Healthcare Systems

Six Categories of Waste (Muda) 1.Delay: idle time spent waiting for something, such as utilization reviews, insurer payments, test results, patient bed assignments, OR prep, medical appointments. 2.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. 3.Overproduction: manufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, surplus medications, excessive levels of paperwork. Cont. 

4.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. 5.Defects: design of goods that do not meet customer needs, such as medication errors, wrong side surgery, poor clinical outcomes. 6.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 Six Categories of Waste (Muda)

27% of New Outpatient appointments are being wasted! Are there significant Outpatient Capacity losses? Increase Capacity of Outpatient Clinics? Opportunity? DischargedAWAITING TEST RESULT REFD OTHER CLIN/HOSP DNA-TotalCould Not Wait - FAREFER TO OTHER HOSP % New Return

Evidence of Clinical Variation in Healthcare Systems

Are there significant variations in hospital expenditure by GP practice?

Are there significant variations in prescribing practices?

Are there significant variations in clinical practices in prescribing medicines? Variation in Gross Ingredient Cost (GIC) per 1,000 patients across practices

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

Pearson Correlation Coefficient = The chart shows a weak positive correlation between prescribing costs per head and cost per head for General and Acute IP/day case spend. This suggests that practices that tended to spend more per head on prescribing also spent more on General & Acute IP/DC total per head in 06/07 Prescribing costs per head vs General & Acute IP/DC costs per head Does spending more on medicines reduce use of acute services?

Examples of Variation in Clinical Practice Poly pharmacy Referral patterns into acute specialist care Rates of admissions in over 65 years Lengths of stay in over 65 years

Achieving Quality Improvement and Cost Reduction

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

TACTICALSTRATEGIC DEALING WITH THE 5% SPENDING THE 95% BETTER PRODUCTIVITY & EFFICIENCY CRES SERVICE OPTIMISATION TRANSFORMATION

TACTICALSTRATEGIC DEALING WITH THE 5% SPENDING THE 95% BETTER PRODUCTIVITY & EFFICIENCY CRES SERVICE OPTIMISATION TRANSFORMATION

TACTICALSTRATEGIC DEALING WITH THE 5% SPENDING THE 95% BETTER Prevention of admission Improved Day care Improved service liason and discharge Reduced hospital stays and bed days Case management – improved pathways Intermediate care Care home interface Medications reviews Housing/home care support Technologies Maximise health and social care services Cost minimisation Workforce efficiencies Teleheath/telecare Virtual wards Workforce redesign Self care and enablement New models of care in dementia, falls, end of life care Working with communities - coproduction

Steps to Better Healthcare Mental Health Out Patients Theatre Capacity / Planned Care WorkforceIntegrated care communities Child health Optimisation of Health Facilities across Tayside Prescribing and Medicines Finance Support Workforce Support Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases Workforce Modelling, Engagement & Communications with staff Comms Support Communications with public and staff Other OE Support Organisational Effectiveness support Labs Maternity

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