derek feeley: scotland - why quality is the best response to the financial challenge
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The King’s Fund2012 Annual Conference
Derek Feeley
Director General Health and Social Care and Chief Executive of NHS Scotland
NHS Scotland
• c. 5.1 million population• Devolved (since 1999)• 14 Regional Boards• Integrated system ( e.g. no
purchaser/ provider split)• Integration of health and
social care underway• Tax funded/ cash limited• Equal access on basis of
need• Free at the point of care
Health Budget Real Terms Summary
Note: This presentation provides a high level position based on published budget figures. It should be noted that budgets between years are not directly comparable due to transfers between portfolios and other budgetary and accounting adjustments (e.g. HM Treasury cost of capital removal)
00-01£m
01-02£m
02-03£m
03-04£m
04-05£m
05-06£m
06-07£bn
07-08 £bn
08-09£bn
09-10£bn
10-11£bn
11-12£bn
12-13£bn
13-14£bn
14-15£bn
overallIncrease
£bn
OverallIncrease
%
Health Budget (Cash) 5.521 6.162 6.474 7.227 8.048 8.790 9.531 10.215 10.642 11.058 11.182 11.369 11.583 11.803 11.946 6.425 116.4%
Health Budget (Real at 2000-01 prices) 5.521 6.047 6.198 6.769 7.322 7.818 8.255 8.632 8.754 8.962 8.812 8.751 8.682 8.631 8.522 3.001 54.4%
Health Budget Cash and Real Terms Summary 2000-01 to 2014-15
5
6
7
8
9
10
11
12
'00-01
'01-02
'02-03
'03-04
'04-05
'05-06
'06-07
'07-08
'08-09
'09-10
'10-11
'11-12
'12-13
'13-14
'14-15
Financial Year
Budget£bn
Cash
Real
Health spend – 4 nations
0
500
1,000
1,500
2,000
2,500
2007-08 2008-09 2009-10 2010-11 2011-12
England
Scotland
Wales
NorthernIreland
UK identifiableexpenditure
Identifiable Expenditure per capita on Health, UK and countries, £
Source: HM Treasury Oct 2012
Health spend – Scotland and English regions
0
500
1,000
1,500
2,000
2,500
2007-08 2008-09 2009-10 2010-11 2011-12
North East
North West
Yorkshire andthe Humber
East Midlands
West Midlands
East
London
South East
South West
Scotland
Identifiable spend per capita on health, Scotland and English Regions, £
Source: HM Treasury Oct 2012
Identifiable Expenditure per head on health, £ 2011-12
London 2,102North East 2,095North West 2,029Yorkshire and the Humber 1,905West Midlands 1,865South West 1,771East Midlands 1,728 East 1,711South East 1,702England 1,874, Scotland 2,091,
Source: HM Treasury, Oct 2012
4 key challenges
• Economic
• Demographic
• Population health
• Changing expectations
Triple Aim
Health of the
Population
Experience of Care
Best Value for Money
The triple aim
Integration
3 quality ambitions
• Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
• No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.
• The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
HSMR: Scotland Jan. ’08 Mar. ‘12
0.80
0.85
0.90
0.95
1.00
1.05
Jan-M
ar 2
008
Apr-Jun 2
008
Jul-S
ep 2
008
Oct-D
ec 2
008
Jan-M
ar 2
009
Apr-Jun 2
009
Jul-S
ep 2
009
Oct-D
ec 2
009
Jan-M
ar 2
010
Apr-Jun 2
010
Jul-S
ep 2
010
Oct-D
ec 2
010
Jan-M
ar 2
011
Apr-Jun 2
011
Jul-S
ep 2
011
Oct-D
ec 2
011
Jan-M
ar 2
012p
HS
MR
1.03
0.89
10.6% reduction
6640 less than expected deaths
0.6
0.7
0.8
0.9
1.0
1.1
1.2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Quarters
Sm
oo
thed
S
MR
Hospital Standardised Mortality Ratios (Seasonally Adjusted)Scotland: Oct-Dec 2002 to Jan-Mar 2012
average yearly reduction 4.2%
(Apr 2010 to Mar 2012)
1.4% average yearly reduction
(Oct 2002 to Jan 2010)
Implications for costs – what do we know?
• Poor quality is costly• Costs and benefits are
spread over time and between stakeholders
• The context matters• Better data would help
Quality and cost - it’s complicated….
Too bad all the people who know how to run the country are busy driving cabs and cutting hair.
-- George Burns
Why quality?
• Waste, harm and variation
• Poor quality costs more
• Clinical engagement
• Thrive or survive?
• Route to longer term sustainability
• What is the alternative?
The alternative?
Or this…..?
0
0.5
1
1.5
2
2.5
Jan-
08
Apr-0
8
Jul-0
8
Oct-08
Jan-
09
Apr-0
9
Jul-0
9
Oct-09
Jan-
10
Apr-1
0
Jul-1
0
Oct-10
Jan-
11
Apr-1
1
Jul-1
1
Oct-11
Harm - General ward C.Difficile rate(per thousand patient days)
1.15
0.12
90% reduction
Cost of infection
Cost of infection (Pennsylvania)
Tackling variation – high cost, high volume services
Prepared by Peter Knight JIT June12
Bedday rate for patients aged 75+, emergency admissions
4000
4500
5000
5500
6000
6500
Year ending
Bed
day r
ate
per
1000 a
ged
75+
Borders
Lothian
BoardaverageHighland
Ayrshire &ArranTayside
Sept-11
Re-shaping Care Prog/LTC Prog
~550 beds
Sustainability - quality and efficiency
Improving quality and reducing costs
Our choice
Surviving – the 3%
Thriving – the 97%
The future - getting to the third curve
Time
Perform
ance
Performance
Improvement
Co-production& assets
1941, William A. Foster
"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction
and skillful execution; it represents the wise choice of many
alternatives.”
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