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Quality and safety in an age of austerity
Dr Jammi N Rao MD FRCPDirector, Gorway Global Consulting,
Non-Exec Director, and Chair of Quality and Risk Committee, HEFT, Birmingham
AUSTERITY
The 2007-8 financial crisis and the ensuing economic recession has had far-reaching effects all over the world. Public expenditure on the NHS has remained steady at about £120 billion since 2009. As a percentage of GDP UK spend on health is low despite the Blair promise of 2001 but the NHS is recognised to be the most efficient system
Austeritynoun
1. sternness or severity of manner or attitude.
2. difficult economic conditions created by government
measures to reduce public expenditure.
Northern Rock nationalised, 22 Feb 2008
Recession
AusterityMay2012 Local elections
Popluarity over time of two search terms that reflect interest in our recent economic fortunes.
Source: chart from Google Trends, 22 June 2015
May2015 General elections
Campos C, Dent A, Fry R, Reid A. Impact of the recession. Regional Trends 43, 2010-11. Offie of National Statistics. http://www.ons.gov.uk/ons/rel/regional-trends/regional-trends/regional-trends--july-2011-edition/impact-of-the-recession.pdf. Accessed 22 Jun 2015.
© Gorway Global Consulting
http://www.nuffieldtrust.org.uk/data-and-charts/uk-spending-public-and-private-health-care
© Gorway Global Consulting
http://www.nuffieldtrust.org.uk/data-and-charts/uk-health-spending-share-gdp
http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
Commonwealth Fund report “Mirror, Mirror on the wall, 2014 update
WHAT DO WE MEAN BY QUALITY
© Gorway Global Consulting
Quality: The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Safe: avoiding injuries to patients from care that is intended to help them
Effective – avoiding both under use and overuse of services that are based on
scientific knowledge
Patient centred – care that is respectful
and responsive to individual patient
preferences
Timely reducing waiting and delays for both patient and carer
Efficient: avoiding waste. Equipment, supplies, ideas and
energy
Equitable care that does not vary in quality
due to personal characteristics,
geography, demographic factors
DOES AUSTERITY THEN MEAN STAGNANT OR DECLINING QUALITY?
Yes if you are a victim of the Micawber Syndrome.
© Gorway Global Consulting
High Quality Good Access Contain Costs
The Micawber Syndrome
Access
Cost
Quality
Cost
Quality
Access
• Result: HappinessPick any two
• Result: MiseryPick three
© Gorway Global Consulting
Health care systems around the world will not survive in austere times – let alone deliver high performance – without exceptional medical leadership. This is because the most important opportunities to improve productivity are to be found in unwarranted variations in clinical practice, such as prescribing, the use of diagnostic tests, and lengths of stay in hospital.
Chris Ham, Kings Fund. 2015.
Kings Fund work on improving productivity in NHS
https://vimeo.com/93357257
© Gorway Global Consulting
Length of stay
Use of specific procedures
Follow up rates in outpatients
Antibiotic prescribing rates
Referral rates for common symptoms
Rates of use of imaging modalities
The standard economic view of NHS productivity
This leads to a certain view of the role of medical leadership, not always helpful to quality and safety....
© Gorway Global Consulting
Medical Leadership(or is this medical management)
Focus on the needs of the Trust
Think like a manager
satisfy inspectors
Help the Trust to meet targets
avoid negative
press
manage upwards
© Gorway Global Consulting
it is clinically meaningless and academically reckless to use ... (SHMR – standardised hospital mortality ratios, SHMI standardised hospital mortality index) ...to quantify actual numbers of avoidable deaths.
Bruce Keogh1,July 2013
1. Keogh, B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf
© Gorway Global Consulting
ED 4 hour waits. % seen within 4 hours seems to vary with the numbers that come in
© Gorway Global Consulting
“Use quantitative targets with caution. Goals in the form of such targets can have an important role en route to progress, but should never displace the primary goal of better care. When the pursuit of targets becomes, for whatever reason, the overriding priority, the people who work in that system may focus too narrowly. Financial goals require special caution; they reflect proper stewardship and prudence, but are only a means to support the mission of the NHS: healing.”
1. A promise to learn, a commitment to act. The Berwick report, Aug 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
Don Berwick1, Aug 2013.
LETS LOOK AT QUALITY AGAIN
© Gorway Global Consulting
Quality: The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Safe: avoiding injuries to patients from care that is intended to help them
Effective – avoiding both under use and overuse of services that are based on
scientific knowledge
Patient centred – care that is respectful
and responsive to individual patient
preferences
Timely reducing waiting and delays for both patient and carer
Efficient: avoiding waste. Equipment, supplies, ideas and
energy
Equitable care that does not vary in quality
due to personal characteristics,
geography, demographic factors
© Gorway Global Consulting
Medical Leadership
Focus on ‘the what’
Think like a
patientConsent
Standards
Bad eggs Learning systems
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
Conclusions The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.
http://www.bmj.com/content/350/bmj.h2747
2015; 350 doi: http://dx.doi.org/10.1136/bmj.h2747 (Published 16 June 2015)Cite this as: 2015;350:h2747
© Gorway Global Consulting
http://journal.diabetes.org/clinicaldiabetes/v17n11999/Pg19.htm
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
© Gorway Global Consulting
Achieving quality and safety by eliminating procedures and practices that confer little or no health benefit is like.....
© Gorway Global Consulting
photo courtesy www.nycorganizers.com
acknowledgements: deborahjcabral.com
.... decluttering your garage...
.... to make space for your car...
© Gorway Global Consulting
Thank you