Quality and Safety in Healthcare in an Age of Austerity

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.

http://www.nuffieldtrust.org.uk/data-and-charts/uk-spending-public-and-private-health-care

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

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.

High Quality Good Access Contain Costs

The Micawber Syndrome

Access

Quality

Access

• Result: HappinessPick any two

• Result: MiseryPick three

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

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....

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

manage upwards

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

ED 4 hour waits. % seen within 4 hours seems to vary with the numbers that come in

“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

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

Medical Leadership

Focus on ‘the what’

Think like a

patientConsent

Standards

Bad eggs Learning systems

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

http://journal.diabetes.org/clinicaldiabetes/v17n11999/Pg19.htm

Achieving quality and safety by eliminating procedures and practices that confer little or no health benefit is like.....

photo courtesy www.nycorganizers.com

acknowledgements: deborahjcabral.com

.... decluttering your garage...

.... to make space for your car...

Thank you

Quality and Safety in Healthcare in an Age of Austerity

gorway global consulting

chair of quality

declining quality

health services

ensuing economic recession

energy equitable care

nhs https

kings fund work

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