Mark Jennings, Director of Health Care Improvement at The King's Fund, discusses the impact of the economic downturn on health care.

1. Quality in a
Cold Climate:
The Opportunities
Mark Jennings
Director of Health Care Improvement
24th November 2009
©The King’s Fund 2009

2. + Quality
NHS Plan Efficient care is
quality care
(2000 - 2011)
(2011 on)
•Growth
•a new paradigm
•‘Quality costs’
•Continuous
•Productivity falls improvement +
_
Siege Efficiency
(2011 on) Cost Control
•Fragmented system (1980s and 90s)
•Wrong decisions •Slash and burn
•Lower quality and •‘Efficient’ but lower
efficiency quality
_
©The King’s Fund 2009

3. A New Health Care Paradigm
Health care can only considered
to be high quality if it is also
efficiently delivered.
©The King’s Fund 2009

4. Why do you rob banks?
"because that's
where the money
is."
Will Sutton
©The King’s Fund 2009

5. Where is the money?
Clinical reconfiguration?
Moving care outside hospital?
Estates rationalisation?
Health and social care integration?
Organisational restructuring?
Improving what we already do?
Variation in care and care delivery
©The King’s Fund 2009

6. Why look at variation?
Improve cost
Improve quality
Improve effectiveness
Improve patient experience
©The King’s Fund 2009

7. Natural variation Artificial variation
Inevitable Created by the way
characteristic of any the system is
healthcare system managed
Variation in patient Variation in the way
characteristics the care is provided
©The King’s Fund 2009

8. Natural variation Artificial variation
demographic differences:
staff skills and skill mix
– sex
– age individual practice
– socio-ecomonic status
scheduling of staff and
– race and ethnicity appointments
time of year staff absence:
type and severity of illness – planned absence
– unplanned absence
Patient & public
expectations ward rounds
geography
availability of buildings
availability of technology
past spending patterns
©The King’s Fund 2009

9. Wennberg
“Variations in Care are
often idiosyncratic and
unscientific with local
medical opinion and local
supply of resources
appearing more
important than science in
determining how medical
care is delivered”
[J.Wennberg, BMJ, October 2002]
©The King’s Fund 2009

10. Unjustified variations in health care
cause…..
Increased cost
Reduced quality
©The King’s Fund 2009

11. Variations in:
What we do
How we do it
©The King’s Fund 2009

12. ©The King’s Fund 2009

13. Inpatients
Percentage of patients admitted on the day of operation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Acute hospital trusts
[Source: NHS Better Care, Better Value Indicators]
©The King’s Fund 2009

14. Outpatients
20.00
18.00
16.00
14.00
DNA Rate (%)
12.00
10.00
7.10%
8.00
6.00
4.00
2.00
0.00
0.00 0.50 1.00
1.90
1.50 2.00 2.50 3.00 3.50 4.00
Follow Up to New Ratio
Follow Up/New Ratio to DNA% - Q1 2008/2009
[Source: NHS Better Care, Better Value Indicators]
©The King’s Fund 2009

15. ©The King’s Fund 2009

16. Programme budgets - Cancer
©The King’s Fund 2009

17. Thresholds
Control chart for Standardised Admissions Ratios - Tonsillectomy
250
Standardised Admission Ratios
200
150 95% confidence
limits
100
50
0
0 100 200 300 400 500
Expected number of cases
[Source: NHS Better Care, Better Value Indicators]
©The King’s Fund 2009

18. Day surgery
Day case rates for laparoscopic cholecystectomny
[Source: NHS Institute Focus on HVC update 2008]
©The King’s Fund 2009

19. Prescribing
[Source: NHS Better Care, Better Value Indicators]
©The King’s Fund 2009

20. Reactions to variation data
The data is wrong
The data is right, but it’s not a real problem
The data is right, it’s a real problem but it’s not my problem
The data is right, it’s a real problem ,and it’s my problem
…………………but I don’t need to do anything about it
Adapted from Jarman / Berwick
©The King’s Fund 2009

21. Push and Pull…..
Push
Pull
©The King’s Fund 2009

22. Thank you
Mark Jennings
Director of Health Care Improvement
M.Jennings@kingsfund.org.uk
+44 (0)777 1996410
©The King’s Fund 2009