Creating a cost effective and sustainable health system using an evidence base Health Workforce 2025...
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Transcript of Creating a cost effective and sustainable health system using an evidence base Health Workforce 2025...
Creating a cost effective and sustainable health system using an evidence base
Health Workforce 2025 Anne Kolbe
ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD
Chair, New Zealand National Health Committee
Declarations of Interest
• Vocationally registered paediatric surgeon• Chair, National Health Committee• Director, Pharmaceutical Management Agency
(PHARMAC) 2010 - 2013
National Health Committee
Section 11 advisory Committee responsible for providing the Minister of Health with recommendations on:• Which technologies should be publicly
funded in New Zealand• To what level and where technology should
be provided• How new technology should be introduced
and old technology removed
Today …
Challenges - why we need to change!• Health, wellness and independence - prosperity• Vote Health• GDP and GNP• Burden of disease• Technology - goods and services• Capital, back office and IT infrastructure• Workforce
Today …
Opportunities • Evidence - data, information and knowledge• Models of care• Explicit prioritisation
Enablers• Values based relationships• Innovative macro level thinking• Business / clinical partnership• Collaboration and teamwork• Leadership
Leadership values
• Honesty• Integrity• Openness• Passion• Diligence• Perseverance
• Courage• Resilience• Humility• Concern for others• Commitment to
service
Leadership competencies
• Know oneself• Understand the business• Horizon scan, develop and maintain the
“collective” vision, position the business• De-construct and manage complexity• See opportunities not problems
Leadership competencies
• Embrace innovation• Take risks and learn from mistakes and
allow others to do the same• Listen, empathize and learn!• Delegate and facilitate the actions of others• Build and nurture teams• Recognize and celebrate success
Working together!
Astute leaders foster co-operation, collaboration, networks
and partnerships
What are we trying to achieve?
• Safe, quality health, wellbeing and independence outcomes for individual patients and populations
• Live within our means - value for money and affordability
• Sustainability
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
Sustainability
Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debt.
Source: OECD Health Data, 2012
Source: OECD Health Data, 2012
Source: OECD Health Data, 2012
Growth in core Crown health spending has outstripped national income …
Core Crown health expenditure per capita and GDP per capita indexed real growth
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
DHBs
Disability
Educa-tion
Public Health
Primary HealthMaternity
Ministry
Chart Title
Vote Health 12/13: NZ$14 billion
Source: New Zealand Treasury 2012
LEGATUM INSTITUTE | THE 2013 LEGATUM PROSPERITY INDEXTM
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
Why is health care spending increasing?
Demographics - in part
Non demographics - may be as important!• Income growth - expectations• Technology - widening scope to treat• Lower productivity growth than the rest of the
economy - health care is labour intensive
Consider …
Our systems have developed to manage acute life threatening conditions. • Care is episodic and reactive• Emphasis on hospitals and doctor lead
care organised around medical specialties• Patients often seen as passive rather than
active contributors to their own care
Increasing population of people with Long Term Conditions (LTC)
• COPD, diabetes, CVD, dementia and some cancers
• Most of these people have >1 LTC• Many are over 65 years • LTC are a potent driver of ambulatory care
sensitive admissions and costs
But the world has changed …
Trends in Age-Standardized Death rates for the Six leading Causes of Death in the United States, 1970 – 2002.
Jemal A, Ward E et al (2005). Trends in the Leading Causes of Death in the United States, 1970 - 2002.Journal of the American Medical Association 295 (10): 1255 - 59
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
NHS• 3.6 m (21.9%) of ED attendances
require admission• 37% increase in 10 years• 65% are older (>65 years) - frail,
dementia, complex needs• Utilise 51,000 ABD (70% of total
available ABD)• 33% fewer, general and acute
beds• Ave LOS now increasing for
patients >85 years
Evidence of fractured care, breakdown in out of hours care,
medical workforce crisis,capital and IT limitations
RCP 2012
Just in case you think …
Australia
12 chronic conditions accounted for 1.5m (21.8%)
of hospital separations• Stroke• COPD• CHD• Diabetes
Average LOS 6 -10 days
AIHW 2010-11
New Zealand
21% increase in acute medical discharges (225,000)
• Chest Pain 3.6%• GI 3.5%• Respiratory Infections 3.5%• Cellulitis 3.0%• Circulatory Disorders 2.5%• COPD 2.5%• Abominal pain 2.5%• Neonatal 2.8%
NZ Ministry of Health 2012
The challenge is to adapt the system to the
changing burden of disease in the face of expanding technology
options and constrained resources
Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012
So what are the implications for strategic policy?
• Encourage active healthy populations - minimize needs and costs
• Early identification of diseases• Quality and cost effective management of disease
in the community - health and social sector• Ensure the workforce, IT infrastructure, capital
investment and funding streams are developed and aligned to enable the changing models of care
NHC approach …• Evidence based, assessment and
prioritisation of non-drug technologies with a focus on models of care
• Four domains• Clinical safety and effectiveness• Societal and ethical• Economic• Feasibility of adoption
• 11 decision making criteria• A4R framework
NHC Programme Budget 12/13
Source; NHC Executive analysis 2013
Source; NHC Business Plan 2013
NHC Tiered Business Approach to Work PlansSector Engagement and Participation
Source; NHC Business Plan 2013
NHC Programme Budget 12/13
Source; NHC Executive analysis 2013
Tier 1 Strategic OverviewRespiratory Disease in New Zealand
• $265m public casemix hospital discharges• 10 disease states within respiratory disease• prevalence, incidence, health outcomes, health
utilisation and cost
Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care
Source: NHC Respiratory Disease in New Zealand
Source; NHC Executive analysis 2013
Source:2013 NHC Executive analysis of 2010-2011/12 NMDS and 2010 National Mortality Collection
Burden of Respiratory Disease
Burden of Respiratory Disease
Source: NZBDS 2013
DALY Breakdown by Percentage Death Breakdown by Percentage
Incident Diseases: Efficiency Gains Required to Reach $5 million
2013 NHC Executive Analysis of 2011/12 NMDS
Source; NCH Decision Making Paper 2013
Tier 2 COPD: A Pathway to Prioritisation
Source: OECD Data 2011
NHC Programme Budget 12/13
Source; NHC Executive analysis 2013
Renal Sympathetic Nerve Ablation
Estimated prevalence of resistant hypertension• Australia n= 260,000 • New Zealand n= 97,000
Costs • Index admission A$11,000• Medical management A$1,200
“Back of the envelope” budget impact …• Australia >A$3 billion• New Zealand A$1 billion
So where does this intervention fit in a model of care for refractory hypertension and what is the appropriate target population? Isler M et al. Lancet 2010; 376: 1903-9
Krum H. Hypertension 2011; 57: 911-7HealthPACT 2013
TAVI for Aortic Stenosis
Application; NHS 16-25 per million population?
Comparator; sAVRepl
Approximate costs index admission + 2years FU care
• sAVRepl A$25,000• TAVI A$63,000
Questions• How to identify the population most able to
benefit?• Substitution or Addition financial methodology?
So …
Success …
• Long run game - there are no simple solutions or quick wins!
• The changes are complex, multifaceted and need to occur at all levels
• “Big picture” strategy - involves action• Evaluation, evaluation, evaluation … and
constant tweaking!• Consistent and persistent national leadership
…before writing the prescription for
the health workforce of the future
it will be important to consider the best business strategy for the delivery of health
care into the future!