Evidence and magic

How to transform Quality in NZ?

Wellington Feb 2009

Bruce Arroll,

Department of General Practice & Primary Health Care

Faculty of Medical & Health Science

University of Auckland, Auckland, New Zealand

Acknowledge

Prof John Buchannan “grand” father of quality in Auckland Kept the interest in the topic when we were flagging

Disclaimer

Fresh eyes on what is happening

At a global level I am happy with the health system

I work at the University 70% of my time and 30% I

work in a clinic in Manurewa, which I partly own,

one of the most disadvantaged suburbs in New

Zealand

No concerns about waiting lists – a side show

Story

Story of 6 year old girl

She is having chemotherapy for a blood cancer

She is bald

All her class mates are laughing at her

Her teacher considers

Her teacher does something outrageous →

Problem solved

This is magic or transformation – a step change

Rod Jackson

Health is all about quality and cost and nothing else

Perceptions are generally wrong –you need to audit

and compare – we overestimate

We need a step improvement in quality

Shave our heads for quality

Make quality the centre of the health system If we can grow moustaches for prostate cancer

surely we can shave our heads for quality

My contribution to quality

What would quality look like

The computer system would have audit functions

made user friendly as well as for clinical stuff

The current systems are really designed to make

clinical work more effective with audit as a

secondary consideration

Press a button and get an audit

We should know how we are doing as a nation

Each clinic would have a “quality person”

What would quality look like

Diana North and Drinfo –press a button and find out

how you are doing and selects those who need to

be called in to get their management improved

Ensure that practitioners know how to use their

computers

Enter the data in to data base not in as text

A robust method of evaluating performance

UK make figures public- audit police

Are the decks burning #1

2007-2008 gout audit

38% of patients with gout with uric acid levels <

0.36 mmol/l

Practice in same suburb 43%

After intervention 45%

How does this rate nationally

No one knows

Are the decks burning #2

Auckland 2001 81% of patients on ACE

inhibitors/CHF

UK 2007 80% of patients on ACE inhibitors with

CHF

Auckland 2005 70% of patients on ACE inhibitors

Personal communication V Andersen 2009

Does this matter => hospitalisations, QoL, death

Are the decks burning #3

Immunisation DTP NZ 2004-5 79.3% coverage

DTP UK 2003-4 94%

NZ vs UK

We don’t know Echocardiogram for patients with CHF 92.5% in the

UK in an Auckland population 58% NZ most likely no better than the UK on any

measured parameter in the QoF and probably worse on most if not all

Perhaps we should measure what’s happening here as a starting point

UK system unlikely to go backwards

What is needed

A transformation i.e a step change in attitude towards quality

Consider a systemic approach Pegasus with CME and audit synchronised

There are plenty of criticisms but the UK is probably as good as or better than us on every indicator that they use -they are the bench mark

A national system

What’s missing ?

Political devolution of responsibility to DHB/PHOs

means nobody is in charge

Problem with transferring electronic detail from one

clinic to another using Medtech software.

Eg adverse drug reaction info is lost

Computers do this well humans do not

Some one will die or get sick

No single person can change this situation other

than perhaps the minister of health

Summary

Gary Sinclair

Aims for the best not just better health care

If we want the best we need a transformation.

Waiting for change to happen spontaneously is

wishing for magic

We need to embrace quality

We need to measure how we are doing-QoF nz

survey

Summary

We need to consider a system that works for NZ

without the downside of QoF

The UK may not have the Rugby world cup but they do have the world cup on quality

Somebody needs to be in charge