The King’s Fund2012 Annual Conference

Derek Feeley

Director General Health and Social Care and Chief Executive of NHS Scotland

NHS Scotland

• c. 5.1 million population• Devolved (since 1999)• 14 Regional Boards• Integrated system ( e.g. no

purchaser/ provider split)• Integration of health and

social care underway• Tax funded/ cash limited• Equal access on basis of

need• Free at the point of care

Health Budget Real Terms Summary

Note: This presentation provides a high level position based on published budget figures. It should be noted that budgets between years are not directly comparable due to transfers between portfolios and other budgetary and accounting adjustments (e.g. HM Treasury cost of capital removal)

00-01£m

01-02£m

02-03£m

03-04£m

04-05£m

05-06£m

06-07£bn

07-08 £bn

08-09£bn

09-10£bn

10-11£bn

11-12£bn

12-13£bn

13-14£bn

14-15£bn

overallIncrease

£bn

OverallIncrease

%

Health Budget (Cash) 5.521 6.162 6.474 7.227 8.048 8.790 9.531 10.215 10.642 11.058 11.182 11.369 11.583 11.803 11.946 6.425 116.4%

Health Budget (Real at 2000-01 prices) 5.521 6.047 6.198 6.769 7.322 7.818 8.255 8.632 8.754 8.962 8.812 8.751 8.682 8.631 8.522 3.001 54.4%

Health Budget Cash and Real Terms Summary 2000-01 to 2014-15

5

6

7

8

9

10

11

12

'00-01

'01-02

'02-03

'03-04

'04-05

'05-06

'06-07

'07-08

'08-09

'09-10

'10-11

'11-12

'12-13

'13-14

'14-15

Financial Year

Budget£bn

Cash

Real

Health spend – 4 nations

0

500

1,000

1,500

2,000

2,500

2007-08 2008-09 2009-10 2010-11 2011-12

England

Scotland

Wales

NorthernIreland

UK identifiableexpenditure

Identifiable Expenditure per capita on Health, UK and countries, £

Source: HM Treasury Oct 2012

Health spend – Scotland and English regions

0

500

1,000

1,500

2,000

2,500

2007-08 2008-09 2009-10 2010-11 2011-12

North East

North West

Yorkshire andthe Humber

East Midlands

West Midlands

East

London

South East

South West

Scotland

Identifiable spend per capita on health, Scotland and English Regions, £

Source: HM Treasury Oct 2012

Identifiable Expenditure per head on health, £  2011-12

London 2,102North East 2,095North West 2,029Yorkshire and the Humber 1,905West Midlands 1,865South West 1,771East Midlands 1,728 East 1,711South East 1,702England 1,874, Scotland 2,091,

Source: HM Treasury, Oct 2012 

4 key challenges

• Economic

• Demographic

• Population health

• Changing expectations

Triple Aim

Health of the

Population

Experience of Care

Best Value for Money

The triple aim

Integration

3 quality ambitions

• Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

• No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

• The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

HSMR: Scotland Jan. ’08 Mar. ‘12

0.80

0.85

0.90

0.95

1.00

1.05

Jan-M

ar 2

008

Apr-Jun 2

008

Jul-S

ep 2

008

Oct-D

ec 2

008

Jan-M

ar 2

009

Apr-Jun 2

009

Jul-S

ep 2

009

Oct-D

ec 2

009

Jan-M

ar 2

010

Apr-Jun 2

010

Jul-S

ep 2

010

Oct-D

ec 2

010

Jan-M

ar 2

011

Apr-Jun 2

011

Jul-S

ep 2

011

Oct-D

ec 2

011

Jan-M

ar 2

012p

HS

MR

1.03

0.89

10.6% reduction

6640 less than expected deaths

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Quarters

Sm

oo

thed

S

MR

Hospital Standardised Mortality Ratios (Seasonally Adjusted)Scotland: Oct-Dec 2002 to Jan-Mar 2012

average yearly reduction 4.2%

(Apr 2010 to Mar 2012)

1.4% average yearly reduction

(Oct 2002 to Jan 2010)

Implications for costs – what do we know?

• Poor quality is costly• Costs and benefits are

spread over time and between stakeholders

• The context matters• Better data would help

Quality and cost - it’s complicated….

Too bad all the people who know how to run the country are busy driving cabs and cutting hair.

-- George Burns

Why quality?

• Waste, harm and variation

• Poor quality costs more

• Clinical engagement

• Thrive or survive?

• Route to longer term sustainability

• What is the alternative?

The alternative?

Or this…..?

0

0.5

1

1.5

2

2.5

Jan-

08

Apr-0

8

Jul-0

8

Oct-08

Jan-

09

Apr-0

9

Jul-0

9

Oct-09

Jan-

10

Apr-1

0

Jul-1

0

Oct-10

Jan-

11

Apr-1

1

Jul-1

1

Oct-11

Harm - General ward C.Difficile rate(per thousand patient days)

1.15

0.12

90% reduction

Cost of infection

Cost of infection (Pennsylvania)

Tackling variation – high cost, high volume services

Prepared by Peter Knight JIT June12

Bedday rate for patients aged 75+, emergency admissions

4000

4500

5000

5500

6000

6500

Year ending

Bed

day r

ate

per

1000 a

ged

75+

Borders

Lothian

BoardaverageHighland

Ayrshire &ArranTayside

Sept-11

Re-shaping Care Prog/LTC Prog

~550 beds

Sustainability - quality and efficiency

Improving quality and reducing costs

Our choice

Surviving – the 3%

Thriving – the 97%

The future - getting to the third curve

Time

Perform

ance

Performance

Improvement

Co-production& assets

1941, William A. Foster

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction

and skillful execution; it represents the wise choice of many

alternatives.”