World Class Performance – Turning Rhetoric into Reality?

Health System Snapshot: NHS Lothian Basic facts

• Population (2008) • Projected pop. growth to 2031(%) 2 • Life expectancy (males) 2,3 • Life expectancy (females) 2,3 • GDP/capita (USD PPP) 4

Lothian

841,193* 16 76 years 81 years 31,935

OECD

6 76 years 82 years 32,666

Breakdown of spend Other Healthcare statistics Lothian

Healthcare spend breakdown 4 , %

Primary care Other 10 28 Community services (e.g. home health) 13

1 Ages 16 and over 2 2006

39 Acute care

• • • • • Number of physicians per 1,000 pop .4,2 Number of hospital beds per 100,000 pop. 4,2 % of population covered by health insurance 4 Infant mortality (deaths/1,000 live births) 4 Healthcare spend/capita (USD PPP) 0.96

533 100 4.2

2,392.7

3 2005 4 2007 • Projected pop. growth among 65+ to 2031 (%) 4,2 64

10 Psychiatric care

• Population ages 15+ who are daily smokers (%) 3,4 23.2

* Represents total population receiving primary care in Lothian, some of whom may live in other regions

OECD

0.85

602 94 5.5

3,062 36 22.3

SOURCE: National Centre for Health Outcomes Development, Office of National Statistics, NHS Scotland Cost Book 2007-2008 Laing and Buisson 2007-2008

Our Aspiration

•

NHS Lothian aspires to be at the level of Scotland’s best and

a world top 25 health region

in terms of outcomes and value.

•

To achieve this, NHS Lothian’s 5-year strategic priorities are to:

– – – – – Sustainably

improve access to high quality care

, increasing share of treatments ‘in the right setting at the right time’ and ‘shifting the balance of care’ towards self care and illness prevention Improve health and

reduce health inequalities in collaboration with social care providers

and involve people in how they plan and deliver services, creating a ‘mutual NHS’ Develop more

robust information systems

to support service delivery, and

embrace technological advances

and encourages self care that improves care Develop a

position at the forefront of R&D

, in particular through the BioQuarter science park that is jointly established with academic, industry, and venture capital partners Be an exemplar employer, thereby

motivate and attract good staff

and raise productivity

To achieve this goal we need to answer 5 questions Key Strategy What value do we get for what we spend?

How do we perform compared to world-class standards and our peers at a system and pathway level?

What is the best way to improve our system?

How can we learn from others?

How do we build the capabilities we need to succeed?

C O S T Q U A L I T Y

Cost: Summary of aspirations, challenges, strategy and success stories Aspirations to improve costs

• Meet system aspirations of being recognized as on of the top 25 systems in the world in terms of value for money • Improve productivity and quality while reducing cost in the setting of economic uncertainty

Current strategy to address challenges

• Regularly compare quality performance and non-monetary productivity metrics to benchmarks (though good benchmarks are lacking) • Pursue lean approaches throughout the system and especially in acute care setting • Fine-tune resources along the patient pathway to ensure system operates at optimal capacity •

Success Stories

Lothian has in partnership with GE Healthcare used Lean methodologies to achieve substantial improvements in efficiency of key services

SOURCE: Lothian leadership team interviews

Quality: Summary of aspirations, challenges, strategy and success stories Aspirations to achieve quality

• • • • • Be recognized as region which is among the top 25 regions worldwide in terms of care outcomes Become a centre for medical innovation and commercialization Become national leader in patient safety Reduce inequalities in outcomes for disadvantaged population Improve outcomes for long term conditions •

Current strategy to address challenges

Invest in Bioquarter Edinburgh to take research from ‘bench to bedside to business’ • Use promise of capital investment programs to motivate change among clinicians • Undertake large patient safety improvement project with Institute for Healthcare Improvement • Launch wellness programs to encourage patients to take ownership of their health • Improve systems for measuring outcomes – e.g. Eurocare, primary care data • •

Success Stories

Lothian has exceeded all national targets for the reduction of hospital acquired infections Keep Well campaign has significantly increased numbers of disadvantaged population having a PCP check up

The Lothian Way and Training

Three themes People Centered Partnership Integrity - putting people at the heart of everything we do - being sensitive to individuals needs and providing the right service at the right time in the right place - working in partnership with staff, patients, the public and other agencies to provide the best possible service - being inclusive, involving patients and local people in decisions of their own healthcare - respecting people as individuals and treating them with courtesy and dignity - communicating openly and honestly; with each other and public

Re-Investment: Training & Development

Additional £2.7 million in staff training commitments Directly impact on 17,500 staff • • • • Deals with the challenges emerging from the recent staff survey • Customer Care Patient Experience Health and Safety Communications Management of Change and Staff Engagement Priorities within key strategic themes as set out in our HR & OD Strategy • Living Values Engaging Leadership • Delivering Quality

Succession Planning and Development

Importance of succession planning Designing a world class development programme in conjunction with the Edinburgh Institute of leadership & Management Practice (the Business Schools of Edinburgh and Edinburgh Napier Universities) and a world class university from USA.

Launched in November 2009 20 places per annum on a 2 year – Masters level accredited bespoke programme Employees will be selected for the programme based on competency assessment and potential for senior management position.

Lean in Lothian Benefit Highlights 2008/09

Patient Experience

• Improved patient environments and information • New models for mental health older people • Urgent out-patient assessment slots, Same day triage, clinic outcomes recording (OPD2) • Improved discharge planning–Liberton • 10% reduction in SAS A&E turnaround time • One stop wheelchair clinics introduced: 80% of adults same day provision (was 52 days) •

Same day triage and appointing and improved theatre booking – potential 110 extra hand surgery cases pa

• Pilot of 24/48 hour vetting and booking in MRI • Colorectal service achieving 98% cancer target

Clinical/Corporate Governance

•

Increased use of Patient Management System (TRAK) to improve case management

• Improved information transfer from SAS • Capacity and demand analysis to support delivery of 18 week RTT • Standardised admission, assessment and discharge processes improve reliability • 4 workstreams to improve unscheduled care identified and underway • Increased productivity, reduced duplication Overall anticipated cost saving/avoidance of £1.4million

Skills Transfer

•

Lothian now self sufficient in lean, CAP and workout training

• Integrated with workforce development • >120 delegates attended training • Lean leaders trained in advanced lean • >150 staff participated in events • Learning shared across NHS Scotland

Process Culture

• National recognition of lean project achievements -HSDU • Positive feedback from kaizen participants • More services taking forward further process improvements post-kaizen • Kaizens at St John’s and Astley Ainslie •

Staff partnership support for all projects

BioQuarter

July

Q1 financial review

August

Annual review Horizon scanning day Draft financial plan for 9/10 with LRP plan Winter plan due

September

Mid year appraisals.

Service, workforce and financial planning workshops

October

Mid year review and YEF agreed

November

Draft activity targets to CMTS. Draft NSD proposals

December

The NHS Lothian Annual Planning Cycle

June

Accountability Review submission to SG. Annual accounts approval.

May

Lothian DD plan due Training and development plan agreed

April

New Year Kick off Open staff meeting Appraisals, objectives and development plans signed off. Workforce plan completed.

Start of external audit

March

Budget and LRP sign off, LDP sign off at Board and submit to SG with Revenue and Capital plan. Objectives agreed.

January February

Draft LDP and financial plans to EMT away day, Board away day and SG In year Accountability Review SEAT stakeholders day Prioritisation of new resource

HealthTracker aims at building a global Healthcare community

Member Discussions in progress Alberta Kaiser Permanente HHS Lothian Northampton shire PCT South West SHA Valencia Denmark Knappschaft Rovigo Treviso Toscana Hong Kong Chile Singapore Victoria Queensland

Aspiration

• • Have

global coverage

, members from all continents Sign

2-3 members per country or region

to enable local comparisons

WELCOME to

HEALTH

TRACKER This is the prototype version of the upcoming new service from McKinsey & Company on health care management.

HealthTracker creates insights that deepen and advance health leaders’ ability to improve health system performance and make the most effective use of their healthcare budget.

Please select one of the 5 resources section to start your journey with HealthTracker.

PERFORMANCE

ASSESSMENT

CLINICAL HEALTH

ECONOMICS

IMPLEMENTATION

INSIGHTS

KNOWLEDGE

BANK

LEADERSHIP

NETWORK Performance drivers Executive questions My dashboard My insights Clinical pathway Best practice insights Expert-on-demand McKinsey research McKinsey publications News Expert-on-demand My network Connect & collaborate Events You have mail:

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Epidemiology: Lothian’s disease profile is similar to that of other OECD countries

% of total deaths, latest year available (2007-2008)

Cause of death SW NH

Circulatory diseases 33.0

34.6

33.5

34.0

35.2

All cancers 27.4

26.9

28.9

Respiratory diseases Endocrine and metabolic disorders 1.2

Infective and Parasitic diseases 1.3

12.0

1.1

1.5

10.4

1.1

8.9

2.3

SOURCE: National Centre for Health Outcomes Development, Singapore Yearbook of Statistics 2008, NHS Scotland, OECD 3.6

1.8

17.2

27.7

2.0

10.0

4.0

24.7

Disease outcome performance compared by country, 2007

Standardized mortality rate per 100,000 population * Average or better Worse than average 1 σ worse than average Lothian UK Germany Spain Austria Netherlands Finland USA Japan Disease Coronary heart disease Lung cancer Colon cancer Breast cancer Diabetes * Standardized for differences in age and sex composition among regions Source: NHS Lothian; OECD Health Data 2008

Population health and risk factors: Lothian’s profile is similar to other UK regions but have more challenging profile than Singapore … but differ by lifestyle and risk factors Overall, the regions have similar population age structure 1,2 … Age

81 + 61-80

% share of total population 1 10 3 15 5 19 3 15 Smoking 3

13.6

23.2

21.5

25.9

41-60

31 27 27 28 Obese 4 23.8

23.2

24.8

6.9

21-40

31 31 27 25

75.1

77.5

78.2

63.6

0-20

27 24 24 26 Not exercising regularly 5 SW NH SW NH

1 Differences in sex distributions between the regions is negligible 2 All analyses risk adjusted for age and sex differences among regions unless otherwise noted. Other exogenous risk factors such as socioeconomic variations may be included in future versions of the HealthTracker 3 Share of adults who are daily smokers; For Singapore prevalence amongst adults 18-69 years of age from 2007 MoH survey, For Northampton & South West synthetic estimates for people aged 16+ from Neighbourhood Statistics 03-05, For Lothian data from 2003 Scottish Health Survey for people 16+ 4 Share of adults who have a BMI>30; For Singapore - prevalence amongst adults 18-69 years of age from 2004 MoH survey, For Northampton & South West synthetic estimates for people aged 16+ from Neighbourhood Statistics 03-05, For Lothian data from 2003 Scottish Health Survey for people 16+ 5 Share of adults doing regular physical activity, 30 mins 5x per week; For Singapore prevalence amongst 18-69 years for >20 mins 3x per week from 2004 MoH survey, For Northampton & South West, people aged 16+ for 30 mins 3x per week from 07-08 Sports England survey, For Lothian data from 2003 Scottish Health Survey for 30 mins 5x per week for people aged 16+

Quality: Lothian’s biggest opportunities to save life years lost to cancer are in breast and lung cancer Lung Cancer

Average years of life lost per new case 10.9

9.8

3,242 life years

Breast Cancer

Average years of life lost per new case 16.5

14.8

2,805 life years Lothian Best performing UK region 1 Total life years saved per 100,000 population Total life years saved in the region

Colo-rectal Cancer

Average years of life lost per new case 10.1

981 life years 37 70 New cases per 100,000 pop. 2

Prostate Cancer

Average years of life lost per new case 6.8

6.3

940 life years 112 141 New cases per 100,000 pop.

2

Stomach Cancer

Average years of life lost per new case 41 53 New cases per 100,000 pop.

2

Cervical Cancer

Average years of life lost per new case 14.2

10.4

560 life years 21.2

18.1

87 116 New cases per 100,000 pop.

2 7 10 New cases per 100,000 pop.

2 1. Best performer among UK SHAs; 2. Standardized for age and sex mix differences across the regions; <75 premature mortality only included SOURCE: HealthTracker members data collection, National Center for Health Outcomes Development (England), Information Services Division (Scotland), McKinsey Analysis 6 9 345 life years New cases per 100,000 pop.

2

Patient Safety

• Reducing line infections (3 ITUs) – 60% in 1y, >150 days with no infection • C. difficile – 80% reduction in pilot wards, 40% across others as spread • Leadership – Every board agenda, monthly at EMT, regular walkrounds, feedback and actions

Quality: Lothian could significantly improve on patient safety indicators by reaching the performance of the best HealthTracker members Safety indicator MRSA 1 cases per 1,000 inpatient bed days Aspiration 0 Falls per 1,000 inpatients 2 0 Deep vein thrombosis cases per 1,000 inpatients 0 0.07

NH 0.13

SW 0.28

NH Poorest performer among members 0.17

Not yet available NH 0.35

SW SW

*Data used is 2007 or latest available 1 MRSA = Methicillin-Resistant Staphylococcus Aureus 2 Total number of inpatient falls among people aged 65 and over which result in a hip fracture SOURCE: HealthTracker members

eHealth Metrics

• 23,000 IT users • 12,000 PCs • 279 sites • 10,000 service desk calls per month • 95% customer satisfaction score • We spend 0.86% of our budget on eHealth c. £11 m

Big Ticket Deliverables

Acute

• Single PMS across all acute sites (2008) • Single PACS solution with Scotland-wide archive (2009) • Electronic ordering of laboratory and radiological investigations (2007-09) • Call centre technology for Patient Appointments (2009-) • Single regional laboratory system (2004-09)

Big Ticket Deliverables

General Practice 2009

• 124 Practices • 85% using the same Practice System • Maturity of information system use allows very rich data mining activities to influence patient care • Electronic referrals to secondary care >95%

Big Ticket Deliverables

Infrastructure

• Upgraded Wide Area Network to 1GB core with 100MB to most medium sites and 10MB to remainder.

• Storage Area Networks at each main site with cross-site replication.

• Server consolidation and virtualisation to reduce servers and use less energy • Single Active directory ( incl. GPs) to manage all users safely • Nearly universal use of CHI (>98% acute hospital and GP, >70% community, pharmacy etc)

Work in Progress

Applications

• Extend functionality in PMS to facilitate the eradication of home-grown audit/clinical databases • Modify PMS to fully support 18 Wks RTT and Cancer Tracking • Improve results reporting features to allow on-line sign off from multiple sites and locations • Implement Clinical Portal to enable clinicians to see all parts of record held on multiple, different systems including GP

Work in Progress

Infrastructure

• Rollout of Microsoft OCS collaboration tools to 1000 people to facilitate smart working instead of travel to meetings • New hosting of external web site to develop patient feedback electronically and create community of users and consultees, and improve document workflow • Exploration of potential of Virtual Avatars in the clinical setting e.g. HIV drug compliance and sexual health history • Airline type check in booths • Digital telephony to confirm/change clinic appointments • Digital ECGs • Front sheet e-summary of all attendances and admissions

Heart Failure, COPD, diabetes

Call to check situation

Call centre

Constant monitoring of potentially unstable conditions (e.g. COPD) Reminders to self monitor Automated feedback Links to online information

Remote server Home

Patient takes readings and enters symptom score Internet GPRS Record of readings and symptom scores Urgent referral if required Relatively stable conditions (e.g. diabetes, BP) checked intermittently (normally by practice nurse

GP practice

Telephone or videolink Consultation arranged as appropriate

Models of telemetric supported self monitoring

Early Results COPD

Complete questionnaire each day Physiological measures as needed Call centre monitors

Do the patients like it?

“I’ve never felt so well looked after in my life. I think it’s a godsend like.”

(Patient aged 58)

“I don’t worry about him the same as I used tae. It’s all taken care of before it can get tae that level. That machine can tell Alec he’s ill even before he kens it hisself”

(Spouse of patient aged 75)

“There’s some times you phone them up for an appointment ye cannae get one. . . So I feel if I’ve got that

(telehealth device)

I’ve got a chance of a doctor anyway.”

(Patient age 75)

Conclusions

Patients like Telehealth It encourages evidence based practice and quality care Telehealth systems need robust underpinning structures to observe and manage the data provided Implementation needs to involve users early and must emphasise patient benefit They may not save time/resources in primary care We need rigorous research to discover where and how the systems are best applied

Implementation: what have we learned so far

The infrastructure planning is more important than the device Clinicians need to believe there is a clear need for the device They will become involved if they believe patients will benefit Equipment should be easy to use and ideally, designed around the existing service

Primary Aim in this Planning Window

• Provide the right in information, at the right time in the right place, However : • 5 million casenote volumes • 37 linear kilometres of shelving • We therefore need to reduce our reliance on paper ASAP • Implementation of scanning solution in Health Records • Accelerate EPR solution

Primary Care IM&T Needs

What is needed….

78% of consultations are NOT about QOF – more info about managing demand Poorly performing doctors, & excellence….

Information by GP - not by practice Number of GPs - by hours worked Resource for analysing pt identifiable data

5 Themes

5 Themes 5 Teams

5 Themes 5 Teams 5 People

Themes of Lothian’s 5x5x5 programme I

Patient Experience

II

Cost v Quality in a new economic context

III

Building community capacity to deliver Health Inequalities

IV

Worlds Best Clinical Quality

V

Demand Management, focusing on unscheduled care – with IM&T threading through all themes