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John Matheson Director of Finance, eHealth and Pharmaceuticals • NHSScotland – – – – – – 5 million people £12 billion 14 Health Boards 8 Support Boards Integrated delivery Moving towards social care integration Spending – by portfolio • 33% Local Government • 34% Health and Wellbeing • 8% Education and Lifelong Learning Health and Wellbeing Local Government Other Administration Infrastructure and Capital Investment Culture and External Affairs • £34 billion • £6,500 for each person in Scotland • £93 million per day • £129 million per working day Rural Affairs Finance Justice Education Aims To deliver the highest quality healthcare services to the people of Scotland For NHSScotland to be recognised as worldleading in the quality of healthcare it provides The Healthcare Quality Strategy for Scotland • Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making. • Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. • Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times. Our ‘2020 Vision’ EVERYONE IS ABLE TO LIVE LONGER HEALTHIER LIVES, AT HOME, OR IN A HOMELY SETTING ROUTE MAP TO THE 20:20 VISION 12 PRIORITY AREAS FOR ACTION Primary Care Integrated Care Quality of care Safe Care Unscheduled & Emergency Care Person Centred Care Care for Multiple & Chronic Illnesses Early Years Health of the Population Health Inequalities Prevention Innovation Value & Financial Efficiency & Productivity Sustainability Workforce 11/02/13 “Give me six hours to chop down a tree and I will spend the first four sharpening the axe” Abraham Lincoln 1809-1865 Efficiency and Productivity Workstreams Core Workstreams Alignment of workstreams with the ‘20:20’ Vision Outpatients, Primary and Community Care Acute Flow and Capacity Management Prescribing Procurement Productive GP Demand and Capacity Planning National Therapeutic Indicators Social Work Day/ Short Stay Surgery/ Ambulatory Care PAPS, Formulary and Advisory Network Good Practice Outpatients Enhanced Recovery Secondary and Primary Care Interface Intensive Improvement Activity SAS Modernisation Inpatient Capacity and Flow Repeats, Waste and Polypharmacy National Contracts Review Orthopaedics Performance Management and Incentives Regional Consortia Theatres National Approach and Consistency Dashboards RTC Community Reshaping Care Ophthalmic Referrals Cross-cutting Workstreams HR Services Facilities PMS QoF Indicators Enabling Workstreams Shared Services LTC eHealth Prevention and Early Intervention Evidence Based Care Workforce Information and Analytics Health Behaviour Change Low Value Clinical Interventions Capacity and Modernisation Benchmarking Smoking Cessation Evidence Based Clinical Thresholds Lifestyle Interventions NICE/ HIS Standards Leadership and Capability Baselining Finance Productive Opportunity Patient Safety Governance and Engagement Whole Systems Analysis Support and Enablers: • Identify and share good practice • Innovative approaches to data to identify productive opportunities • Tools for demonstrating productive gain and benefits realisation “The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland’s health care leaders –NHS executives, QIS experts, clinical professionals, civil servants, and more – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care.” Don Berwick Quarterly Clostridium difficile Infection cases in Patients aged 65 and over 2000 January – March 2007 to July-September 2012 1800 1600 1400 1200 1000 800 600 400 200 0 Jan 07 - Jul 07 - Jan 08 - Jul 08 - Jan 09 - Jul 09 - Jan 10 - Jul 10 - Jan 11 - Jul 11 - Jan 12 - Jul 12 Mar 07 Sep 07 Mar 08 Sept 08 Mar 09 Sept 09 Mar 10 Sept 10 Mar 11 Sept 11 Mar 12 Sept 12 Cases have decreased by 1,410 – 79.4% (from 1,775 cases in Jan-Mar 2007 to 365 in Jul-Sept 2012) The Early Years Collaborative - Ambition To make Scotland the best place in the world to grow up in by improving outcomes, and reducing inequalities, for all babies, children, mothers, fathers and families across Scotland to ensure that all children have the best start in life and are ready to succeed. Population of Scotland 4 3 75+ Bed days per capita 7 6 5 2 1 0 Shetland Islands Clackmannanshire Stirling Angus Orkney Islands Fife Dumfries & Galloway East Ayrshire Falkirk North Lanarkshire North Ayrshire Perth & Kinross South Lanarkshire Moray West Lothian Aberdeenshire Highland South Ayrshire Argyll & Bute Dundee City Aberdeen City East Dunbartonshire Scottish Borders East Lothian Renfrewshire Edinburgh, City of East Renfrewshire Eilean Siar Midlothian West Dunbartonshire Inverclyde Glasgow City ISD 2010/11 IRF mapping data Public Finances – Fall in Government Expenditure Doomed, we’re all doomed Vision • • People are supported to live well at home or in the community for as much time as they can They have a positive experience of health and social care when they need it Reshaping Care Change Fund • The Reshaping Care Change Fund is a key element within the Scottish Government’s preventative spend strategy – £300 million will be invested over the period 2011-12 to 2014-15. • Health and Social Care Partnerships across Scotland are using the Fund as bridging finance to make better use of their total combined resources for older people’s services. • Evidence shows that the Fund is already helping to redesign care services for Scotland's growing older population - helping to prevent delays, provide more proactive community-based services and better care and support at home. • In line with the Scottish Government's proposals to integrate adult health and social care, the Reshaping Care Change Fund to 201415 is now explicitly linked to delivery of joint commissioning strategies. Principles of integration Services should be planned so that they: • Are integrated from the point of view of recipients • Take account of the particular needs of different recipients • Take account of the particular needs of recipients in different parts of the area in which the service is being provided • Are planned and led locally in a way which is engaged with the community and local professionals • Best anticipate needs and prevent them arising, and • Make the best use of the available facilities, people and other resources Why integrate resources? • To share the challenges of managing service delivery in the context of demographic change across primary, secondary and social care, with a real focus on reducing demand and managing services to maximise quality, capacity and effectiveness • To understand total resource use and patterns of spend and activity, to recognise and address variation that works against principles of wellbeing, and to help identify areas of service that bring the greatest opportunity for redesign to support preventative and anticipatory care, reduce unplanned care and to improve efficiency and effectiveness • To create a shared incentive that engages all the key players in addressing the continuing pressure in growth and demand throughout the entire system • To ensure that the most expensive care is used appropriately and maximised at every opportunity An approach based on integrated strategic planning • Evidence – planning for populations, not delivery structures or functions – pooling resources to support the population based plan – “Hegemony of acute care” - Northern Ireland • Strategic planning – Each integrated partnership must prepare a strategic plan setting out how its integrated arrangements will achieve the national health and wellbeing outcomes (s23) Challenges (1) • We must ensure: – provision of safe, sustainable high quality care – shared service planning and delivery more effectively rooted in preventative and anticipatory care – shared, transparent understanding of spend, activity and variation across the entire journey of care, particularly for the growing frail older population – strategic planning arrangements that give real traction on the totality of resource to the integrated partnerships, to deliver a shift in the balance of care and outcomes – incentives for localities: delivering better outcomes with less use of institutional care must result in a benefit for localities in terms of capacity to invest in preventative care – local ability to plan using overall spend for defined populations and user groups and to use budgets flexibly – services designed with and for people and communities, not “delivered top down for administrative convenience” Challenges (2) • We must avoid: – planning in terms of historic functional activity rather than population need – failing to improve on the status quo in terms of unwarranted variation and the balance of care – opaque understanding of activity and outcomes inhibiting opportunities to plan for better use of total resources – destabilising management of hospital services – unnecessary transactional complexity – punishment for good performance: delivering better outcomes with less use of institutional care must be in the best interests of all parties (integrated partnerships; local authorities; health boards) Public Bodies (Joint Working) (Scotland) Bill • Consultation on health and social care – May to Sept 2012 • Public Bodies (Joint Working) (Scotland) Bill laid before Scottish Parliament 29 May 2013 • First Reading – stage 1 will begin Autumn 2013; subsequent stages contingent on progress • Second reading • Enactment – Spring 2015 Still to come: • Secondary legislation • Regulation • Statutory guidance Legislation Aims to Address • Inconsistency in the quality of care for people, and the support provided by carers across Scotland particularly in terms of services for older people and adults who access a range of support services across health and social care; • Unnecessary delays in hospital when people are clinically ready for discharge; and • Prompt availability of services to enable people to stay safely at home in order to avoid admissions to hospital or care home wherever possible. Models (Section 1 SS 4) Body Corporate • Delegation of functions by the local authority to a body corporate that is to be established by order under section 9 ( an “integration joint board) and delegation of functions by the health board to the integrated joint board” Delegation between partners • Delegation of functions to local authority to the health board or • Delegation of functions to health board to the local authority or • Delegation of functions to local authority to the health board and by health board to the local authority Integrated resources Model A: single partnership hospital H&SC Partnership Strategic Commissioning Plan (£150m) Local Authority Adult Social Care Managed Communit y Health Care Managed Hospital Services (LA) (NHS) (NHS) Managed Budget Optional Other CHP services eg childrens NHS Board £10m £50m £50m £50m • The strategic plan defines the outputs and outcomes for the integrated partnership • The integrated budget reflects the distribution of resources required to deliver those outputs and outcomes • In this model, whole hospitals or some hospital services may be included by agreement between the parent bodies where direct management responsibility for the whole hospital or services within a hospital rests with the single health and social care partnership. In some existing partnerships whole hospitals and some services in acute hospitals are already directly managed by the CH(C)P and by agreement these could be incorporated into the health and social care partnership and possibly extended by agreement over time. • In order to maintain stability of services, it is envisaged that any transfer of resources will be incremental in scale Integrated resources Model B: multiple partnership hospital H&SC Partnership Strategic Commissioning Plan £150m Local Authority Local Authority Local Authority Adult Social Care (LA) Managed Communit y Health Care (NHS) £50m £50m Managed Budget Managed Hospital Services Optional Other CHP services eg childrens £10m £10m NHS Board Hospital Services Hospital Services £40m £40m • The scope of the Strategic Commissioning Plan is the same in Model A and B • Resource flows are driven by delivery of the agreed Strategic Commissioning Plan • To avoid disaggregation of hospital services within a single site, the operational management and budgetary responsibility for unscheduled care remains with NHS Board • The hospital budget for all services in scope of the SCP will be fully transparent to the Chief Officer What next? • A position statement on managing integrated resources to be agreed by the SG, NHS and local government • Ongoing work to support effective strategic planning locally – particularly local articulation of agreed objectives to shift the balance of care • Technical guidance for managing integrated resources Current Issues • Protected Self Interest • Imbedded Culture • Tokenistic Change • No Change at Grass Roots • Cash Cows • Clock is Ticking • Needs recognition that one size just doesn’t fit all Questions?