Quality and Safety in Healthcare in an Age of Austerity

Quality and safety in an age of
austerity
Dr Jammi N Rao MD FRCP
Director, Gorway Global Consulting,
Non-Exec Director, and Chair of Quality and Risk
Committee, HEFT, Birmingham

AUSTERITY
The 2007-8 financial crisis and the ensuing economic recession has had
far-reaching effects all over the world.
Public expenditure on the NHS has remained steady at about £120 billion
since 2009.
As a percentage of GDP UK spend on health is low despite the Blair
promise of 2001 but the NHS is recognised to be the most efficient
system
Austerity
noun
1. sternness or severity of manner or attitude.
2. difficult economic conditions created by government
measures to reduce public expenditure.

Northern Rock
nationalised, 22 Feb 2008
Recession
Austerity
May2012 Local
elections
Popluarity over time of two search terms that reflect interest in
our recent economic fortunes.
Source: chart from Google Trends, 22 June 2015
May2015 General
elections

Campos C, Dent A, Fry R, Reid A. Impact of the recession. Regional Trends 43, 2010-11. Offie of National
Statistics. http://www.ons.gov.uk/ons/rel/regional-trends/regional-trends/regional-trends--july-2011-
edition/impact-of-the-recession.pdf. Accessed 22 Jun 2015.

© Gorway Global Consulting
http://www.nuffieldtrust.org.uk/data-and-charts/uk-spending-public-and-private-health-care

http://www.nuffieldtrust.org.uk/data-and-charts/uk-health-spending-share-gdp

http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
Commonwealth Fund report “Mirror, Mirror on the wall,
2014 update

Quality:
The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge
Safe: avoiding
injuries to patients
from care that is
intended to help them
Effective– avoiding
both under use and
overuse of services
that are based on
scientific knowledge
Patient centred
– care that is respectful
and responsive to
individual patient
preferences
Timely reducing
waiting and delays for
both patient and carer
Efficient: avoiding
waste. Equipment,
supplies, ideas and
energy
Equitable care that
does not vary in quality
due to personal
characteristics,
geography, demographic
factors

DOES AUSTERITY THEN MEAN
STAGNANT OR DECLINING QUALITY?
Yes if you are a victim of the Micawber Syndrome.

High Quality Good Access Contain Costs
The Micawber Syndrome
Access
Cost
Quality
Cost
Quality
Access
• Result: HappinessPick any two
• Result: MiseryPick three

Health care systems around the world will
not survive in austere times – let alone
deliver high performance – without
exceptional medical leadership. This is
because the most important opportunities
to improve productivity are to be found in
unwarranted variations in clinical practice,
such as prescribing, the use of diagnostic
tests, and lengths of stay in hospital.
Chris Ham, Kings Fund. 2015.

Kings Fund work on improving
productivity in NHS
https://vimeo.com/93357257

Length of stay
Use of specific procedures
Follow up rates in outpatients
Antibiotic prescribing rates
Referral rates for common symptoms
Rates of use of imaging modalities
The standard economic view of NHS productivity
This leads to a certain view of the role of medical leadership,
not always helpful to quality and safety....

Medical Leadership
(or is this medical management)
Focus on the
needs of the Trust
Think like
a
manager
satisfy
inspectors
Help the Trust to
meet targets
avoid
negative
press
manage
upwards

it is clinically meaningless and academically
reckless to use ... (SHMR – standardised hospital
mortality ratios, SHMI standardised hospital
mortality index) ...to quantify actual numbers of
avoidable deaths.
Bruce Keogh1,
July 2013
1. Keogh, B. Review into the quality of care and treatment provided by 14
hospital trusts in England: overview report http://www.nhs.uk/nhsengland/bruce-
keogh-review/documents/outcomes/keogh-review-final-report.pdf

ED 4 hour waits. % seen within 4 hours seems to vary with
the numbers that come in

“Use quantitative targets with caution. Goals in the
form of such targets can have an important role en
route to progress, but should never displace the
primary goal of better care. When the pursuit of
targets becomes, for whatever reason, the overriding
priority, the people who work in that system may focus
too narrowly. Financial goals require special caution;
they reflect proper stewardship and prudence, but are
only a means to support the mission of the NHS:
healing.”
1. A promise to learn, a commitment to act. The Berwick report, Aug 2013.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2267
03/Berwick_Report.pdf
Don Berwick1,
Aug 2013.

Medical Leadership
Focus on ‘the
what’
Think
like a
patient
Consent
Standards
Bad
eggs
Learning
systems

Conclusions The small inconsequential benefit seen from
interventions that include arthroscopy for the
degenerative knee is limited in time and absent at one to
two years after surgery. Knee arthroscopy is associated
with harms. Taken together, these findings do not
support the practise of arthroscopic surgery for middle
aged or older patients with knee pain with or without
signs of osteoarthritis.
http://www.bmj.com/content/350/bmj.h2747
2015; 350 doi: http://dx.doi.org/10.1136/bmj.h2747 (Published 16 June 2015)Cite
this as: 2015;350:h2747

http://journal.diabetes.org/clinicaldiabetes/v17n11999/Pg19.htm

Achieving quality and safety by eliminating
procedures and practices that confer little
or no health benefit is like.....

photo courtesy www.nycorganizers.com
acknowledgements: deborahjcabral.com
.... decluttering your
garage...
.... to make space for
your car...

Thank you

Quality and Safety in Healthcare in an Age of Austerity

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