Achieving financially sustainable healthcare now and in the future is likely to mean changes to how and where people access services. This means that NHSScotland needs to consistently deliver high-quality care at a lower cost and against rising expectations and demand. This session investigates the current thinking and practice around the critical links between improving quality and delivering on efficiency. Professor Cam Donaldson, author of ‘Credit Crunch Healthcare’, challenges delegates on their thinking around ‘traditional’ delivery of efficiencies and how this can impact on improving quality. Sally Campbell from NHS North West England also describes the journey to delivering best value in HR services. See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

1. ACHIEVING HIGH QUALITY, FINANCIALLY
SUSTAINABLE HEALTHCARE

2. Why are you here?
• Achieving financially sustainable healthcare now and in future
is likely to change how and where people access services
• This means that NHSScotland needs to consistently deliver:
• high quality care
• at a lower cost
• against rising expectations and demand.
• This session will investigate and develop current thinking and
practice around the critical links between improving quality and
delivering on efficiency

3. Who will you hear from?
• Chair: Simon Belfer, Director of Finance,
NHS National Services Scotland
• Session Lead: Professor Cam Donaldson
Yunus Professor of Social Business &
Health, Glasgow Caledonian University,
author of ‘Credit Crunch Healthcare’
• Sally Campbell - Managing Director of
Cheshire HR Service
• Discussion and audience voting
• Wrap up
• Introduction
• Challenge delegates on their thinking
around ‘traditional’ delivery of
efficiencies and how this can impact
on improving quality.
• Describe the journey to delivering
best value in HR services.

4. Three session aims
•Explore the links between quality and efficiency
•Opportunity to share innovative ideas and suggestions
to influence this work
•Able to contribute to the national work being
undertaken to support NHS Boards in this area

5. 2020 Vision for Health and Care in Scotland
• Our vision is that by 2020 everyone is able to live longer healthier
lives at home, or in a homely setting.
• We will have a healthcare system where we have integrated health
and social care, a focus on prevention, anticipation and supported
self-management.
• When hospital treatment is required, and cannot be provided in a
community setting, day case treatment will be the norm.
• Whatever the setting, care will be provided to the highest standards
of quality and safety, with the person at the centre of all decisions.
• There will be a focus on ensuring that people get back into their
home or community environment as soon as appropriate, with
minimal risk of re-admission.

6. The challenge inside the 2020 vision
•Over the next few years, demand and the
circumstances for delivery will be radically different
•We will need to continue to provide high quality
health and care services, meeting what the people of
Scotland expect
•We will be measured by securing the best possible
outcomes for people from the care and support they
receive.

7. Examples of the challenges
• Healthcare inflation
• Reducing health inequality:
• Despite efforts to address, we have made very little progress.
• Ageing population:
• By 2033 the number of over 75 is likely to have increased by almost 60%
• Continuing shift towards long-term and multiple conditions, with complex needs
• By 2033, demography could grow spend on health and social care by over 70%
• Dementia:
• Estimates will rise from 71,000 to 127,000 sufferers in the next 20 years
• Tremendous financial costs to the NHS and social services
• Health and cost impact on carers - more likely to take prescribed medication, visit
GP with higher levels of stress and physical symptoms

8. Public Service Reform – Christie response
•decisively shifting towards prevention
•integrating more public services locally, driven by better
partnership, collaboration and effective local delivery
•investing in the people who deliver services through
enhanced workforce development and effective leadership
•focussing on better performance, through more
transparency, innovation and use of digital technology.

9. Professor Cam Donaldson
Yunus Chair in Social Business & Health
Glasgow Caledonian University

10. Collaborating for Quality
Achieving high-quality, financially-sustainable
health care
Cam Donaldson
Scottish Exhibition and Conference Centre, Glasgow
11-12th June 2013

11. Celebrating the NHS, London Olympics opening
ceremony

12. Otherwise known as ‘leftie...crap’!

14. Two main directions follow
• Health care reform to enhance incentives for efficiency:
• user charges
• ‘internal markets’
• remuneration
• integration
• The need for economic evaluation of health care:
• assessments of cost effectiveness and cost benefit
(a challenge to physicians)
• systematising evaluation thinking
(a challenge to managers)

15. Two main directions follow
• Health care reform to enhance incentives for efficiency:
• user charges
• ‘internal markets’
• remuneration
• integration
• The need for economic evaluation of health care:
• assessments of cost effectiveness and cost benefit
(a challenge to physicians)
• systematising evaluation thinking
(a challenge to managers)

16. The focus of ‘Triple Aim’
• Patient experience (quality)
• Population health
• Cost (Value and financial responsibility)

17. Important antecedents
• Rational collective action
• Integration

18. My triple aim at Triple Aim
• Is integration sufficient?

19. Platitudes of health care reform
• Reforms all over the world state that the ‘new’ system will:
• adopt ‘a balance of care’ approach
• be about ‘effectiveness and efficiency’
• adopt ‘an evidence-based approach’
• ‘involve communities and other stakeholders’.
• But no-one ever says how!!! i.e. what’s the process?

20. My triple aim at Triple Aim
• Is integration sufficient?
• Are we recognising and managing scarcity?

21. Managing scarcity: the clinical challenge
• Any decision to change the way care is delivered will impact on
HEALTH OUTCOMES. This will:
• improve A
• remain unchanged B
• decrease C

22. Managing scarcity: the clinical challenge
• Any decision to change the way care is delivered will impact on COST.
This will:
• decrease 1
• remain unchanged 2
• increase 3

23. “Allocation of funds and facilities are nearly always based on the opinion of
consultants but, more and more, requests for additional facilities will have to be
based on detailed arguments with ‘hard evidence’ as to the gain to be expected
from the patient’s angle and the cost. Few could possibly object to this.”
Who said this?

24. • “Allocation of funds and facilities are nearly always based on the opinion of
consultants but, more and more, requests for additional facilities will have to be
based on detailed arguments with ‘hard evidence’ as to the gain to be expected
from the patient’s angle and the cost. Few could possibly object to this.”
Cochrane AL. Effectiveness and Efficiency: random reflections on health services. Nuffield Provincial Hospitals
Trust, London, 1972.

25. Deciding whether it’s worth it:
A challenge to clinicians
2  = ×
3 × ×
A B C
1  
HEALTH OUTCOMES
C
O
S
T
 = recommend change to new treatment
X = recommend status quo
= judgement required

26. An economics-based framework for needs
assessment: the management challenge
An economic approach addresses need from the perspective of
resources:
1. What resources are available in total?
2. In what ways are these resources currently spent?
3. What are the main candidates for more resources and what would be their effectiveness and cost?
4. Are there any areas of care which could be provided to the same level of effectiveness but with less resources, so
releasing those resources to fund candidates from (3)?
5. Are there areas of care which, despite being effective, should have less resources because a proposal from 3. is
more effective (for £s spent)?
Can be applied at ‘micro’ or ‘macro’ levels

27. Shameless promotion: part II

28. But it’s not new
Who said this?
“If I had a plan, it would be simply to take the poorest and least organised
hospital in London and, putting myself there, to see what I could do – not
touching the Fund for years, until experience had shown how the Fund
might best be available.”

29. A novel idea!
“If I had a plan, it would be simply to take the poorest and least organised
hospital in London and, putting myself there, to see what I could do – not
touching the Fund for years, until experience had shown how the Fund
might best be available.”
Florence Nightingale (1857)

30. My triple aim at Triple Aim
• Is integration sufficient?
• Are we recognising and managing scarcity?
• Where does ‘population health’ fit?

31. Lessons
We need to work towards:
• maintaining publicly financed systems
• thinking more about explicit evaluation and priority setting at all
levels of the system
• dealing with chronic disease management:
 integration plus priority setting?
• working ‘with’ rather than ‘on’:
 people as well as systems
• engaging the public:
 what is socially relevant?
• rethinking the notion of the ‘clinician-scientist’.

32. Sally Campbell
Managing Director of Cheshire HR Service

33. Developing a new model of HR Services

34. Cheshire HR Service - Overview
• Established in 2006, experienced in supporting NHS organisations in various sectors of
healthcare
• Hosted by East Cheshire NHS Trust as an ‘arms-length’ division with an operating
framework to provide increased autonomy
• Provider of a full range of business focused HR and L&D services
• We offer customers a wealth of experience and knowledge of working with the
complexities of the changing healthcare environment
• Our mission ‘to deliver excellence in people management’

35. Cheshire HR Service - Timeline
Pre 2006
Separate HR Teams
– Acute,
Community, PCT
2007 - 2011
NHS HR Shared
Service
5 Organisations
2011 - 2013
NHS HR Service
Provider –
50+ customers
2013+
NHS Service
Provider with
Commercial Partner
2006 2013

36. The HR Challenge
• Safety & Effectiveness
• Value for Money
• Quality
• Increased Patient & Staff
Satisfaction
NHS Outputs
• Potential to save £616m-£1bn
nationally
• 56% of HR function could be
provided as a shared service
• 20-50% operational savings
• Best practice approaches
DoH Back Office
Report 2010 • People and skills taking centre
stage
• Risk management and
governance giving HR pivotal
role
• OD and change capability
high demand
Drivers

37. • Small shared HR Service already existed
• Changes to commissioning structure – new organisations forming
• Introduction of Electronic Staff Record (ESR) across NHS
• Different payroll arrangements
• Absence of coherent HR strategy/lack of strategic HR input
• Cumbersome and outdated HR processes, inadequate technology
• Poor levels of satisfaction with HR
• Increased measurement and monitoring of HR indicators
Our Key Drivers

38. • Separate HR Departments
• Multiple sites
• Multiple Processes and Procedures
• Multiple contact points
• Disparate, outdated technology
platforms
• Manual and duplicate data entry
• Strategic staff performing
administrative tasks
• Results
• Costly, disparate HR functions.
• No performance metrics
• No customer service focus
• Shared HR Service
– Harmonised and centralised HR
services
– Single point of contact for HR
customers
– Single employee access portal and
data entry
– Enhanced Technology platforms
– Enhanced HR reporting
• Results
– Cost reduction
– Customer focused HR delivery
– Strategic staff re-focused on strategic
delivery
Transforming HR Services

39. Our vision for a model service
Future
proofing
Strategic health
of organisation
Policy & Process
Administration
Process improvement
automisation, Self-service
/HR Service Centre
Centres of expertise
Customer retained HR activities

40. Systems
Support
Service
Recruitment
Service
Learning &
Development
Service
HR
Consultancy
Service
Wellbeing
Service
Business Partnering
Our Services

41. Business Partnering
Inefficient case mix, lots of ER activity, chasing of information,
limited business skills
Analytical skills, strategic consultancy, workforce planning skills,
psychometric testing, service improvement training
OD, workforce planning, productivity, service change, governance
and compliance, business strategy
2009-2011

42. Tier 1:
HR Direct
24/7 Online Advice and Tools
Tier 2:
Advice Line/Administrators
Case Handlers/HR Advisors,
recruitment/general
administration, online system
management, MI Reports
Tier 3:
Specialist Advisors
Case Managers, specialist advisors,
people coaching, mediation, people
development, policy development
Services underpinned by Systems Support

43. Multiple Systems
Non-Standard Complex
Processes
Multiple Locations
Transactional
Efficiencies
Baseline
Remove
Complexity
Remove complexity
Standardise Processes
Remove complexity
Standardise Processes
Implement Common
System
Establish new
organisation
Remove complexity
Standardise Processes
Implement Common
System
Centralise transaction
processing
Establish new organisation
Remove complexity
Standardise Processes
Implement Common
System
Centralise transaction
processing
Implement e-enabled
common system
Migrate to Virtual
transaction processing
Multiple Systems
Non-Standard Simple
Processes
Multiple Locations
Transactional
Efficiencies
20%
Multiple Systems
Standard Simple
Processes
Multiple Locations
Transactional
Efficiencies
40%
Common Systems
Standard Simple
Processes
Multiple Locations
Transactional
Efficiencies
50%
Common Systems
Single/ Few Locations
Transactional
Efficiencies
60%
e-enabled system
Virtual Locations
Transactional
Efficiencies
75%
Increasing process maturity
Standard Simple Processes
Standard Simple
Processes
Multiple Systems
Multiple Locations
Transactional
Efficiencies
Baseline
Multiple Systems
Non-Standard Simple
Processes
Multiple Locations
Transactional
Efficiencies
20%

44. • Diversity of cultures from multiple organisations and ownership of HR
• Allocation of resources
• Geography/location
• Managing Change
• Business Continuity
• Developing technology against competing demands
• Achieving change in behaviours – customer/business focus
• Developing internally – capability to “let go” and become commissioning
partners
Challenges

45. • Supported organisations in making savings year on year
• Increased customer satisfaction – organisation, manager, staff
• Technology benefits for HR and customers – modern, fast,
efficient, compliant
• Improved job satisfaction in HR (above the best national average
score)
• Skill Mix/Career Development - Right people undertaking right
tasks
• Increased confidence and capability of managers
Was it worth it?

46. Internal HR
The Organisation New Capabilities
Self Diagnose their current state on maturity map
Set realistic expectations aligned to culture and
practice
Identify quick wins
Make sure leaders are a partner on the journey
HR Business Partnering and Strategy
Managing SLA’s/outsourced services
Business Case Development
Demonstrating value through information
Renegotiating “the deal” between HR and managers
Absolutes Internal HR
Investment in technology
Commitment to concept of new mode of control
Clear governance arrangements
Simplify customer facing end
An OD/Change Programme which focuses on:
Defining roles/mind the gaps
Developing capability to let go and take
on the new
Change in behaviours/ taking a customer perspective
HR Business Partners as commissioners of HR
services
Don’t put off dealing with capability issues
What did we learn?

47. Discussion and audience participation

48. So Just How Effective Are We?

49. Question 1
Who are the greatest band of all time?
1. Pink Floyd
2. Beatles
3. Abba
4. Chas & Dave

50. Question 2
How easy or difficult would it be for your organisation
to introduce ‘an economics-based framework for
needs assessment’ into its management processes?
(please enter a number from 1-4, where 1=very easy and
4=very difficult)

51. Question 3
How would you assess the culture of transparent
measurement and learning and wider application of
quality improvement techniques throughout your
organisation?
(please enter a number from 1-4, where 1=very easy and
4=very difficult)

52. Question 4
How ready is Scotland to deliver the scale and speed of
change required?
1. Lost cause
2. Behind
3. Ahead
4. Well ahead

53. Question 5
The theme of this year's conference has been collaborating for
quality. Which of the following statements best describes your
view on the level of collaboration that currently exists across
Health & Social Care?
1. There is no collaboration
2. We collaborate across our organisation, but collaboration
with social care partners could be better
3. We have good collaboration across health & social care
4. We collaborate actively with a range of partners in public,
third and private sectors

54. Question 6
How engaged are you personally in collaborative work
between Health & Social Care partners?
1. Not at all
2. Very occasionally
3. A reasonable amount
4. Almost all the time

55. Question 7
What is the most important area for collaborative work over
the coming years?
1. Primary Care
2. Secondary Care
3. Care at home and in the community
4. Support Services (IT, Finance etc)

56. Question 8
What would be the biggest help/support to you as
individuals/organisations with your change agenda?
1. Information from other health systems/different sectors
2. Time with peers/colleagues to discuss opportunities
3. Supported development programmes
4. Internal consultancy support to the assessment
of options for change

57. Question 9
To what extent has today given you new information or fresh
ideas and impetus to engage?
1. Not at all
2. Not much
3. Quite a lot
4. Huge

58. Question 10….(Chairman’s Special
Question)
How much UK tax should Google pay? Enough for:
1.Billy Connolly to get a haircut
2.A chocolate bar for everyone in this room
3.A Google chrome laptop for every P1 child in Scotland
4.Cam Donaldson to get a new Ferrari each year

59. Wrap-up