creating a cost effective and sustainable health system using an evidence base health workforce 2025...

Creating a cost effective and sustainable health system using an evidence base

Health Workforce 2025 Anne Kolbe

ONZM, MBBS (Hons), FRACS, FRCSEng (Hon), FCSHK (Hon), FRCSEd (Hon), MAICD

 Chair, New Zealand National Health Committee

Declarations of Interest

• Vocationally registered paediatric surgeon• Chair, National Health Committee• Director, Pharmaceutical Management Agency

(PHARMAC) 2010 - 2013

National Health Committee

Section 11 advisory Committee responsible for providing the Minister of Health with recommendations on:• Which technologies should be publicly

funded in New Zealand• To what level and where technology should

be provided• How new technology should be introduced

and old technology removed

Today …

Challenges - why we need to change!• Health, wellness and independence - prosperity• Vote Health• GDP and GNP• Burden of disease• Technology - goods and services• Capital, back office and IT infrastructure• Workforce

Today …

Opportunities • Evidence - data, information and knowledge• Models of care• Explicit prioritisation

Enablers• Values based relationships• Innovative macro level thinking• Business / clinical partnership• Collaboration and teamwork• Leadership

Leadership values

• Honesty• Integrity• Openness• Passion• Diligence• Perseverance

• Courage• Resilience• Humility• Concern for others• Commitment to

service

Leadership competencies

• Know oneself• Understand the business• Horizon scan, develop and maintain the

“collective” vision, position the business• De-construct and manage complexity• See opportunities not problems

Leadership competencies

• Embrace innovation• Take risks and learn from mistakes and

allow others to do the same• Listen, empathize and learn!• Delegate and facilitate the actions of others• Build and nurture teams• Recognize and celebrate success

Working together!

Astute leaders foster co-operation, collaboration, networks

and partnerships

What are we trying to achieve?

• Safe, quality health, wellbeing and independence outcomes for individual patients and populations

• Live within our means - value for money and affordability

• Sustainability

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

Sustainability

Continuing to provide the range and types of services (outcomes) currently available, or better, without incurring excessive levels of taxes and / or debt.

Source: OECD Health Data, 2012

Source: OECD Health Data, 2012

Source: OECD Health Data, 2012

Growth in core Crown health spending has outstripped national income …

Core Crown health expenditure per capita and GDP per capita indexed real growth

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

DHBs

Disability

Educa-tion

Public Health

Primary HealthMaternity

Ministry

Chart Title

Vote Health 12/13: NZ$14 billion

Source: New Zealand Treasury 2012

LEGATUM INSTITUTE | THE 2013 LEGATUM PROSPERITY INDEXTM

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

Why is health care spending increasing?

Demographics - in part

Non demographics - may be as important!• Income growth - expectations• Technology - widening scope to treat• Lower productivity growth than the rest of the

economy - health care is labour intensive

Consider …

Our systems have developed to manage acute life threatening conditions. • Care is episodic and reactive• Emphasis on hospitals and doctor lead

care organised around medical specialties• Patients often seen as passive rather than

active contributors to their own care

Increasing population of people with Long Term Conditions (LTC)

• COPD, diabetes, CVD, dementia and some cancers

• Most of these people have >1 LTC• Many are over 65 years • LTC are a potent driver of ambulatory care

sensitive admissions and costs

But the world has changed …

Trends in Age-Standardized Death rates for the Six leading Causes of Death in the United States, 1970 – 2002.

Jemal A, Ward E et al (2005). Trends in the Leading Causes of Death in the United States, 1970 - 2002.Journal of the American Medical Association 295 (10): 1255 - 59

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

NHS• 3.6 m (21.9%) of ED attendances

require admission• 37% increase in 10 years• 65% are older (>65 years) - frail,

dementia, complex needs• Utilise 51,000 ABD (70% of total

available ABD)• 33% fewer, general and acute

beds• Ave LOS now increasing for

patients >85 years

Evidence of fractured care, breakdown in out of hours care,

medical workforce crisis,capital and IT limitations

RCP 2012

Just in case you think …

Australia

12 chronic conditions accounted for 1.5m (21.8%)

of hospital separations• Stroke• COPD• CHD• Diabetes

Average LOS 6 -10 days

AIHW 2010-11

New Zealand

21% increase in acute medical discharges (225,000)

• Chest Pain 3.6%• GI 3.5%• Respiratory Infections 3.5%• Cellulitis 3.0%• Circulatory Disorders 2.5%• COPD 2.5%• Abominal pain 2.5%• Neonatal 2.8%

NZ Ministry of Health 2012

The challenge is to adapt the system to the

changing burden of disease in the face of expanding technology

options and constrained resources

Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our FutureWellington, December 2012

So what are the implications for strategic policy?

• Encourage active healthy populations - minimize needs and costs

• Early identification of diseases• Quality and cost effective management of disease

in the community - health and social sector• Ensure the workforce, IT infrastructure, capital

investment and funding streams are developed and aligned to enable the changing models of care

NHC approach …• Evidence based, assessment and

prioritisation of non-drug technologies with a focus on models of care

• Four domains• Clinical safety and effectiveness• Societal and ethical• Economic• Feasibility of adoption

• 11 decision making criteria• A4R framework

NHC Programme Budget 12/13

Source; NHC Executive analysis 2013

Source; NHC Business Plan 2013

NHC Tiered Business Approach to Work PlansSector Engagement and Participation

Source; NHC Business Plan 2013

NHC Programme Budget 12/13

Source; NHC Executive analysis 2013

Tier 1 Strategic OverviewRespiratory Disease in New Zealand

• $265m public casemix hospital discharges• 10 disease states within respiratory disease• prevalence, incidence, health outcomes, health

utilisation and cost

Identify the disease state for Tier 2 assessment with the aim of improving health outcomes whilst maintaining or reducing costs through the prioritisation and application of the most cost effective new and existing health technologies across a model of care

Source: NHC Respiratory Disease in New Zealand

Source; NHC Executive analysis 2013

Source:2013 NHC Executive analysis of 2010-2011/12 NMDS and 2010 National Mortality Collection

Burden of Respiratory Disease

Burden of Respiratory Disease

Source: NZBDS 2013

DALY Breakdown by Percentage Death Breakdown by Percentage

Incident Diseases: Efficiency Gains Required to Reach $5 million

2013 NHC Executive Analysis of 2011/12 NMDS

Source; NCH Decision Making Paper 2013

Tier 2 COPD: A Pathway to Prioritisation

Source: OECD Data 2011

NHC Programme Budget 12/13

Source; NHC Executive analysis 2013

Renal Sympathetic Nerve Ablation

Estimated prevalence of resistant hypertension• Australia n= 260,000 • New Zealand n= 97,000

Costs • Index admission A$11,000• Medical management A$1,200

“Back of the envelope” budget impact …• Australia >A$3 billion• New Zealand A$1 billion

So where does this intervention fit in a model of care for refractory hypertension and what is the appropriate target population? Isler M et al. Lancet 2010; 376: 1903-9

Krum H. Hypertension 2011; 57: 911-7HealthPACT 2013

TAVI for Aortic Stenosis

Application; NHS 16-25 per million population?

Comparator; sAVRepl

Approximate costs index admission + 2years FU care

• sAVRepl A$25,000• TAVI A$63,000

Questions• How to identify the population most able to

benefit?• Substitution or Addition financial methodology?

So …

Success …

• Long run game - there are no simple solutions or quick wins!

• The changes are complex, multifaceted and need to occur at all levels

• “Big picture” strategy - involves action• Evaluation, evaluation, evaluation … and

constant tweaking!• Consistent and persistent national leadership

…before writing the prescription for

the health workforce of the future

it will be important to consider the best business strategy for the delivery of health

care into the future!