Feature / Global Leadership

Health quality guru Don Berwick’s assertion that the Scottish NHS was well on the way to becoming the safest health system on the planet was one of the most memorable moments of the HFMA annual conference last December. On its own, the endorsement would have merited further examination of the Scottish approach, particularly as it is based on that most holy of grails, quality-driven efficiency. But interest has ramped up after prime minister David Cameron called in Dr Berwick to ‘make zero harm a reality’ in the NHS in England.

Scotland’s approach is both top-down and bottom-up, with clinical, finance and general management staff working together, both at national and local level. Shedding staff is not really an option given the Scottish government’s policy of no compulsory redundancies – shifting the focus to other traditional means of savings, such as back office efficiencies, and sharpening attention on reducing waste and upping quality.

‘My focus is on quality-driven financial management, in that if one gets the quality right then delivering on the finances is made easier,’ says Scottish government director of finance, ehealth and pharmaceuticals John Matheson. ‘It is much more constructive to have a conversation with a clinical colleague about enhancing the quality and safety of their service leading to increased efficiency rather than a direct conversation around efficiency.

‘All that we do in NHS Scotland is driven by the quality strategy in further enhancing safe, person-centred and effective care. I am often asked what are we disinvesting in. We are disinvesting in harming patients. It’s as simple as that. It sounds trite, but we mean it – we are harming a lot fewer patients than we were three or four years ago.’

Financial balance remains central to its thinking. ‘Financial stability and value are very much an integrated part of our approach. By the end of 2013/14, we will have delivered about £1.6bn in efficiencies,’ Mr Matheson says.

The quality strategy – Putting people at the heart of our NHS, which was launched in May 2010 – is delivered through the triple aims of: increasing the health of the population through initiatives such as the Early years collaborative; enhancing the experience of care through improvement programmes such as the Scottish patient safety programme; and delivering best value for money through the Efficiency and productivity framework.

He emphasises that all staff are engaged in meeting the three aims of the quality and safety work. He has been integral to discussions on the design, review and implementation of the strategy at a senior level.

The aspiration of quality driven financial performance has been translated into the complex delivery system in a number of ways. First, through mainstream structures such as the regular monthly finance director’s meetings. These are used to encourage discussion of quality and safety elements and to ensure the finance community is aware of the crucial role they play in the delivery of quality care.

Second, finance staff are involved in frontline improvement teams working on the changes in real time. Mr Matheson says: ‘This has two aims; to allow a new group of staff to learn the improvement model and for the clinical staff to learn the importance of resources in the broad improvement of care. ‘

Jason Leitch, clinical director of the NHS Scotland quality unit, which is responsible for the patient safety programme, explains that the dynamic within management boards (both nationally and in the 14 health boards) has changed significantly. Clinicians and finance directors feel equally responsible for quality and financial performance.

He adds that NHS Scotland is on an improvement curve, balancing quality and finance. Improving quality, by reducing waiting times, for example, helped gain the respect of clinicians, making them more open to his message. ‘You have to choose to do quality. It won’t happen by accident,’ he adds.

Government support

While health boards have responsibility for delivering required efficiency savings and maintaining financial balance, they are supported by the Scottish government’s Efficiency and Productivity Portfolio Office.

The office’s head Linda Semple says her team provides a range of support packages to the local health boards – these can be direct support or programme support based on Scotland-wide efficiency initiatives. For example, a national programme aims to drive out waste in outpatients – through reducing ‘did not attend’ rates and clinic cancellations – while another looks at prescribing. Under the latter, it has developed a benchmarking tool that can be followed up with more targeted work at individual board level.

‘We are not imposing any of what we do on boards – our role is to facilitate organisations to deliver their own efficiency savings; to deliver on quality and value for money. Too often these two things are separated.’ The best health systems in the world are examining quality, and this is linked to efficiency, she adds. ‘Often where you see waste and duplication of processes, it is not just about efficiency, but also about clinical issues.’

One example is its guidance on medicines reviews, particularly for older people. ‘Over the age of 75 you are more likely to be on multiple medicines and many of the side effects are a result of the interaction with other medications. Some people suffer falls because their medicine makes them unstable. A review can ensure they have the correct medication, take it in the right way and have no counter indications.’

NHS Tayside, which has worked with the US Institute of Healthcare Improvement, set up by Dr Berwick, has been carrying out work as part of the national patient safety programme and its own Steps to better healthcare initiative, explains finance director Ian McDonald.

As part of the former, it looked at six key clinical areas, including preventing pressure ulcers, central line infections and surgical site infections. ‘We looked at them not necessarily in terms of savings – albeit if they came it would be a bonus – but in terms of how we could get improved outcome measures for these areas,’ he says.

‘With each of these patient safety programmes we had a multi-professional team, including an individual from finance assigned to the team to identify any potential benefits of scale and reductions in cost.’

As a result of the work on pressure ulcer prevalence, Tayside estimated avoided costs of £1.1m between May 2009 and the end of 2011. This was based on academic work from 2004 that ascribed a cost to the healthcare provider of a single pressure ulcer. ‘As a finance director, if I spend £1m on that, it means I don't have £1m to spend on something else,’ he adds.

Mr McDonald says the initial focus was in secondary care, but with patient safety and quality at the heart of the new Scottish general medical services contract, a lot of the lessons learned will be carried into primary care.

While the headline target for efficiency savings has been 2%-3% in recent years, NHS Tayside has been required to look for more (4%-5%). ‘Normal housekeeping measures would enable us to save about half of the 3%, but we felt we had to do something different.’

This led to the development of the Steps to better healthcare programme. Mr McDonald says this has included a re-examination of all of its spending to ensure it is appropriate. But it was not just a financial exercise. The board looked at bed numbers, use of assets and theatre throughput and rostering, for example.

Right across the world, healthcare systems are trying to become more efficient by improving the quality and safety of the care they provide – and Scotland is one of the countries leading the charge.