John MathesonDirector of Finance, eHealth

and Pharmaceuticals

• NHSScotland– 5 million people– £12 billion– 14 Health Boards– 8 Support Boards– Integrated delivery– Moving towards

social care integration

Health and Wellbeing

Local Government

Finance

EducationJustice

Administration

Infrastructure and Capital Investment

Rural Affairs

Culture and External Affairs

Other

Spending – by portfolio

• 33% Local Government• 34% Health and Wellbeing• 8% Education and Lifelong

Learning

• £34 billion• £6,500 for each person in

Scotland• £93 million per day• £129 million per working day

Aims

To deliver the highest quality healthcare services to the people of Scotland

For NHSScotland to be recognised as world-

leading in the quality of healthcare it provides

• 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.

The Healthcare Quality Strategy for ScotlandThe Healthcare Quality Strategy for Scotland

EVERYONE IS ABLE TO LIVE LONGER HEALTHIER LIVES, AT

HOME, OR IN A HOMELY SETTING

Our ‘2020 Vision’Our ‘2020 Vision’

ROUTE MAP TO THE 20:20 VISION

Primary Care

Quality of care

Integrated Care

Safe Care

Unscheduled & Emergency Care

Health of the Population

Prevention

Early Years

Health Inequalities

Value & Financial Sustainability

Efficiency & Productivity

Innovation

Workforce

12 PRIORITY AREAS FOR ACTION

11/02/13

Person Centred Care

Care for Multiple & Chronic Illnesses

“Give me six hours to chop down a tree and I will spend the first four sharpening the axe”

Abraham Lincoln1809-1865

Efficiency and Productivity Workstreams

Alignment of workstreams with the ‘20:20’ Vision

Prevention and Early Intervention

Health Behaviour Change Smoking Cessation Lifestyle Interventions

Evidence Based Care Low Value Clinical Interventions

Evidence Based Clinical Thresholds NICE/ HIS Standards Patient Safety

Support and Enablers:

• Identify and share good practice

• Innovative approaches to data to identify productive opportunities

• Tools for demonstrating productive gain and benefits realisation

Outpatients, Primary and Community Care

Acute Flow and Capacity Management

Prescribing Shared ServicesProcurement

Productive GP

RTC Community

Reshaping Care

Outpatients

SAS Modernisation

PMS QoF Indicators

Ophthalmic Referrals

LTC eHealth

Demand and Capacity Planning

Day/ Short Stay Surgery/ Ambulatory Care

Enhanced Recovery

Inpatient Capacity and Flow

Orthopaedics

Theatres

National Therapeutic Indicators

PAPS, Formulary and Advisory Network

Secondary and Primary Care Interface

Repeats, Waste and Polypharmacy

Performance Management and Incentives

National Approach and Consistency

HR Services

Facilities

Finance

Social Work

Good Practice

Intensive Improvement Activity

National Contracts Review

Regional Consortia

Dashboards

Workforce Capacity and Modernisation

Leadership and Capability Governance and Engagement

Information and Analytics Benchmarking Baselining Productive

OpportunityWhole Systems

Analysis

Core

W

orks

trea

ms

Enab

ling

Wor

kstr

eam

sCr

oss-

cutti

ng

Wor

kstr

eam

s

“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

January – March 2007 to July-September 2012

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 ScotlandPopulation of Scotland

0

1

2

3

4

5

6

7

Glasgow

City

Inverclyde

West D

unbartonshire

Midlothian

Eilean S

iar

East R

enfrewshire

Edinburgh, C

ity of

Renfrew

shire

East Lothian

Scottish B

orders

East D

unbartonshire

Aberdeen C

ity

Dundee C

ity

Argyll &

Bute

South A

yrshire

Highland

Aberdeenshire

West Lothian

Moray

South Lanarkshire

Perth &

Kinross

North A

yrshire

North Lanarkshire

Falkirk

East A

yrshire

Dum

fries & G

alloway

Fife

Orkney Islands

Angus

Stirling

Clackm

annanshire

Shetland Islands

75+

Bed

day

s p

er c

apit

a

ISD 2010/11 IRF mapping data

Public Finances – Fall in Government ExpenditurePublic 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

• 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 2014-15 is now explicitly linked to delivery of joint commissioning strategies.

Reshaping Care Change FundReshaping Care Change Fund

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

• 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)

An approach based onintegrated strategic planning

• 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 (1)

• 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)

Challenges (2)

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 boardor• 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

Adult Social Care

(LA)

£50m

Managed Community Health

Care

(NHS)

£50m

Managed Hospital Services

(NHS)

£50m

H&SC Partnership

Optional Other CHP

services eg

childrens

£10m

Strategic Commissioning Plan (£150m)Managed Budget

Local Authority

NHS Board

• 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

NHS Board

Integrated resources Model B: multiple partnership hospital

Local Authority

• 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

Local Authority

Local Authority

Adult Social Care

(LA)

£50m

Managed Community Health

Care

(NHS)

£50m

Managed Hospital Services

£10m

H&SC Partnership

Optional Other CHP

services eg

childrens

£10m

Strategic Commissioning Plan £150mManaged Budget

Hospital Services

£40m

Hospital Services

£40m

• 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

What next?

• 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

Current IssuesCurrent Issues

Questions?