Evidence and magic How to transform Quality in NZ? Wellington Feb 2009 Bruce Arroll, Department of General Practice & Primary Health Care Faculty of Medical & Health Science University of Auckland, Auckland, New Zealand

Acknowledge l Prof John Buchannan l “grand” father of quality in Auckland l Kept the interest in the topic when we were flagging

Disclaimer l Fresh eyes on what is happening l At a global level I am happy with the health system l I work at the University 70% of my time and 30% I work in a clinic in Manurewa, which I partly own, one of the most disadvantaged suburbs in New Zealand l No concerns about waiting lists – a side show

Story l Story of 6 year old girl l She is having chemotherapy for a blood cancer l She is bald l All her class mates are laughing at her l Her teacher considers l Her teacher does something outrageous → n Problem solved l This is magic or transformation – a step change

Rod Jackson l Health is all about quality and cost and nothing else l Perceptions are generally wrong –you need to audit and compare – we overestimate l We need a step improvement in quality

Shave our heads for quality l Make quality the centre of the health system l If we can grow moustaches for prostate cancer surely we can shave our heads for quality

My contribution to quality

What would quality look like l The computer system would have audit functions made user friendly as well as for clinical stuff l The current systems are really designed to make clinical work more effective with audit as a secondary consideration l Press a button and get an audit l We should know how we are doing as a nation l Each clinic would have a “quality person”

What would quality look like l Diana North and Drinfo –press a button and find out how you are doing and selects those who need to be called in to get their management improved l Ensure that practitioners know how to use their computers n Enter the data in to data base not in as text l A robust method of evaluating performance n UK make figures public- audit police

Are the decks burning #1 l gout audit l 38% of patients with gout with uric acid levels < 0.36 mmol/l l Practice in same suburb 43% l After intervention 45% l How does this rate nationally l No one knows

Are the decks burning #2 l Auckland % of patients on ACE inhibitors/CHF l UK % of patients on ACE inhibitors with CHF l Auckland % of patients on ACE inhibitors n Personal communication V Andersen 2009 l Does this matter => hospitalisations, QoL, death

Are the decks burning #3 l Immunisation n DTP NZ % coverage n DTP UK %

NZ vs UK l We don’t know l Echocardiogram for patients with CHF 92.5% in the UK in an Auckland population 58% l NZ most likely no better than the UK on any measured parameter in the QoF and probably worse on most if not all l Perhaps we should measure what’s happening here as a starting point l UK system unlikely to go backwards

What is needed l A transformation i.e a step change in attitude towards quality l Consider a systemic approach n Pegasus with CME and audit synchronised l There are plenty of criticisms but the UK is probably as good as or better than us on every indicator that they use -they are the bench mark l A national system

What’s missing ? l Political devolution of responsibility to DHB/PHOs means nobody is in charge l Problem with transferring electronic detail from one clinic to another using Medtech software. l Eg adverse drug reaction info is lost n Computers do this well humans do not n Some one will die or get sick l No single person can change this situation other than perhaps the minister of health

Summary l Gary Sinclair n Aims for the best not just better health care l If we want the best we need a transformation. Waiting for change to happen spontaneously is wishing for magic l We need to embrace quality l We need to measure how we are doing-QoF nz survey

Summary l We need to consider a system that works for NZ without the downside of QoF l The UK may not have the Rugby world cup but they do have the world cup on quality l Somebody needs to be in charge