Prospects for service redesign to support integrated care in New

Presentation by Dr Graham Scott
Chair: Expert Advisory Group on a revised Performance and
Incentive Framework
To HQSC conference ‘Towards Integrated Care in NZ’
Wellington 14 November 2013
Expert group on the performance
and incentive framework
 Members
 Dr Graham Scott (chair)
 Prof Sir Mason Durie
 Vince Barry
 Dr Richard Tyler
 Geraint Martin
 Dr Murray Horn
 Dr Judith Smith
 development of a performance and incentive framework for PHOs that will need
to be accompanied by a monitoring and management programme.
 encouraging more patient-centred care closer to home
 contributing to a financially and clinically sustainable health system
 Take a ‘whole of systems’ approach
 The initial focus will be on driving performance improvement in primary care
 Support government priorities
 Sustainable / Implementable /Future proofed
 Align with DHB annual planning and monitoring
Work thus far
 Expert Advisory Group have considered NZ and
international experience of health performance
 Identified some main elements of a potential
framework for New Zealand;
 Reviewed the ‘straw man’ proposal by the GP
Leadership Forum
 Holding a series of large regional workshops, and other
engagements - like Tumu Whakarae - and other
methods (such as web feedback), for critiquing,
further developing and testing the framework it
Lessons about integrated care
 From the UK
 More systematic management of chronic disease
 Active engagement of patients
 Population based approach
 More integrated models of care
 Lessons from NZ – the leading innovators are confirming the lessons of international
 Better integrated service delivery cannot be engineered from the centre nor easily
 Local circumstances play a large part
 Local leadership is essential
 Focus on solutions not problems
 Values and culture are critical – hierarchies and politics kill innovation
 Key conclusion is that centrally imposed performance and incentive frameworks won’t
make it happen. They can set the basic requirements and provide some motivation and
empowerment. But high levels of success come about from innovation, leadership,
community engagement and local circumstances; and from flat inclusive
organisational arrangements not hierarchies; not consultation but positive engagement
and co-production
Our proposed framework
 System level measures to assess performance across whole
districts, supported by contributory measures which reflect local
priorities and approaches towards system level improvement.
 System wide scope: DHBs, PHOs and general practice be the
starting point for developing measures, but there should be
rapid expansion to a wider range of health professions and
services, and in time to a full range of disability and social sector
services, potentially including Whanau Ora.
 Replace PPP measures, align with other performance systems
and reduce overall compliance costs
 Flexibility for local initiatives to be included
Levels of performance
 Four distinct levels of performance, from entry, to improving, to
excellence to breakthrough;
 Assessment of performance at each of these levels should apply
to each district wide health system as a whole;
 Assessment of performance may sometimes be judged by
reaching a set target, and sometimes be judged by achieving a
narrow range of variability in practice or use of resources;
 The range of performance within a district will be made visible
by this approach, and that high performing organisations will
have to work with lower performing organisations in order to lift
achievement across the system.
Performance indicators
 There to support improvement in quality, access and value
 Need both:
 consistency for the purpose of performance comparison, and
 tailoring to local plans and improvement activities.
 Combine elements of information for judgement (targets)
and for exploration and improvement (tin-openers)
 system level measures largely nationally determined, and be
predominantly used for judging performance between
 contributory measures be largely locally determined at
district level, and have a strong element of quality
improvement, indicating various professional and
organisational contributions to system level performance.
 Need to balance indicators of results and capabilities
The choice of performance
 Health outcomes are the goals but we must account
for practical issues:
 Often not easy to measure
 Subject to multiple influences - some beyond the direct
control of the service provider
Proxies for outcomes (impacts, outputs, inputs, capability,
quality) are often the best choice
Poor choice of performance indicators may induce distortions
to behaviours and other unintended consequences
The indicators must makes sense and be owned by the
Must be able to aggregate contributory measures up to system
Change from pre-requisites at the base to freedoms at the top
Resources attached to the framework, including the existing
money associated with the PPP, should largely pass to frontline
health professionals.
A proportion of this should be used for capability e.g. to support
professional participation in quality improvement programmes.
Health professionals largely motivated by high standards of
services to patients and communities
Freedom of professional judgement over use of clinical
resources - but within quality improvement systems -should be
a key element of the incentive for high performance
Triple Aim as adapted by the HQSC
• At a national level governance of the framework should be
independent, credible, expert and responsive to consumer
need, with a transparent appointment process for clinical
and other essential expertise.
• Options are being discussed through the workshops and
through the consultation
• Implementation may be through existing structures - with
changes if needed – to avoid duplicating or creating new
organisational structures.
• At a local level alliances should agree performance and
quality improvement priorities and preferred contributory
measures for services within the framework.
Implications for Maori health
 Sends a signal for joint responsibility for health of the population
across all services and stakeholders: challenges of providing high
quality services for Maori are challenges for everybody across the
 Maori perspectives can feed into governance and continuing
 Triple aim framework is broad, and can be inclusive of Maori
 System wide measures broken down by ethnicity and deprivation
categories to ensure that equity for Maori is an explicit lens for
 Framework can incorporate service integration beyond core
health services e.g. in Whanau Ora
 Contributory measures appropriate for local health needs can
incorporate responsiveness to particular Maori issues
 Documentation onto Health Improvement and
Innovation Resource Centre website early October
Draft measures and indicators on Health Quality
Measures NZ
Stakeholder engagements October-November:
Christchurch ,Wellington, Hamilton, Auckland
Extensive on-line conversation and feedback through
Final EAG advice in December – the ‘starter pac’
Implementation starts mid-2014
Please help
 We need to test the proposals we have come up with so far,
and we need to ensure that the measures which will be
used at each level are fit for purpose.
 Only then will we be in a position to set out an effective
integrated performance and incentive framework which
will help to enable the best levels of performance in health
care that we can achieve

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