National Health Committee. 2015/ /19 Strategic Plan DRAFT

Transcription

1 National Health Committee 2015/ /19 Strategic Plan DRAFT

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3 Contents PART 1 MESSAGE FROM THE COMMITTEE 4 PART 2 INTRODUCTION Who Are We? Our Purpose The Environment Who We Work With 9 PART 3 THE STRATEGY Strategic Direction Leading and Influencing Sector Change Finding the Balance Applying the Full Extent of the NHC Mandate 20 PART 4 ORGANISATION Organisation development Capability and Capacity Risk Risk Factors Notional Budget Commercial Model Budget information Key Assumptions Budget Projection 2015/ / Glossary and Abbreviations 26 Note: The words in this document emphasised in bold italic are the headings for the outcomes within the business plan. DRAFT June

4 PART 1 MESSAGE FROM THE COMMITTEE Enhancing patient outcomes, improving the fiscal sustainability of the health and disability sector and contributing to economic growth are the key outcomes to be achieved by the NHC. Our focus as a Committee is on developing recommendations which are supported by analysis and assessments which are done the right way to the right level and at the right time. The NHC s strategic focus is leading and influencing the cultural change necessary in the system to achieve sustainable health outcomes supported by: finding the balance assisting the Sector to improve clinical outcomes and meet immediate fiscal challenges while providing the medium to long view on improving patient outcomes and sector sustainability applying the full extent of the NHC mandate. During 2014/15 we have seen excellent engagement with the Sector. The NHC is continuing to increase its profile and how it can add value to the Sector. We have been testing our mandate and are moving to a place where the Sector is willing to engage in more difficult discussions about long term sector challenges. The Sector has provided clear messages that they want the NHC to move away from disease specific analysis to more population and whole of system approach. The NHC has a very broad perspective of the health and disability system and is therefore able to support the Sector with whole system design. For example, we are expanding the proactive assessment process beyond the assessment of the level and mix of current services to assessment of new models of care to tackle significant population health, condition prevention, patient outcome and service affordability issues, such as the increasing prevalence of chronic conditions. Our drive to provide high quality prioritisation assessments has resulted in ongoing continuous improvement and evolution of the NHC business model. This is supported by our work with other agencies and has encouraged our focus on models of care rather than specific technologies and interventions in isolation. Our challenge is to improve the alignment between the NHC s work programme and other prioritisation agencies such as PHARMAC and healthalliance which procure clinical devices and technology for the Sector. We are continuing to evolve our work with the Health Research Council as part of the Health Innovation Partnership (HIP). During 2015/16 we expect to move towards more prescribed research protocols aligned to the NHC s four domains and timeframes. We are also developing our relationship with Callaghan Innovation. We want to strengthen the adoption of innovations so that they contribute more effectively to the health and disability system s continuing capacity to deliver the health outcomes New Zealanders expect - despite emerging pressures and fiscal realities. The NHC is in the fortunate position of being able to leverage the work of our international partners to the benefit of the New Zealand health and disability sector. 2015/16 is expected to see the EXCITE model established in New Zealand, in collaboration with the NHC, to further develop the work being undertaken in fit for purpose genetics. We are always grateful for the support of the health and disability sector and their acknowledgement and acceptance of the Committee s unique position to contribute to an effective and sustainable health and disability system for New Zealand. Our strategic plan continues to evolve to recognise the Sector s expectations and challenges. Anne Kolbe Chair Peter Guthrie General Manager DRAFT June

5 PART 2 INTRODUCTION 1. The National Health Committee (NHC) 1.1 Who Are We? The National Health Committee (NHC) is a statutory Advisory Committee under section 11 and 13 of the New Zealand Public Health and Disability Act 2000 (NZPHDA 2000) 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 The NHC is required under section 14 of the NZPHDA 2000 to operate a Public Health Advisory Committee (PHAC); a subcommittee to provide the NHC with advice on the public and population health aspects of its recommendations to the Minister of Health. Technology encompasses any intervention that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long-term care. This includes pharmaceuticals, devices, interventions and organisational systems. The NHC focuses on models of care. Models of Care is a term used within the sector to describe many approaches to how care is provided to patients and consumers. The NHC use of the term models of care (refer figure 1) refers to the development of: a pathway of care which is optimal for 80% of target patient population a business model that supports and manages the resource critical nodes in the pathway of care a system wide approach to the model including clinical care, operational, business, systems enablers, policy, and performance. Figure 1: NHC Models of Care DRAFT June

6 1.2 Our Purpose The NHC provides the Minister of Health with independent, evidence based advice on which technologies and interventions should be publicly funded and how to manage the introduction and sustainable implementation of these in the New Zealand health and disability sector. The NHC investigates interventions that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long term or end of life care. This includes models of care and organisational systems that can be used by other agencies such as District Health Boards (DHBs), healthalliance and PHARMAC to inform decisions on new pharmaceuticals or devices. Specifically, the NHC provides advice on the introduction of new technologies, the significant expansion of existing technologies and the reprioritisation of old technologies. Evidence around technologies and interventions is assessed against four domains: clinical safety and effectiveness ethical and societal considerations economics feasibility of adoption. The NHC is not required to commercialise its recommendations. Therefore, it operates within accountability for reasonableness (A4R) framework and publishes its findings. It is careful to do so in a manner, which allows other agencies to maximise the financial benefits from those recommendations. Figure 2: NHC Domains and Decision Making Criteria Four Domains Decision Making Criteria Clinical safety and effectiveness Clinical safety and effectiveness Health and independence gain Materiality Societal and ethical Feasibility of adoption Policy congruence Equity Economic Acceptability Cost effectiveness Affordability Feasibility of adoption Risk Other criteria Through working internationally, nationally (ie whole of government), with the health and disability sector, and within the Sector the NHC expects to make an impact in the following key areas to assist the Sector achieve the aims articulated in the NZ Triple Aim Framework: improved patient outcomes through the consistent delivery of clinically effective, ethically sound, socially acceptable and sustainably implementable technologies and interventions. For the Sector to derive maximum advantage from a new technology, or group of technologies, it must be DRAFT June

7 identified early, prioritised and assessed in a timely manner, recommended and diffused across the health and disability system in a consistent and rapid manner. The challenge for the NHC is the balance between completing this process in a timely manner whilst ensuring thorough high quality outputs inform decision making. value for money through clinically effective and cost effective interventions. Considering the implementation of new interventions as part of the overall model of care to ensure the maximum benefit while minimising unintended consequences. This approach provides for a more thorough examination of the clinical and business implementation implications and therefore increases the potential to assist the DHBs meet their objectives. Introduction of new interventions and the repositioning of existing technologies is also an opportunity to implement sector change. reduction and management of the rate of growth in health spend through agreeing approaches to long standing prioritisation issues such as structured mechanisms to allow for new interventions to enter the system and limiting ad hoc introduction. A structured mechanism supporting the balanced introduction of appropriate new technologies is required to ensure patients and New Zealanders retain access to an appropriate level of care within current funding constraints. In particular understanding the churn and costs created by introducing or removing interventions and factoring that into recommendations and implementation approaches. sustainability of the health and disability system through horizon scanning, utilising the relationships with equivalent international agencies, preparing the Sector for change, utilising a systems design approach, assessing new technologies within the model of care, assessing affordability and ensuring unintended and unanticipated impacts are minimised. providing clear direction for implementation, monitoring, measuring and evaluating which is disseminated to all levels of the Sector. improved economic growth through innovation evaluations which identify and pull New Zealand developed technologies into use. Our plans also recognise and will be revised in due course to ensure consistency and alignment with the New Zealand Health Strategy. 1.3 The Environment The New Zealand health system performs comparably to other OECD countries. Our health spending per person is lower than the OECD average, yet we achieve similar health outcomes to those who spend more. While New Zealand Governments have prioritised Vote Health over the last 40 years the Sector can only expect modest increases in the future. Finding the balance between health, wellness and independence outcomes and the wise stewardship of resources to deliver value for money will increasingly challenge the Sector. There will need to be some transformational change if we are going to maintain or improve health outcomes and reduce the financial gap. Figure 3 shows the New Zealand health and disability sector cost curve. The gap between the dark blue and light blue lines is the difference between long term increase trends and future funding projections. It highlights the challenge to develop affordable and sustainable health services. DRAFT June

8 Figure 3: Core Crown health expenditure per capita and GDP per capita Source: Nicholas Mays, London School of Hygiene and Tropical Medicine, Affording Our Future, Wellington, December 2012 Key drivers of cost pressures are uniformly agreed to be; population growth, the high health and support needs group within the aging population, and technology driven demand for care. Technology driven demand for care is seen by Treasury and the Sector as a key area for attention. While new technology has been shown to reduce cost through increasing productivity, it is also known that new technologies significantly contribute to costs through changing the treatment threshold for access to care - that is patients with a much lower level of need or marginal ability to benefit can now receive care. The health and disability sector is large, developed, diverse, and operates in a limited regulatory environment and is vulnerable to having expensive technologies which are not necessarily fit for purpose, pushed into it from a variety of sources. Introduction of new technologies also highlights unresolved issues in the system. Just assessing the new intervention in isolation does not address the underlying system-wide concerns. There are significant issues which are challenging the health and disability sector, these include: the impact of the development of genomics the impact of long term conditions on health and support services the impact of inequities and disparities on health outcomes the changing expectations and requirements for end of life care the complex, comorbid and often elderly patient reducing ambulatory sensitive admissions and acute demand for hospital services personal responsibility for health managing patients closer to home refocussing resources in the community developing a workforce responsive to the speed of change. DRAFT June

9 There also some challenges the NHC faces in order to deliver including: defining and agreeing a way forward on some fundamental long standing issues for health including what should the Sector s position be on the timing of the adoption of new technology the achievability of putting a formal structure around the current informal introduction process for new interventions achievement of the above while still providing the ability for the New Zealand system to participate and contribute to international knowledge generation and benefit our patients through participation in clinical trials developing and agreeing a meaningful outcomes framework that clearly articulates the outcomes achieved by the NHC and Sector outcomes the NHC contributes towards. The NHC, working beside other agencies such as Pharmac, Accident Compensation Corporation (ACC), healthalliance, District Health Boards (DHBs) and the Ministry of Health (MoH), is uniquely positioned to help build an effective and sustainable health and disability system for New Zealand. The Committee has an accepted position and role in the Sector and is increasingly seen as the thought leader and change agent to provide advice and direction on sustainable investment and reprioritisation. There is opportunity to develop this leadership to consider the wider issues and challenges facing the Sector. 1.4 Who We Work With We are responsible to the Minister of Health and work with many stakeholders. Our key stakeholders are the District Health Boards (DHBs). They are the deliverers of the health and disability care to their resident populations. They expect the NHC to provide advice to the Minister of Health and negotiate with the Minister on their behalf. They, and the Minister, expect us to do this using evidence and in an open and transparent way under an accountability for reasonableness (A4R) framework. The key central agency stakeholders, in addition to DHBs, who the NHC works collaboratively with include: the Minister of Health who has overall responsibility for the health and disability sector the Ministry of Health which as principal advisor to the Minister has the responsibility for the management, development and sustainability of the health and disability system the National Health Board which is responsible for funding and monitoring and performance of the public health service other agencies and entities including ACC, PHARMAC and healthalliance who have mandates and decision making powers for specific elements of the Sector ie funding injury treatment and support, community and hospital pharmaceuticals and medical devices, and non-clinical support services respectively other government agencies eg Ministry for Business, Innovation and the Environment (MBIE), Ministry of Social Development especially with respect to socio-economic determinants of health, Treasury, Tertiary Education Commission, Institute of Environmental Science and Research and the Ministry of Education. The whole of Government opportunities lie in data sharing and aligning strategic business plans so we can maximise our efforts and reduce the critical gaps and overlaps in the public sector. In addition to the central government agencies involved in the Sector there are many other stakeholders who need to be considered as they will be impacted by the NHC advice provided to the Minister once implemented, these include: DRAFT June

10 Clinicians, the Medical Council of New Zealand, Colleges and professional bodies who represent front line clinicians and lead the development of important opinions for the introduction, use and removal of technology across the health and disability sector. Manufacturers of technology through their representative organisations, the Medical Technology Association of New Zealand (MTANZ) and Medicines New Zealand. In order to implement the pull model the NHC must carefully engage with industry. The pull model identifies and pulls New Zealand developed technologies into use within the health and disability sector. Work to understand the risks and benefits of industry participating in the development of the pull model will be undertaken via a pilot project to assess an innovative, disruptive technology which can improve health s contribution to GDP growth Patients and their families the final recipients of the prioritisation process. Patient perspectives are considered as part of the assessment process. Whilst the NHC s primary focus is the public sector and Vote Health we recognise that technology is often introduced by the private sector. We endeavour to work with private providers as they have a role in the overall NZ health system and this perspective and experience needs to be considered when assessing the overall model of care. Figure 4: NHC Tiered Approach for Prioritising Work Plans/Seeking Advice and Engaging with the Health and Disability Sector CLINICAL ADVICE & ENGAGEMENT SECTOR ADVICE & ENGAGEMENT NHC PRIORITY AREAS Colleges and Speciality Societies Health Sector Forum, DHB CEOs and Chairs through NPRG Programme Budget, Models of Care & Surveillance NHC presentation to Clinical Leaders on: - Indicative priority sub-areas - Sector Working Group membership - 'Choosing Wisely' input Priority Area Tier 1: Strategic Overview Outputs: Committee recommendations for T2 Published document E N G A G E M E N T A D V I C E College/Society nominations of key investment / reprioritisation opportunities College/Society membership to gain support / approval More detailed analysis Advisory and Working Groups Implementation and Analysis Tier 2: Sub-Area Analyses Outputs: Committee recommendations for T3 Tier 3: Assessments Outputs: Assessment reports Production and Dissemination of Information to Clinicians and Patients Committee Recommendation Formulation Recommendations to Minister Outputs: Recommendations to Minister of Health Supporting documentation Outputs: Published recommendations Supporting assessment reports NHC Monitoring SECTOR IMPLEMENTATION NHC Evaluation (as required) Source: NHC Executive DRAFT June

11 Each group of stakeholders has their own expectation of their role in the prioritisation process and how much influence they should have over the final decisions. Engagement with key stakeholders early in the process is essential (refer Figure 4). This provides an opportunity for stakeholders to genuinely participate in the process as well as mitigate implementation risks. Maintaining the NHC profile with the Sector s stakeholders also enables the reinforcement of a consistent prioritisation process across the Sector. DRAFT June

12 PART 3 THE STRATEGY 2. Strategic Direction The NHC s strategic focus for the next four year plan is to Lead and Influence Sector Change. Our role is to act as a Sector expert to help individual parts of the Sector address their medium to long term challenges as well as to set the agenda and improve the Sector s overall contribution to population and economic wellbeing. Essential is our ability to influence the behaviour of decision makers, including clinicians and health professionals, across government and within the health and disability sector. This strategic focus is supported by two key goals: 1. Finding the Balance - Assist the Sector to improve clinical outcomes and meet immediate fiscal challenges while providing the medium to long view on improving patient and population outcomes and sector sustainability 2. Applying the Full Extent of the NHC Mandate - Strengthening the NHC mandate for prioritising the most cost effective health technologies. Developing an approach which generates buy-in from all stakeholders and is implementable, provides a logical and practical sequence of actions and utilises both formal and informal levers to achieve the best outcome. Figure 5: Strategic Framework Whole of Government Outcomes Improved population health & wellbeing Better Public Services Improved economic growth for NZ Sector Outcomes Improved patient & population health outcomes Improved sector sustainability Sector contribution to economic growth Sector Priorities Clinical Leadership Financial sustainability Integration Health Targets NHC Impact Improved patient & population outcomes Most effective mix of clinical services delivered Whole of government systems thinking Bending the cost curve Contribution to economic growth through innovation NHC Strategy Leading & influencing sector change Finding the balance Applying the full extent of the NHC mandate NHC Strategic Functions Innovate Identify / Prioritise / Advise / Recommend Implement Monitor / Evaluate Sector Level Model of care approach integrated prioritisation across the continuum of clinical and business decision making Intervention Level Prioritising the best mix of clinical services to meet current & future need and maximise health outcomes DRAFT June

13 2.1 Leading and Influencing Sector Change Creating and sustaining system change by leading development of recommendations that are implementable and achieve sustainable health outcomes Why is this important? The NHC has a core function of leading the development of recommendations that are implementable and sustainable. The Committee has an accepted position and role in the Sector and is increasingly seen as the thought leader and change agent to provide advice and direction on sustainable investment and re-prioritisation. There is opportunity to bring together the NHC s leadership helicopter perspective of the Sector, evidence based activity and implementation approach to drive change to respond to the wider issues and challenges facing the Sector. We need to move beyond the current disease focus to a population and systems focus to maximise our ability to create sustained change How are we going to do it? By evolving our existing methodology and business model: Provision of leadership to respond to Sector challenges: Support the Sector to develop solutions to sector challenges - Build sector awareness of the need to prioritise resource investment across the model of care, assist Sector to develop knowledge and skills to contribute to / undertake national, regional and local prioritisation/reprioritisation. Provide the Sector with updates on emergent trends in health and though the National Prioritisation Reference Group (NPRG) provide opportunities to discuss future trends and solutions to long term sector challenges Apply a pull model for health technology by clustering recommendations to gain the attention of technology providers and users by using the evidence to alter the reactive flow of technology to a proactive model. Proactive assessment process extended beyond the assessment of level and mix of current services to include new models of care - a broader model of care methodology rather than assessment of single technology or intervention in isolation. Feedback from the Sector suggests that the NHC will be of most value operating at this level as it will be able to achieve sector change as well as contribute to sector financial sustainability. Extension of the model to tackle significant population health, condition prevention, patient outcome and service affordability issues, such as the increasing prevalence of chronic conditions. Field evaluations to include testing new interventions, feasibility, affordability, and new or revised models of care. Undertake field evaluations to generate evidence for promising technology in partnership with the Health Research Council and aligned with the NHC work programme and domains. Undertake innovation evaluations to support health s contribution to economic growth in partnership with Callaghan Innovation and aligned with the NHC work programme. Contribute to sustainable health outcomes. Consistent delivery of clinically effective, ethically sound, socially acceptable and sustainably implementable technologies and interventions. Develop recommendations that clearly articulate rationale for implementation against the four domains and the A4R framework allowing the Sector to understand where and how services and resourcing needs to be prioritised to gain improvements in patient outcomes and return on investment. Involve the NPRG and other stakeholders in the development of recommendations. DRAFT June

14 Contribute to the financial sustainability of the Sector. Establish a notional budget which captures the benefit of the NHC s recommendations on a whole of sector basis. Initially savings in the budget will favour cost avoidance, over time the contribution of productivity and reprioritisation savings will grow until all three measures are contributing effectively to the notional budget target agreed with the Sector and recommended to the Minister. Increased sector participation in prioritisation. Iterative sector engagement through the assessment process to minimise the potential for unintended consequences of recommendations, particularly with clinicians and DHBs. Also increase responsiveness to the Sector through facilitating the National Prioritisation Reference Group and through regular dissemination of horizon scanning and think pieces relating to long term sector issues to support the Sector develop solutions to sector challenges. Close the learning loop for the Sector and demonstrate best practice - providing evidence and prioritisation recommendations, utilising international partnerships, providing advice on implementing the recommendations, measuring and monitoring implementation and most importantly, providing feedback to the Sector to inform their next prioritisation decision making process or change Progress to Date The last three years have been focussed on developing the foundations to support the current mandate of the NHC. Progress is underway in key areas of the current plan including: proactive assessments undertaken using programme budget analysis to identify large and growing spends by disease group that the Sector should be concerned about annual reactive assessments undertaken which capture technologies, service access or patient outcomes the Sector is concerned about generation of evidence for new technologies in partnership with the Health Research Council (HRC) improving health s contribution to GDP growth by working in partnership with agencies such as the Callaghan Innovation (CI) to identify and pull New Zealand developed technologies into use a tiered approach to leading the Sector in building cases for change to ensure buy in to recommendations and their consistent, sustainable implementation in line with Treasury s business case for change pragmatic use of health technology assessment (HTA) process to ensure timely advice, including leveraging the work of overseas HTA agencies wherever it is sensible to do so integration with the work of other Health Sector Forum (HSF) agencies to avoid duplication and leverage benefits from other work such as DHBs work in COPD, PHARMAC s cardiac work, Health Quality and Safety Commission s (HQSC s) orthopaedic work, MBIE s National Science Challenges and Callaghan Innovation s support of emerging health technologies, which have the potential to improve New Zealand s economic performance. support for horizon scanning of emergent trends through membership of HealthPACT and its international links such as to Euroscan and its reporting line to AHMAC development of a notional budget methodology in consultation with the Sector review and amendment of the NHC terms of reference including transition from traditional health technology assessments to models of care further work to understand the relevance of implementation throughout the NHC process consideration of the approach to monitoring and evaluation work with the Sector to establish the National Prioritisation Reference Group, in place of the regional networks described in the previous 2014/15 plan DRAFT June

15 appointment of advisors to the Committee development of the relationship with Universities New Zealand work towards establishment of a national and international trusted expert contracting panel How will we know we re successful? Sector Outcomes Sector awareness of the emergent trends and prioritisation tools across the model of care adds value to their processes to enable system change. Achievement of the notional budget releases value to the Sector through cost avoidance, efficiencies and reprioritisation measured using the notional budget methodology to be agreed with the Sector. Improved patient outcomes through implementation of NHC recommendations measured by consistent access to services across the country based on the relevant hospital focussed procedure codes. Specific patient outcome measures will also be developed for each set of recommendations and could include reduced mortality and morbidity, reduced complications compared with current interventions etc. The Sector working with the business sector contributes to economic growth through successful completion of innovation evaluations. NHC Outcomes Provision of leadership to respond to sector challenges through: increased Sector awareness of prioritisation and emergent trends measured by the provision of regular reports to the Sector (ie horizon scanning, think pieces and reports from international partners eg HealthPACT briefs) applying a pull model for health technology by clustering approximately 15 recommendations per year the proactive assessment process being extended beyond the assessment of level and mix of current services to include new models of care measured by the number of assessments undertaken each year using the model of care approach field evaluations which generate evidence for promising interventions related to the strategic work programme measured by the fund being fully utilised to support the NHC work programme innovation evaluations which generate solutions to sector challenges and measureable benefits to the New Zealand economy. Contribute to sustainable health outcomes. Outcome measures will be developed for each set of recommendations and could include reduced mortality and morbidity, reduced complications compared with current interventions etc. Contribute to the financial sustainability of the Sector through agreeing the notional budget methodology with the Sector and subsequently achieving the notional balanced budget target each year Increased sector participation in prioritisation and reprioritisation processes and decision making measured by participation in the National Prioritisation Reference Group and contributions to the annual referral round Stakeholders engage and lead consistent, sustainable and measurable implementation for their own organisations due to their participation in NHC work including the tiered assessments and DRAFT June

16 implementation framework measured by DHBs who implement recommendations as per the NHC advice NHC continues to add value to the Sector as a result of opportunities for sharing resources and capability between the Sector and NHC being undertaken, and enhanced NHC capacity and capability measured by DHB satisfaction, and review of NHC terms of reference, prioritisation and assessment processes and strategic sector relationships. DRAFT June

17 2.2 Finding the Balance Assist the Sector improve clinical outcomes and meet immediate fiscal challenges while providing the medium to long view on improving patient and population outcomes and sector sustainability Why is this important? The NHC needs to find the right balance between short term assistance for the Sector to manage current challenges and preparation of the system to deal with emergent need and new interventions over a 5-10 year horizon. The Sector needs to be able to manage now to find the space to think about the longer term. The NHC has a two-fold responsibility: firstly to help the Sector address ongoing challenges, the NHC runs an annual reactive referral round to ensure that areas of concern for the Sector not identified through the proactive process are able to be considered for prioritisation assessment. secondly the NHC needs to identify and assess where the medium and longer term care, health and outcome and economic pressures will arise, in order to provide the advice the Sector needs to keep ahead of future cost waves. It does this through the proactive assessment process or pull model approach. The Sector has identified that it lacks the available capability and capacity to complete investment and disinvestment or reprioritisation assessment processes within their organisation and so look to the NHC for direction. The NHC operates on a finite capacity and needs to focus its efforts on areas of whole of system strategic advantage. So it needs to ensure that the work it does with the Sector is positioned to provide wide benefit to all DHBs or is used as a platform to progress whole of system development How are we going to do it? The NHC will continue to emphasise the importance of sector prioritisation and evidence based investment decision making, and provide advice and support for local activities in this area through working in close conjunction with the Sector to: continue the annual reactive referral round for the health and disability sector to propose areas of concern where they consider the NHC could add value by providing clear direction continue to proactively prioritise using a tiered business case approach that describes the model of care, the pull model and proactive assessments by focussing on two proactive workstreams each year and the thinking for future replacement workstreams. Figure 6 describes the planned timing for the reactive and proactive workstreams over the next four years. It also describes how some of the reactive referrals have been incorporated in the proactive work programme. During this four year period there will be a transition from the disease focussed assessments (eg ischaemic heart disease) to a population focus (eg frail elderly). The subsequent evolution to a systems focus will begin with the assessment of musculoskeletal and eye, the test case for the model of care approach. This will potentially impact the current intended analyses for DRAFT June

18 neoplasm / endocrine, digestive / mental health and hepatobiliary / kidney and urinary. The NHC will review planned workstreams annually as part of the planning process. Over time the NHC will undertake high level comparative analysis of all large scale spends within the Sector. Figure 6: Proposed Timing of Workstreams Cardiac Cluster Cardiovascular ->Ischaemic Heart Disease Respiratory -> Chronic Obstructive Pulmonary Disease Aortic Abdominal Aneurysm Diagnostics -> Haematuria Genetics Frail elderly Musculoskeletal / Eye Age-related macular degeneration, low back pain & IORT 2014/15 Reactive Referrals Neoplasm / Endocrine Hepatobiliary / Kidney and Urinary (TBC) Digestive / Mental Health (TBC) Disease Population Models of Care (System) Key 2012/13 reactive referral 2013/14 reactive referral 2014/15 reactive referral Proactive workstream Intended proactive workstream Progress to date During the 2013/14 financial year the NHC and its stakeholders completed an assessment of four expensive and disruptive cardiac interventions. The evidence for the three new interventions is relatively poor resulting in recommendations not to publically fund any of them. For the fourth, an intervention already used in the Sector, not to increase current public funding while further assessment of the intervention rate is assessed. The cost avoidance impact of these recommendations is conservatively estimated to be in the order of $5 8 million per annum. With DRAFT June

19 uncontrolled national diffusion of these four interventions the worst-case scenario was costs in excess of $100 million per annum. These recommendations have been welcomed in the Sector, particularly by DHB governors, as they provide clarity for immediate resource allocation and provide a sustainable road map for longer term service expansion that clinicians have endorsed How will we know we re successful? Sector Outcomes The Sector s areas of concern are addressed through the annual referral round referral process measured by recommendations associated with sector referrals Long term sector challenges are addressed through the proactive assessment process measured by recommendations associated with proactive assessments NHC Outcomes Sector s areas of concern are addressed through reactive referral round measured by completion of the annual referral round each year and DHB satisfaction with process and outcome Assessment process results in implementable recommendations measured by potential unintended consequences minimised, assessment process timeframes reduced and Tier 1, 2 and 3 assessments undertaken as planned. DRAFT June

20 2.3 Applying the Full Extent of the NHC Mandate Strengthening the NHC mandate for prioritising the most cost effective health technologies. Developing an approach which generates buy-in from all stakeholders and is implementable, provides a logical and practical sequence of actions and utilises both formal and informal levers to achieve the best outcome Why is this important? Treasury has noted that prioritising the most cost effective health technologies is important and can be controversial. 1 Treasury s view is that the NHC is positioned well to lead in this area, and consideration should be made to strengthening the NHCs mandate. The NHC is also well positioned to consider other hard to resolve and long term sector challenges. Figure 7: Position of the NHC and other organisations showing their influence over the main drivers of the cost curve HA/HBL Source: NHC Executive Prioritisation and bending the cost curve is the responsibility of everyone in the Sector. However the NHC has a specific role to provide leadership, prioritisation expertise, cross health and business sector relationships, and independent advice to the Minister to achieve this goal. The NHC has a mix of formal and informal levers the Committee could develop ranging from Ministerial Direction, to planned change management via active NHC leadership and Sector 1 New Zealand s Health System: A Discussion Document on Current Performance and Future Directions, New Zealand Treasury 2014 DRAFT June

21 influencing, through to more passive information sharing. To be successful, the NHC needs to develop an approach which is acceptable to all stakeholders and implementable, provides a logical and practical sequence of actions and utilises both formal and informal levers to achieve the best outcome. To derive the maximum advantage interventions and technologies must be identified early, prioritised, assessed in a timely manner, recommended, and diffused across the health and disability system in a consistent and rapid manner. The sector needs to be fully engaged and genuinely participate throughout this process. The NHC must work collaboratively with the Sector to achieve shared outcomes. The NHC has developed a strategic work programme (refer Figure 6) for the next four years. This will require the NHC to utilise the full extent of the mandate it has been given and to maximise the range of formal and informal levers at its disposal How are we going to do it? Ensuring Sector engagement contributes to improved implementation of recommendations: Maintain and enhance sector relationships through regular communication and interface with the NHC. Develop a strategic communications plan focused on sector awareness and maintaining the integrity of the NHC brand. Collaborative relationship agreements formalised with key stakeholders in the Sector and across government. Initially these relationships will be informal, moving to more formal arrangements over time. The NHC has made some progress with the development of relationship agreements, in particular with DHBs and PHARMAC. Sector commitment to introducing consistently or not introducing emerging technologies based on the NHC recommendations. In addition reaching agreement with DHBs to hold technology diffusion while being assessed by the NHC. Use of formal and informal levers contributes to improved implementation of recommendations: Establish an implementation framework for the National Health Committee to: o o o o Ensure that the best mix of actions is taken across settings, functions and outputs to achieve sustainable implementation of agreed change and measurable outcomes. Ensure the Sector has the tools available to implement NHC recommendations Set out a staged and measurable process to demonstrate the impact of the NHC recommendations Demonstrate the credibility and reputation of the NHC by specifying to decision makers how the NHC will operate with and within the Sector to achieve implementable recommendations. Implement cross agency opportunities. Work with other central agencies to align business plans and identify opportunities for sharing data and analysis to maximise whole of government efforts. Options to increase leverage implemented. Identify options for increasing the NHC s ability to add value to the Sector. Progress the future focussed work, particularly systems design and pull model approach. Increase alignment with DHB work programmes and utilise the formal mechanisms available through legislation and the DHB accountability framework DRAFT June

22 Develop a change management plan to support the implementation framework. Establish a monitoring and evaluation framework to monitor the NHC s performance and the implemented recommendations to assess effectiveness and continued relevance. Establish and implement a quality framework through all levels of the NHC from governance to process to ensure the NHC continuously improves and utilises best practice evidence and follows robust processes throughout the NHC workflow How will we know we re successful? Sector Outcomes Efficient and effective use of interventions through structured and consistent introduction of new technologies and interventions and reprioritisation out of existing interventions measured by DHB implementation of NHC recommendations. NHC Outcomes Sector engagement contributes to improved implementation of recommendations as a result of: Collaborative relationships maintained with key stakeholders measured through the negotiation and maintenance of relationship agreements with: DHBs PHARMAC and healthalliance Health Research Council and Callaghan Innovation other central government agencies and others where appropriate. Sector commitment to introducing consistently or not introducing emerging technologies based on the NHC recommendations agreed by the Minister. Also holding technologies, which may be useful, but for which there is insufficient evidence, or which the NHC is assessing before recommendation, for further diffusing or reprioritising out of business as usual. Use of formal and informal levers contributes to improved implementation of recommendations Opportunities to facilitate effective implementation of recommendations considered during all phases of the NHC workflow. It is expected that the implementation framework will result in: o o o Recommendations which describe the most appropriate model of care for the population group An increased understanding of the NHC s role in the implementation of new interventions and technologies measured by DHBs implementing recommendations are per the NHC s advice Development of specific performance measures to support implementation and the monitoring and evaluation of recommendations to support continuous improvement measured by results of monitoring activity. Evidence of quality framework in all aspects of the NHC workflow. DRAFT June

23 PART 4 ORGANISATION 3. Organisation development This strategic plan identifies that the NHC business model is expected to continue to mature, but not necessarily radically alter over the plan s four year timeframe. The Committee will need to maintain a flexible approach to developing capability and capacity. This is likely to include establishing long term relationships with external providers, particularly in the assessment function. 3.1 Capability and Capacity Governance is provided by the Committee. The composition of the NHC reflects the skill sets required to make decisions across the four domains in that there is a mix of age, gender and culture as well as clinicians, business executives and other professionals. The Committee will be supported by advisors. Leadership is provided by a clinical / management partnership between the Chair and General Manager. Their role is to build credibility in the health and disability sector, to guide the identification of priority areas for reactive and proactive assessment and to refine capacity to generate spill over benefits for the pull model and health s contribution to economic growth. Management provides coordination of resources to ensure outputs are delivered that result in recommendations to improve models of care and improve fiscal sustainability. Executive will produce evidence based outputs by working across a number of core skill sets including research, systematic review, bio statistics, clinical, epidemiology, health economics and implementation Implementation Year /2016: Enhance skills sets to improve quality and efficiency of outputs Enhance capacity and knowledge by leveraging work programmes between international HTA providers Year 6 to Year /2017 to 2018/19: Review team and partnership skill sets to ensure alignment with mature business model 4. Risk 4.1 Risk Factors Technology assessment can be contentious, but it is now recognised internationally as a key element in countries being able to maintain high quality, clinically effective health and disability systems for their populations. The NHC s greatest ability to ensure success is linked to maintaining a reputation for delivering high quality assessments and recommendations which are implementable. The NHC will also act in an appropriate manner to ensure that New Zealand s long term international interests are maintained and enhanced. DRAFT June

24 4.2 Notional Budget By studying the evidence and taking into account feedback from overseas HTA agencies the NHC has concluded that the traditional HTA approach to technology prioritisation cannot deliver the released value required by our Terms of Reference. To ensure the NHC contributes meaningfully to fiscal sustainability it assists the Sector to manage the reactive flow of technology while at the same time moving New Zealand to the more effective business model of proactive assessment and pull model prioritisations. There is a risk that the Committee will not: choose the right areas of developing technology to investigate gain Sector consensus on a reasonable, material notional budget. The NHC mitigates these risks by: using a tiered approach to identification and prioritisation of work streams; this ensures an evidence based approach to deciding what benefits might be gained prioritising the four year work programme from sector referrals, programme budget analysis, proactive and pull model assessments assessing the intervention against the four domains, including the economic domain which considers the cost effectiveness of an intervention as well as whether the Sector can afford to implement the intervention ensuring a balanced mix of investment in and reprioritisation of technologies agreeing with Sector leaders what a material notional budget might be defined as. 4.3 Commercial Model The NHC has no actual budget means of control over a largely unregulated technology market. There is a risk the Committee will: be unable to persuade the Sector to implement the recommendations it makes make recommendations out of alignment with provider planning cycles The NHC will mitigate this risk by ensuring: all recommendations are evidence based and assessed against the four domains and decision making criteria that clinical advice is taken and stakeholders are actively engaged at a leadership and operational level throughout the assessment process DHB planning, funding and budget teams, MoH and NHB are kept informed of developments as they occur so that implementation can be planned DRAFT June

25 5. Budget information The NHC s budget forms part of the MoH s Policy Business Unit budget. The MoH works in conjunction with the NHC to agree a sustainable level of resourcing which is then split appropriately to allow for both core and externally contracted resource. The NHC also acknowledges the fiscally constrained environment in which it works and actively seeks to expand capability and capacity by leveraging the skill sets and existing outputs of other HTA agencies internationally and other expertise within New Zealand. 5.1 Key Assumptions In preparing this budget the Committee has made estimates and assumptions concerning the future, which may differ from actual results. As the business model continues to mature and deliver results it may be desirable for the NHC to renegotiate its resourcing to sustain a higher level of outputs that will be necessary in the out years of the four year work programme. The budget is contingent on appropriate funding and depending on funding decisions, the NHC s activities and measures for 2015/16 may change. Expenditure increases generally the budget for the next four years assumes that increased activity will be paid for within current funding by moving to directly employ or efficiently contract low overhead resource. However this assumes there is the opportunity to renegotiate the budget each year on an as needs basis. Personnel costs given the NHC s people are its key asset expenditure in human resources will increase to maintain consistency with other public sector organisations. Future costs including inflationary costs will be managed within a static overall funding level for the next four years as part of the NHC s commitment to the Ministry and Sector generally to provide a high level of service from a basis of strict financial prudence. Future funding not agreed the financial forecasts are dependent on the outcome of future negotiations for out-year funding (yet to be conducted). Partnership funds funding for the field evaluation and innovation assessment funds is assumed to include combined contributions of up to $2,000,000 per annum from the HRC and Callaghan Innovation. It is also assumed the HRC and the NHC will enter into a variation to extend their existing agreement for a further 12 months. Legal Risk Fund (LRF) there is no separate Legal Risk Fund to that maintained by the MoH. 5.2 Budget Projection 2015/ /19 National Health Committee Budget 2015/ / / /19 Operational 3,000,000 3,000,000 3,000,000 3,000,000 Innovation Funding 3,000,000 3,000,000 3,000,000 3,000,000 Total NHC funding 6,000,000 6,000,000 6,000,000 6,000,000 Note: For 2016/ /19 the NHC expects to negotiate its funding resources on an as needs basis, so these figures are based on the current year s budget. DRAFT June