Jack Welch, a former boss of General Electric, famously warned that if the rate of change on the outside was more than the rate of change on the inside, then companies would soon fail. Steven Spear, a speaker at our recent annual conference, has observed how different organisations function – from Coca-Cola to Alcoa to health care providers. He concluded that the most successful organisations did not think their way to solutions top down but discovered their way forward through ‘doing’. As Steven wrote in a briefing for our event, the key to progress was faster discovery and the power to design and test change by people at the front line.
This is a different end of the telescope to where discussions about changing the NHS start, and mostly end, in the world of national policy and reform. Discourse about reform is usually about the ‘what’ – so the vision, some aspect of structural (usually administrative) change, and to some extent the blend of national ‘levers’ to achieve it, such as targets, regulation, the dose of competition, or payment incentives. Far less attention is focused on the place where value is truly generated – in the patient-clinician interface and the place in which care is given whether it be a hospital, general practice, mental health trust or community service.
What would accelerate improvement here? This was the focus of our first annual conference on 24 January.
Let’s consider three big ‘coalface’ issues needing attention. The first is the quality of clinical care as measured by clinical or patient reported outcomes. As we know, the latter show marked variation over time and place, and in some cases lag behind international figures. The second is unnecessarily complex management processes within a health care provider which require staff to develop time-consuming, demotivating workarounds, resulting in waste, poor quality and higher risk of adverse outcomes. Every clinician can appreciate Steve Spear’s observations:
‘When we… actually watch people in action, it can be horrifying to realise how little of their time is spent doing what they’re trained to do – and what would be appreciated by other people. Instead, much of their time is spent correcting, coping, reworking and otherwise compensating for things not working well’.
The third is care that isn’t integrated – between any of secondary, primary, community or social care.
Our event looked at examples in each of these areas where progress is being made, and identified some key ingredients for supporting improvement.
Dr Peter Margolis, a paediatrician at Cincinnati Children’s Hospital, and his team have over the past ten years significantly improved the outcomes of children with inflammatory bowel disease. This has been done using structured data capture during every interaction with accompanying research and analysis, quality improvement processes to test and implement advances in new knowledge rapidly, plus meaningful active patient participation. Dr Margolis describes this combination of ‘assets’ as a ‘learning health system’. Originally called Improve Care Now, this has been scaled up to create PEDSnet – a national system with digital infrastructure to support improvement across multiple paediatric conditions.
Several speakers including Steven Spear, based at MIT, Prof Mary Dixon-Woods at Cambridge University, and Prof Tom Downes, a geriatrician at Sheffield Teaching Hospitals NHS Foundation Trust, focused more on improving processes of care. Sheffield’s Discharge to Assess scheme, for example, has successfully reduced length of stay and delayed discharges for older people. The ingredients here included the use of standard quality improvement techniques, involving multidisciplinary teams including patients, and real-time scrutiny of key metrics.
Dr Tim Ferris, Head of Population Health Management at Partners HealthCare, focused on avoidable admissions through care that was not integrated. Partners HealthCare is a Pioneer Accountable Care Organisation in the US, which over four years has improved quality for patients and ‘bent the cost curve’ through careful design and implementation of better integration. The ingredients aiding progress here included incentives aimed at physicians, tight accountability mechanisms, teams using quality improvement techniques and forensic use of data and metrics to assess progress.
You can see some themes emerging – real-time structured data, research/analysis, systematic quality improvement techniques, and clinician and patient/carer involvement. The combination of these ingredients seemed to be key – whether the aim was improved clinical outcomes, improved ‘flow’ or reduced waste. These were explored throughout the rest of the day, drawing on developments in each area, including some such as Q and the planned Improvement Research Institute at the Health Foundation. For those of you who missed our conference, you can watch the streamed sessions on our website.
Clearly there are significant assets in some of these themes being developed across the NHS, especially investment in the data architecture. But there is still some way to go on each, as well as joining the dots to demonstrate the potential synergies. It is in these areas that the Health Foundation with others will be working in the coming years. Watch this space.