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Yesterday I outlined the problems inherent within conventional approaches and thinking about change management. All too often conventional approaches result in no or little positive change for either service users or taxpayers. Albert Einstein was right: to solve problems and improve our thinking has to change. Indeed, real improvement comes through learning by doing and reflecting on these results. It must also be rooted in research that provides data-driven evidence.
Essential to the acquisition of hard-data is knowledge of customer demand that illustrates patterns of need set against the deployment of resources. Good service (as experienced by the customer/patient/service user) always pays, it never costs. The inability to deliver service is paradoxically expensive and the real ‘gold-plating’: it means in the public sector patients or service users receive either too little and then either ‘represent’ to the service or (in the private sector) customers leave altogether.
Conversely, reviewing services from the customer/patient/service user perspective reveals the folly of conventional change management with its preoccupations on activity assumptions, arbitrary plans and make-believe monetary savings which rarely materialise. Improvement begins with adopting a customer mind-set, studying services and putting pre-configured assumptions of what works aside. Use innovative methods to understand how and why services perform the way they do and what it takes to get them better for those that need to use them.
A Better Way to Conceive Improvement
Intelligent change starts with turning convention on its side, researching performance of local NHS and care systems through the external lens of the patient. The way to realise better service and less cost begins with taking a different, horizontal view. Patients flow through healthcare systems.
Adopting a ‘Front-to-Back Thinking’™ mind-set is about recognising that activity and costs are a consequence of what you do not why you do something. Performance improvement comes from studying patient-level demand; analysing the nature of activity that this demand generates and achieving sustainable cost savings through the elimination of activity waste. How well an organisational system meets patient needs should inform both strategy and costs.
Studying patient demand allows for intelligent system and service redesign solutions around cohorts of patients, not pathways. The principal work is two-fold: research and redesign. The former is evidence-informed problem identification through data analysis.
Research is undertaken to understand patient-demand by looking at the ‘what, where, who, why and when’ of their healthcare usage. It is important to recognise here that the requirement is to utilise both quantitative and qualitative research techniques. A common error with many analytical models is to draw linkages between correlation and causation or indeed assert causality as a consequence of data analysis. Data analysis asks ‘what’ questions which need to be linked to demand analysis’s pursuit of ‘why’ to authenticate findings.
This phase entails analysis of time-series consumption and case-mix data; encounter data to understand customer activity and patterns of usage as well as the type, frequency, volumes and predictability of customer demand together with an understanding as the balance in value versus non-value activity. The work provides patient segmentation into meaningful typology groups which forms the foundation for subsequent improvement work.
Redesign implies a set of sequential steps to undertake intelligent improvement activity. Such Improvement must focus on redesigning the care models and systems around patient cohorts, beginning with the ‘vital few’ patients who, although small in number, consume disproportionately large amounts and activity and costs.
It involves using knowledge gleaned in the research phase to undertake prototype service redesign activity. Clarity of the patient purpose is paramount; as is patient-centred performance metrics; redesigned systems, processes and roles; experimentation with operating models and continuous feedback loops to ‘learn to improve and improve to learn’.
Teams of interdisciplinary professionals are assembled and given autonomy to work together first understand and then meet the holistic (medical and non-medical) needs of these patients, who themselves set the boundary. Flexible services and systems are harmonised according to patient need. The role of leaders also changes, from mandatory monitoring in board-level meetings to problem-solving issues that beyond the control and scope of local interdisciplinary teams.
Key skills that are required include medical and technical but extend more importantly to interpersonal, organisational and problem-solving abilities. The focus is on decreasing end-to-end service times, ensuring more work is done right-first-time; reducing or removing activity that adds no value to the patient thereby preventing such patients from boomeranging around the system.
Here the work involves alterations to budgets, roles, measures and, where necessary, technology. Importantly, the purpose is to develop the redesign and determine its anticipated economies through internal base-lining of current performance via patient-level not service-line reporting.
Following the prototype period, leaders make an informed choice about the benefits from adopting the new (systems) design including further roll-out opportunities. This approach is encapsulated in the Consumption Demand Method™ which enables the emergence of better services that act as testing grounds for continuous improvement set against a better understanding of patient demand.
Delayed transfers of care, or ‘DTOC’ as it is colloquially referred to in NHS circles, is an entrenched national problem. It is often claimed that a combination of ‘cultural and structural factors’, an over-reliance in bed-based care and increasing numbers of people with complex conditions moving between providers is causing undue strain on the system. It is one of the principal issues said to affect the performance of A&E units up and down the country.
DTOC has a big impact across the whole healthcare economy in terms of activity, costs and reputation. It is generally accepted to centre on acute services for older people. But the question I pose is: by focusing on the acute are we concentrating efforts on the symptom or the cause? Every problem presents an opportunity. Every challenge requires an intention to signal a desire to improve through thinking and acting differently. DTOC is a symptom of a dysfunctional health care economy.
Concerted effort and numerous attempts have been made, over several years, to successfully address DTOC. These initiatives include the usual list of initiatives including ‘Appropriate Care for Everyone Programmes’ (without ever defining what appropriate in this context means), QIPP projects, engagement and public education packages and Older People’s Joint Commissioning Strategies.
Yet, successive schemes fail to impact on DTOC as they compartmentalise the problem through focusing on urgent care or complex care rather than understanding the root cause of the problems. The impact of these actions on improving DTOC performance remains stubbornly low. Initiatives tend to adopt a reactive and reductionist approach to resolving the problem.
The principal reasons for failure requires detailed study but can be summarised by adopting a (silo) service-first not patient-perspective and focusing on activity reduction and discharge pathways. The causes of waste or ‘system limitations’ affecting DTOC include:
- Outsourcing of adult social care provision
- Multiple patient assessments
- Eligibility criteria in community and social care
- Different organisational budgets, performance metrics and ways of working
- Counter-productive financial incentives across the system
- Service fragmentation such as a ‘medically fit’ focus
- Alleged risk-averse attitudes amongst some clinical staff
- An efficiency rather than effectiveness focus on reducing length of stay
- A target mentality which limits attempts to understand in order to improve
- Understanding the problem from the organisational perspective
‘Pooled budgets’ for services used by older people offers hope to reduce rates but only if it is accompanied by a change in commissioning and operational thinking and ways of working that extends beyond joint ‘commissioning of care’.
‘Current DTOC performance’ is monitored on a regular basis through weekly returns taken on one day each week from local acute trusts. The whole thing resembles the game-show Play Your Cards Right. Snapshot analysis shows the weekly rates of DTOC can vary with some weeks being ‘higher’ and others ‘lower’.
All of which leaves me with more questions than answers, and those questions are – what does this tell us? How does this information help us understand to improve? Does this ‘activity counting’ help develop knowledge and understanding around the patients who experience delays and the type and nature of activity this creates which leads to costs? What has operationally changed as a result of monitoring? How do we know if this has been effective? Or like the game show – is it simply a game of chance? Such ‘activity monitoring’ is as counter-productive as it is distorting. Improvement work must take place in the work not in meeting rooms.
I have recently completed a piece of work looking at the problem. I hope the study will provide the platform to overcome successive false starts, identify root causes and design a healthcare system to reduce DTOC levels through better understanding patient demand. But that, of course, is dependent on the willingness of local NHS leaders to adopt a different mindset.
It begins with adopting a different patient-centred perspective and intelligently analysing the problem. This work seeks to take a holistic approach and understand it from the patient perspective. It asks how many patients cause what type, patterns, predictability and volume of activity which results in costs. This way of thinking and acting is the means to achieve intelligent change leading to sustainable performance improvement.
What you discover is that the DTOC problem is NOT a general acute service for older people problem; hospitals deal with the consequences of the issue. When you compare A&E waiting time against DTOC rates it reveals different sets of challenges. One lot are external system problems where the acute provider is trying to deal with the consequences of fragmented care. But there are also internal system issues such as the impact of the 4-hour waiting time target which distorts performance and paradoxically helps make the problem worse (see my previous blog on the deficiencies with the A&E waiting time target).
As ever with healthcare, DTOC is a ‘vital few’ challenge – small numbers of patients consuming disproportionately high levels of activity, capacity and resources. For example, 1,700 patients admitted suffered with a DTOC over a 12 month period. The length of stay from their emergency admissions contributed to a third of the overall bed capacity of the hospital. Moreover, the real costs of DTOC are much higher than simply a blinkered focus on ‘excess bed days’ would allow for (an abstract and unhelpful financial ‘tariff’ distinction). Less than 2,000 people cost this particular secondary care system over £11 million every year. How much of this money is well spent? We simply don’t know.
But the small numbers show that the problem is predictable and therefore manageable. It also represents a big opportunity providing healthcare leaders have the courage to make profound changes in the way we commission and provide healthcare services. To improve (and thereby reduce) DTOC there is a need to better understand patients and what services they already consume to design more effective medical and non-medical services around their care needs.
The issues affecting DTOC are complex. The mistake often made with improvement efforts is to try and cut through or standardise complexity. Wrong. As W Ross Ashby’s Law of Requisite Variety teaches us the most intelligent way to deal with variety is design systems and services against that variety. In healthcare the way to undertake this is to understand and then design against patient-level demand. This will be effective and if you think about it, if you are effective at something; by definition you will be efficient.
Rather predictably, the political debate over the latest crisis afflicting the NHS is generating more heat than light. Superficially rules. Discourse reduces itself to a reverse Dutch auction over who can promise more cash whilst at the same time compete to declare unconditional support for the NHS. Stephen Dorrell, former Health Secretary and Chair of the Health Select Committee is on to something when he was quoted in The Economist magazine last year saying that anyone who tries to introduce knowledge and understanding to the issues ‘quickly finds out what it must have felt like to be regarded as a heretic in a more religious age’.
Fast forward to the begininng of a new year and we see numerous acute hospitals triggering ‘major incidents’ in response to ‘unprecedented levels of demand’. Their response is often to hold ‘extraordinary meetings’ that occur with such regularly they lose their original connotation. Hopes that periodic cash injections like the multi-million ‘winter bed pressure’ funding or ad-hoc ‘urgent summits’ will resolve the current predictable morass facing acute NHS hospitals is a fool’s paradise.
In fact, we have worn out all the possible tinkering approaches: from restructuring and merging hospitals to only achieve bigger problems; deliberately fragmenting the healthcare system so that no one reliably knows who is doing what, why, when and where; successive bouts of IT-led change that cost more than the benefits derived by both patients or professionals; imposing arbitrary targets that distort behaviour (such as the ubiquitous 4-hour waiting time indicator or referral to treatment times) and lead to ‘gaming’; increasing capacity which makes performance worse to rationing care (particularly in community and social care settings) that results in a false economy.
Indeed, the belief that we can simply talk or spend our way of trouble is indicative of a paucity of understanding. It is worth remembering that since 2000 we have tripled public expenditure on the NHS but not experienced service improvements consummate with such investment. Years later we still feel the need for calamity talks and emergency bailouts.
Such inertia and belief in extra expenditure is a costly distraction from consideration of the real problem facing the NHS; namely that we have an outdated model of healthcare that is capacity-constrained not demand-led. The current crisis of increasing attendance and admission rates (not the same thing as increasing numbers of people) to A&E is one consequence but not the primary cause of the turmoil.
It is possible to achieve the holy grail of healthcare: better care at less cost but this will require a complete resetting of how we intelligently manage, lead and apportion expenditure across the whole system. The only way that will work is to understand the nature of patient demand that appears and then develop a coordinated healthcare response (through redesigning broken systems, processes and payment mechanisms) that meets local needs – no more, no less.
With NHS England’s ‘Five Year Forward View’ talking about the need to change to cope with ‘rising demand’ and last week’s Autumn Statement assigning billions more pounds to the NHS I thought it was a good time to reflect on the state of healthcare in the UK. The whole purpose of my work is to challenge convention (and boy does convention require challenging) by looking at (and creating different) data to understand person demand not arbitrary activity and cost data. Too much work in healthcare is driven by unthinking opinion or hunch – ‘I think therefore let’s do’ and we assume everything is a capacity problem and that there is no waste in the way things currently work.
Yet, if you base work off opinions you are guaranteed to waste millions and this is what happens predictably in Quality Innovation Productivity and Prevention (QIPP) and Cost Improvement Project (CIP) land every single year (which then leads us to say we haven’t got enough money – a vicious circle). This is a systematic issue not a people one. People’s behaviour – whether they are patients or professionals tends to be driven the system not the other way round. I recognise that whenever someone challenges convention they will be dismissed, ridiculed, ignored, and attacked or all of the above! So I try in my work to create inquisitiveness amongst people because the curious person will be the one who seeks greater understanding and from that knowledge. In healthcare to realise sustainable improvement we need to adopt a different perspective and think (and act) ‘front-to-back’.
I’m often asked where such a detailed focus on ‘front-to-back’ analysis will take us. Well, off the back of clever person-level data across the whole healthcare system we can then begin to think about intelligent redesign based on designing for value (set against what good looks like, not from the perspective of the commissioner or provider but the person/relative/guardian who experiences it) and design out or reduce non-value work (and yes, it does exist in health as it does in any other service environment); understand service capability set against current ‘value’ demand for these services; and then and only then look at the work process itself – how does the actually work flow – we have zillions of processes in health. In any process there are only two types of activity going on – value work and waste. The aim is to study, understand and improve the value and remove the waste. This should be the focus of improvement activity that goes on in the work itself, not in board or meeting rooms with flip-chart papers, post-it notes, talking about (often fictional) interpretations of ‘as-is’ and ‘to be’ models. It is what I call ‘intelligent system and service redesign’ and is as different, challenging but enlightening as the approach to data analysis.
Currently, the way we design, manage and measure healthcare is arbitrary and reductionist; from artificial boundaries we call primary, community, secondary, social care to emergency versus urgent versus planned care; the way we devise and manage budgets (we need to move away from service-level to people-level reporting); the codes and performance measures we use (and here we need operational coding and capability measures not arbitrary targets that distort performance; the way we align (or more often misalign) human resources; the IT we use; the contracts we have in place (which are always developed in response to the last 12-month activity data which is statistically daft and therein lies much waste of time, effort and resource). All of this occurs because we do not study and design services and systems against real person demand. Persons (or the labels we give them – patients/service users) actually flow through systems – we need to think and act horizontally not vertically.
Moreover, we must ‘trust’ healthcare professionals to be just that, professional. We rightly pay a fortune to train-up folk and then regressively undermine their very autonomy and judgment through rules, regulations, so-called standards, protocols, directives often set by people far removed from the real work. One of the biggest problems now facing parts of the system is the fact that over recent times we have deliberately dumbed down skills mixes, for example, in adult social care where eligibility criteria explicitly exists to restrict access to support and therefore push disproportionate numbers of ‘people’ with social care and psychological needs into a transactional medical establishment called a hospital where professionals who are not best equipped to deal with ‘help me’ needs honourably struggle. The false economy in all of this is massive.
In some parts of the country commercial providers who run community services now expect district nurses to work to an artificial ‘schedule of rates’ and the ticking clock (this task should take this time and no more). This practice is called activity management and results in the distortion of just about everything. In one particular locality it results in good nurses leaving (as they are doing in their droves) and where they are able to replace them they do so with cheaper staff or agency. This results in cheaper transaction costs for the commercial provider and the ability of that provider to say to the commissioner look we have saved X in activity and costs. Yet the total costs will be XXXX higher as poor care results in people bouncing around the system more often. And I know this is happening because the particular commissioner has just reactively agreed to spend more money it claims it doesn’t have to fund the acute provider to undertake community outreach services to stop so many of these folk coming in! So the commissioner is in effect paying twice for a service while the problem is with the very (activity and cost driven) way the contract has been agreed with the commercial community services provider!! You couldn’t make it up.
I have seen enough of healthcare (in the round – it is imperative not to separate or divorce social from community from primary and secondary) both professionally and personally to think there is a better way, I’m convinced of that. My work is an attempt to systematically humanise health and civilise care as opposed to thinking the future lies in over-medicalising, commercialising or functionalising provision. With the latter three approaches, we have tried and are continuing to try this with disastrous consequences for both patients and taxpayers. I believe the former perspective is the missing feature for a smart health and care system. Now that’s a benevolent vision that’s worth striving for.
I recently attended an intriguing presentation on NHS Right Care. Right Care is an approach to improvement that affords health commissioners with a way to substantially improve ‘health outcomes, value and financial sustainability’. The approach provides the methodological underpinnings to the Commissioning for Value programme which is about identifying priority programmes to offer the best opportunities to improve healthcare. The work is promoted as having a ‘compelling economic narrative that creates a national benchmark and peer comparison’ and that it should be ‘business as usual’. It was this acclaim that got me thinking about the right way to study to obtain good care and the role of standard improvement tools.
A common error with many analytical models is to draw linkages between correlation and causation or indeed assert causality as a consequence of data analysis. Results from quantitative data analysis require empirical validation in real-world conditions. Data analysis asks ‘what’ questions that needs to be linked to pursuit of ‘why’ to authenticate findings. For example, quantitative datasets such as those captured by acute hospital trusts and GP practice data will only tell us ‘what’ is happening. You need other techniques that will reveal why. For example, the purpose of more qualitative methods is to understand ‘why’ and ‘how and where’ to improve. You cannot improve with confidence solely on the basis of ‘what’ findings.
As for the Right Care Methodology I believe its premise is wrong. It represents what I call ‘back-to-front’ thinking with the emphasis being on activity and costs. Essentially reductionist by design (not systematic) and a silo focus on pathways and prizing indicative over empirical evidence. From what I could tell listening to a presentation about the approach and reading the material, Right Care relies on standardised benchmarking and peer-to-peer comparisons. Both approaches have distinct limitations in terms of understanding and identifying performance issues. Indeed, the resulting ‘prioritisation of ideas’ relies on indicative costs which I would suggest lacks rigour and robustness.
The approach relies heavily on benchmarking as a tool for performance improvement. Yet, as I have already blogged about, it is important to recognise the limitations inherent with benchmarking. As an improvement tool, it is only as meaningful as those you are measuring against. Moreover, caution is to be exercised where current performance is significantly better than average but falls short of either Clinical Commissioning Group (CCG) or provider performance ambitions.
Indeed, benchmarking has merits in demonstrating ‘big-picture’ cost comparisons. But is poor at understanding context, value and total costs and should not be used in isolation to either understand or improve service performance. For example, whilst some indicators would imply positive performance around a specialty, local clinical intelligence offers a different story. Furthermore, there may be other indicators that a CCG or provider would like to consider itself against, other than the nationally available data.
Moreover, it cannot provide the means to understand and improve performance. With benchmarking, it’s important to know what you are comparing. And if what you are comparing is actually comparable. I am of the evidential opinion that the only benchmarking and best practice you should do should be within your own organisation, complimented and cross-referenced by other more robust techniques to achieve more comprehensive understanding and analysis.
We need to start moving beyond benchmarking and standardised pathways (for me Right Care is about perceived pathway efficiency not about patients – that term that is hardly ever used and certainly wasn’t in presentation I attended) towards consideration of models of care tailored to patient cohorts founded upon comprehensive research and analysis – both quantitative and qualitative in origin. Instead of obsessing about activity numbers and financial costs, we need to think about purpose and process. Systems and processes determine service effectiveness and cost efficiency. The purpose of any service comes from the people/users/patients/customers. If you improve the process based on the purpose, better outcomes and cost savings follow. That’s what I mean by ‘Front-to-Back Thinking’. Off the back of this you can then engage in what I call ‘intelligent system and service redesign’. I’ll on this theme at a future time.
Today’s King’s Fund inspired Barker Commission on the future health and social care in England calls for a new health and social care settlement, proposing the merger of NHS and social care systems. It calls for a new approach that redesigns care around individual needs regardless of diagnosis based upon a single ring-fenced budget with one commissioner per local area. Obviously, this has fundamental structural implications for the NHS as well as central and local government.
Alas Barker makes the same ‘back-to-front’ thinking mistake as the Dilnot review (and the government’s response last year) into funding social care. Both publications start from the wrong perspective: that to achieve genuine health and social care integration and serve peoples’ needs requires more not less resource.
The argument contained in the Barker report boils down to an out-dated and fragmented system being unable to meet the expenditure pressures of an ageing population with rising number of people who have long-term conditions. Merging NHS and social care systems therefore can create a fairer, free at the point of use system or ‘equal support for equal need’. Well up to a point.
Barker’s proposals advocate for a phased approach over time to ensure financial affordability. What this means is that it is proposed that social care eligibility criteria remains in place with only the fewest people with the highest ‘critical’ needs receiving free care.
Subject to economic improvement, coverage could be extended to those with ‘substantial’ needs. A new ‘Care and Support Allowance’ would offer ‘choice and control’ to people with ‘low’ and ‘moderate’ needs but would not remove the principal of means-testing.
Yet, the existence of eligibility criteria does not save money. The longer a person waits for care, the more likely it is that their condition(s) will worsen. It simply stores-up greater problems, resulting in no support for large numbers of people that only creates larger costs over time.
Dilnot meanwhile represents the worse kind of sticky-plaster solution, based on dodgy data of projected demand for services, out-of-date unit costs for domiciliary and residential care and misguided behavioural assumptions over people’s willingness to take out care insurance.
Its accepted proposal, the cap-cost model for social care, to be introduced in 2016, is unlikely to lead to a market for pre-funded care insurance. Economic modelling undertaken did not take into account variation but instead utilises the ‘average of averages’ for both residential care stay and care costs. Moreover, the care cap and means-tested threshold simply entrench fragmentation and disconnect between health and social care services.
Taken together these two reviews seemingly have a blinkered focus on funding allocation that assumes more care demands equal more resources and that there is no bad money or waste in health and social care activities, processes and systems. This is an entirely false assumption to make. Given the publication of the Barker Commission and resulting obsession with bandying around funding cap and eligibility threshold figures perhaps we could focus on a few telling ones?
During the lifetime of the current government spending review the NHS will provide £7.2 billion of support to local authorities for ‘health-related needs’ in the provision of social care. We presently spend £111 billion on the NHS and £17 billion on social care. We know that typically 70 percent of patients in NHS hospitals have social care, not acute medical, needs. We should be asking ourselves if we actually have a funding crisis or whether we have a failure to intelligently lead, manage and spend crisis.