hamish dibley

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The need to humanise health and civilise care

Front-to-Back ThinkingWith 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.