We all recognise that the NHS faces unprecedented operational and financial challenges. Providers are struggling to meet constitutional service standards or performance targets whilst seeing their organisational deficits increase every year. Commissioners face perpetual ‘over-performance’ challenges.
To overcome the current chronic conditions, the NHS and adult social care must change the way it operates to effectively meet future challenges. The starting point for improved healthcare services at less cost rests on more intelligent use of data to inform future performance improvement. That improvement will be achieved through a preparedness to redesign systems and services around the holistic needs of different cohorts of patients.
The NHS and local social care services have, over the decades, exhausted a range of misguided approaches. These include standardising all service and pathway offerings; over-medicalising service responses; functionalising services into system silos and latterly attempts to introduce commercial rigour into business operations. Today we need to humanise healthcare and focus as much on care needs as medical treatments.
Humanising understanding
There is a better way of tackling the current problems facing the NHS today with significant opportunity for sustainable improvement. However, it requires a change to the way we think, conceive and act on our healthcare services and systems. To this end we need to humanise healthcare to fundamentally change the way to understand and improve healthcare systems.
This understanding starts by adopting the perspective of the patient before worrying about work activity and cost. Through understanding true patient demand, it is possible to deploy a range of research and improvement techniques that allow you to truly understand the causes of the operational performance issues and costs. Augmenting this knowledge through an information management platform can further support better decision-making with resulting improvement in bed capacity and patient flow.
By humanising the collection and analysis of data, for example, allows you to empirically challenge some established NHS conventions. The most glaring of these being that patient numbers using healthcare services are not rising but stable, and that older people are not driving most activity. Healthcare economies in fact rest upon 5% of patients – ‘the vital few’ – who consume a third of resource; between 30-50% of A&E 4-hour breaches and admissions into observation units; up to 40% of bed capacity and between 70-100% of net operating deficits.
The make-up of these patients is driven by two different archetypal features. One consists of failures to identify and address the non-clinical needs of small groups of patients who ‘bounce’ or ‘pinball’ around local healthcare providers, causing disproportionate activity and cost. These patients require integrated care services that are designed around them. The second relates to failures in the organisation and delivery of planned care that leads to other patients ‘tipping’ into emergency and urgent care settings. These are patients with genuine medical needs but who tip into urgent care due to failures in booking, referral and outpatient clinic processes. With this latter group there is a real opportunity to deploy digital technology by design to help improve patient care and maximise the advantages of robotic process automation for routine, predictable and high-volume process steps.
The approach has proven applicability across all aspects of healthcare organisational and service design. It can be used to understand and improve the array of healthcare sectors; service functions such as A&E; clinical or support services. These include pharmacy and pathology. With the latter, this work revealed for one acute trust serving a population of 300,000, some 15,000 patients were responsible for 250,000 pathology tests.
Humanising improvement
Such an approach provides for innovative thinking as to how to propose and undertake improvement work, not only to reduce patient demand but also to better respond to, and therefore manage, such demand. This requires a move away from analysing activity to standardise pathways towards understanding patient demand to customise care for the vital few.
Identifying and focusing in on the human needs of the vital few helps to prioritise improvement work, reducing their consumption of healthcare resource and releasing much needed capacity. You achieve this via proof of concept pilots involving cohorts of patients, redesigning services to achieve better care for these patients needs and thereby reduce costs. Typically, delivering total cost of care savings of between 25-75% is possible for the archetypal patient cohorts.
The ‘principle performance challenges’ facing local healthcare economies – A&E 4-hour breaches; delayed transfers of care (DTOC); RTT waiting times in cancer and elective care can be successfully addressed too. For example, when improving A&E, patient cohort ‘streaming’ in emergency and urgent care pathways results in improved operational performance against the 4-hour waiting time target, fewer queues and better patient service. In the case of one hospital trust, they have consistently bucked the national trend, allowing them to improve their performance against the target indicator by over 3% points.
Likewise, such an approach also serves to inform and constructively challenge current improvement programme planning. A CCG who conducted a wide-ranging review of pediatric urgent care scheme successfully proposed changes in both design and operation and realised savings of £1.3 million.
The healthcare holy grail
To meet future challenges the healthcare sector must be prepared to think and act differently to achieve both NHS service transformation and health and adult social care system integration. Healthcare systems can be transformed through the adaptation of a genuinely patient-centred focus and making better use of data, design and digital solutions.
Numbers of patients placing demands on NHS and adult social care services is far more stable, predictable and repeatable then commonly imagined. But this patient demand is uneven – small numbers of the same patients, the ‘vital few’ consume disproportionate resource in the high volumes of work activity and corresponding costs incurred.
Taking a better approach to analysis through first understanding patient demand naturally leads to adopting more effective and humane improvement efforts: redesigning services to work for patient cohorts not pathways. The outcomes are more integrated and preventative systems that successfully alter the nature of the consumption curve for care and reduces costs across local health economies. That’s the healthcare holy grail.
Hamish Dibley, senior management consultant
