Friday 10 June 2011

Disruptive change – a force for good?

At a keynote speech yesterday, Stephen Dorrell stated that “in my view the Nicholson challenge must be delivered, but the way you do that is by disruptive change in the way the healthcare operates.”  What did he mean by this?

A key thinker here is Clayton M Christensen (clearly not a Brit), professor of Harvard Business School who has pioneered work on disruptive innovation in the commercial setting.  His latest publication, `The Innovator’s Prescription’ http://blogs.hbr.org/innovations-in-health-care/2011/03/a-disruptive-solution-for-heal.html applies this concept to healthcare and is co-authored by two physicians.  This combination works well – the rigour and freshness of an outside eye, applying business logic to the complex health system, tempered by real-world knowledge of the messiness of clinical practice.  It is an interesting and challenging read.  Some of Christensen’s analysis and solution is more relevant to the particular context of US healthcare, with piecemeal provision and complex system of reimbursement and insurance.  The role of the GP as gatekeeper is also not directly comparable (and the book deals less with family practice, perhaps because the clinical co-authors come from secondary care).  But there are many insights which have read-across to the NHS.

One interesting observation is that general hospitals at present try to do two different things which should be separated out.  The first aspect could better be framed as solution shops, using smart diagnostics to identify problems and arrange care around the need of the patients.  He argues that this could be better organised around broad disease areas, such as respiratory, heart or vascular to develop integrated responses rather than passing from one specialist to another.  This makes sense, given that in England and Wales, consultant-to-consultant referrals have increased at a greater rate than GP to consultant referral.  We have all as patients had the experience of bouncing round the system, getting part-treatment at each consultation.  This is contrasted with high-performing organisations like the Mayo Clinic where specialist asthma clinics involve bringing together respiratory, ENT and allergist who together agree a precise diagnosis and identify the best course of treatment.

The second part of the hospital function is cast as value-added process clinics, specialising in high volume standardised procedures such as cataract surgery (quoting the oft-cited Aravind Eye Surgery) or hip and knee replacements (Coxa Hospital in Finland), rather similar to the ISTC model in the UK.

The third component of health care is described as facilitated network business for managing chronic care, which is rightly identified as the single greatest challenge for future systems.  Christensen points to a subscription-type network , with trained staff (not all clinical) trained to facilitate better self-management.   He talks about new entrants to the market producing something the customer wants which is initially not as good as those produced by market leaders, but takes root with new customers who are disenfranchised by existing models.   This might for instance mean Slimming World type activities and trainers to support healthy lifestyles for those people who might not regularly visit their GP.  Self-help groups or expert patient programmes are other forms of network which apply.

One of his general points is that “the disruption of professions is a natural and necessary step in making an industry’s products and services more affordable and accessible.”   The book therefore emphasises the need for greater clinical responsibility to be given to nurses and other professionals (note, although existing evidence is mixed on the cost savings from substitution).  Christensen therefore highlights the potential for primary care retail clinics which are nurse-run for `rule-based disorders’ such as bladder infections or wart removals, which make up about 17% of all GP visits.  As mentioned before, I found the book perhaps less convincing on general practice.  He highlights their core business – once other activities have been diverted to the core functions above – as being the early detection of serious, chronic conditions and some minor ailments which are not rule-based.  But the risks and dis-benefits of disaggregating general practice activities are not spelt out, perhaps because of differences in the US health system.

So there is much here to think about, particularly at this time of unprecedented financial demands and uncertainties in healthcare restructuring.   The notion of disruption coming from outside and forcing new ways of working is interesting and has stimulated good thinking in the last couple of years about what it might mean for healthcare http://www.nhsconfed.org/Publications/Documents/Disruptive%20Innovation.pdf.  One reader of Christensen’s book noted that another aspect of healthcare ripe for disruption is medical research, given the long lead time (10-15 years) and inefficiencies of translational research from compound to trial to approved product.  The same argument  could apply to research on effectiveness and delivery of care.  But that’s another story…

What managers really, really want…

[A personal view from a top manager on the research which would make a difference]

At this week’s SDO/HSRN conference, there was a stimulating lunchtime session with Simon Pleydell, Chief Executive of South Tees NHS Foundation Trust.    He outlined to researchers the challenges for managers of meeting 5-10% reductions in real terms against increasing demands.  This meant a saving for his trust of £22million in the next year.  Simon Pleydell emphasised that this was the driving preoccupation of all leaders of health organisations today.  At the same time, there was great volatility at the top - an average length of time for a Chief Executive in post of 18 months.   How could research help managers to make difficult decisions at a time of contraction and flux?

He outlined his own wishlist of four key areas where evidence could help (I have indicated some relevant studies against each from the SDO portfolio):

1)     What workforce and skills are needed to deliver high quality and safe care? 
Key issues concerned nursing grade mix, substitution and roles.  For South Tees trust, 68% of costs were on workforce (and 80% of these were in frontline roles) and so the right people for the right care was crucial.  For instance, what is the right mix of band 4s on the wards?

[A recent SDO network digest on evidence relating to support workforce
http://www.nhsconfed.org/Publications/digests/Pages/SDO-Digest-1.aspx
and some SDO-funded studies on workforce http://www.sdo.nihr.ac.uk/projlisting.php?srtid=4]

2)      Integration and moving services out of the community
There is policy push for moving services out of hospital, but evidence to date suggests that costs are higher although with positive ratings for quality and acceptability to patients.   More studies may be helpful on those aspects of care which could be transferred without compromising on costs and productivity or other ways of modernising services.


3)      Care of elderly with multi-functional problems and dementia
At his hospital, over half of inpatients had some form of confusion.  This had a huge impact on services, how delivered, medication safety, workforce training and day to day practice on the wards.  What research could help with this?

Number of SDO studies on older people http://www.sdo.nihr.ac.uk/projlisting.php?srtid=17 and current call for new dementia research projects

4)      Introduction of new technologies
Every week, clinicians were introducing exciting new technologies.  At his trust, this included da Vinci robots for minimally invasive surgery.  How were these new technologies embedded in the service?  What were the mechanisms for judging their cost-effectiveness [note, NICE interventional procedures http://guidance.nice.org.uk/IP would assess some] and how was this evidence dispersed to managers?  What was the wider impact of new technologies on the hospital - for instance of image-guided surgery on workforce, surgical practice, throughput and theatre use?

Live SDO technology adoption projects http://www.sdo.nihr.ac.uk/projlisting.php?srtid=18

In all this, he stressed he couldn’t wait four years for the answers.

After discussion and encouragement of greater exchange between researchers and managers, I asked him for the pieces of health services research which had made a difference to him.   He mentioned a few areas which reflected his personal interests.  These included moving care to the community; safety and human factors (including work from the IHI on improvement science and observational studies on how errors happen); and work on leadership and workforce, such as Michael West and Beverley Alimo-Metcalfe. 

The challenge though was to get managers to read outside their personal areas of interest and lead them to evidence which might help them face today’s demands and the unknown challenges of tomorrow.

Thursday 9 June 2011

Questions, questions, questions (ii)

Just returned from the SDO/HSRN conference in Liverpool with a rich mix of researchers, managers, clinicians and patients (and actually a few individuals who were all of the above).   Below are some of the questions relating to research itself – methodology, resources, capacity, dissemination – which I came across at some point of the conference.  Would be good to hear of others…

Do we need a standardised measure of readmission?   How easy is it to link datasets at a person-level and for what use?  Which datasets are currently underused or could be better linked to others (such as clinical audit)?  How can researchers deliver quick productivity (cost/benefit) impacts of service innovations to NHS managers without compromising on methods? How can we get better standardised data from independent and third sector?  What learning will we be able to draw from WSD when complete – the biggest health services trial of its kind?  How can research on organisations deal with rapid change in the structures and systems being studied?  How can we use story-telling techniques to engage patients and staff in service re-design?  Do we need a pan-European health service research forum?  What are the limits of standard systematic review methodology for health service research questions?  Which European country is most productive in terms of health service research outputs (spare our blushes)?  What post-doctoral fellowship opportunities exist in health services research?  How can we educate managers better on the flaws with using uncontrolled before-after studies to evaluate local interventions (given regression to the mean)?  Do we know enough about what works for those patients excluded from trials (eg only 10-15% of stroke patients might fit inclusion criteria)? Is there a gap in funding for health services research around design and built environment? How can we build knowledge of implementation science into national clinical guidelines ie making the delivery as evidence-based as the treatment?  What mechanisms work for better `push’ and `pull’ of evidence into practice?  What unit of analysis for competition could be used when comparing pathways across a whole system of care, as opposed to hospitals?  How can we test the reliability of measures (of patient experience) used to compare organisational performance?

Questions, questions, questions (i)

“A boss knows all, a leader asks questions.”  [Russell H Ewing]

Just returned from the SDO/HSRN conference in Liverpool.  With a nod to Padgett Powell and his inspired book*, The Interrogative Mode http://www.guardian.co.uk/books/2010/nov/07/padgett-powell-interrogative-mood-review, here are just some of the questions that were discussed, explored, tested and contested during packed parallel and plenary sessions.  These should be of interest to NHS managers, clinical leaders and patients (additional questions to follow for researchers …).

 If integration is the answer, what is the question?   Do staff like working in paediatric specialist outreach (`satellite’) clinics?  What kind of managed supervision of giving methadone works best? What makes a good commissioning manager? How can we do better case finding in general practice of patients with chronic kidney disease?   What effect do out of hours and daytime response services have in preventing admission to hospital for older people?   What kind of contracting and negotiation models are used by managers?  Does feeding back results of patient reported outcomes to surgeons improve their performance? How do commissioning managers use evidence?  How reliable are measures of patient satisfaction when comparing organisations?  What is the right mix of staff across disciplines in community mental health teams?  What training do care home support staff need?  Are place of death preferences different for cancer and non-cancer patients at the end of life?  What is the impact of new clinical decision support systems for urgent care on everyday work practice?  What is the association between multiple morbidity and rates of hospitalisation?  Has greater patient choice affected equity of access in the last ten years?  How do rates of revascularisation vary for different ethnic groups? What impact has Improving Access to Psychological Therapies had on service use for people with anxiety and depression?  How can we achieve continuity of care for offenders with health problems?  What impact does introducing physician assistants in anaesthesia have on use of trauma theatres?  Does active support (daily telephone calls by dedicated feeding team after discharge) improve breastfeeding rates for disadvantaged mothers? Is a chronic illness case management approach cost-effective?  Which tools work best in predicting patients at high risk of hospitalisation?  How do commissioners monitor performance of general medical services? What do we know from the evidence about the best way to get managers and clinicians to work together?  How can smoking cessation clinics draw on wider evidence of behaviour change to introduce interventions which work? What would QoF for secondary care look like?  What do patients think of enhanced recovery schemes for orthopaedics?  How are mental health organisations implementing stepped care for people with depression (and why are there no evidence-based guidelines for how to deliver this)?   What aspects of ward design and the built environment lead to safer care?  What are the service impacts of standard reviews for patients six months after a stroke?  Are the views of patients and clinicians different on the quality and safety of different places of birth and why does this matter? 

*Extract from the inimitable original:
“Are your emotions pure? Are your nerves adjustable? How do you stand in relation to the potato? Should it still be Constantinople? Does a nameless horse make you more nervous or less nervous than a named horse? In your view do children smell good? If before you now, would you eat animal crackers? Could you lie down and take a rest on a sidewalk?...”