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…
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