Innovations in the health care workforce needed to deliver productivity improvements

The NHS in England faces a huge challenge over the next decade. The tighter public spending settlement for the NHS means it will have to increase productivity by 4 per cent per annum. The health sector is a labour intensive industry; it will only be possible to deliver productivity improvements by using human as well as financial resources differently.

Christensen et al (2000) have previously argued, 'Managers and technologies need to focus on enabling less expensive professionals to do progressively more sophisticated things in less expensive settings.' At a recent Salzburg Global Seminar supported by the Dartmouth Center for Health Care Delivery Science, the message was clear – health care teams need to transfer responsibility for delivering care to those that have the relevant skills but no more. According to Al Mulley, Director of the Dartmouth Center, health care delivery systems where staff 'function at a lower level are inefficient, at a higher level they are unsafe'.

Challenging the accepted wisdom about professional roles and responsibilities in the care team could have significant productivity gains. Wherever possible, staff need to be given the opportunity to work consistently at the level of their knowledge and capabilities. This is not about undermining or devaluing clinical skill and judgement, but about ensuring that the right care is given by the right person with the right skills. Furthermore, this transfer of responsibility should not stop at health care professionals. It needs to extend to us as patients and citizens too. Patients are also members of the clinical team and real benefits can come from encouraging the patient to take responsibility for self-management, self-care and for maintaining health.

The chronic care model clearly identifies the important role that patients play in self-management and self-care (Bodenheimer et al 2002). But not all patients feel confident enough to take on this role. The patient activation measure (Hibbard et al 2004) was developed to measure patients' knowledge and confidence to self-manage. For people at any level of activation, having the necessary information and knowledge is a basic prerequisite to self-management. Research shows that higher levels of activation are associated with better self-management activities (Hibbard et al 2007). Furthermore those with low activation see self-management primarily as compliance – ie, following the advice of doctors or taking medication as directed (Dixon et al 2009). Those with higher levels of activation talked about self-management as taking control. They see themselves playing a much more proactive role in their own health care.

If the NHS is to deliver productivity improvements on the scale needed, it will need to radically change the skill mix involved in the delivery of care within teams. It will also need to radically change the balance of professionally–delivered care, and self-care. Empowering patients to be more active participants in their care is not a 'nice-to-have' – it is imperative if we are to deliver on higher-value care.

This blog is also available on the British Medical Journal website

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#593 Dr.Bhimani

Well done.In all NHS reforms,the most important factor that is not being talked about is patient's self responsibility,self care and system abuse

#594 Dr.Bhimani

Well done.In all NHS reforms,the most important factor that is not being talked about is patient's self responsibility,self care and system abuse.
The question is how do we engage the public in self care?

#597 Ajay Khandelwal

This looks very interesting Anna. At NESTA, in the People Powered Health Programme, we are experimenting with six sites around the UK, using co-production approaches, in the field of LTCs, and supporting clinicians and patients to create new types of solution, such as those that harness peer to peer networks. A key challenge for us, as you describe, is helping teams and systems re-callibrate the balance of care between professional care, and I'm interested in the research about how we can achieve this.

#602 Helen Lewis
Lay representative

There are worries amongst the informed public, that for example, upgrading nurses to prescribing roles is not without risks to patient safety. At grassroots levels, experience suggests that nurse training is very different from doctors, and they are sometimes less willing to acknowledge or less able to recognise when they are outside their competence limits.

#604 Jim Phillips
patient who learned to self manage

interesting blog and agree with all, many health professionals report that a significant amount of their time is taken up around lifestyle and social issues that patients are struggling with. The NHS response currently seems to be to give clinicians the skills to support these patients to become more activated and support them to set and achieve goals etc.. is this the best use of resources? Is more cost effective to allow the clinician to be the technical expert and use lower cost methods of providing behaviour change support. Yes care teams need the basics. There is a whole range of people from volunteers to community groups who can be trained to provide lifestyle and behaviour change support and help less confident patients develop the much needed confidence and skills needed to self manage. If principles of co-production are applied then there is the potential to move so called problem patients from being seen as a drain on resources to becoming an asset and resource in the local community to others.
However we need to be careful we don't start blaming patients for being poor self managers when it is often the NHS that has dis-empowered them in the first place. There appears to be a creeping medicalisation of the self management agenda taking something that at its essence is very simple and turning it into the domain of the professionals.
Unfortunately there is a lack of commissioning skills and knowledge supporting people to self manage. All to often the lazy response is to commission some courses for people to go on.

#605 Bernd Sass
National Centre for Independent Living

yes, I agree some course for 'activating self-care' is not an effective response. Co-production needs to be interwoven with the whole system, starting with assessments in social care. In an integrated holistic system there should be no status difference between 'technical expert' and 'lower cost methods of providing behaviour change or peer support'. NHS staff would then understand that they better work alongside peer supporters on common and shared outcomes with significant quality and productivity gains as we are keen to demonstrate with our programme on user-driven commissioning.

#606 doc

doctors always used to give self management advice , nothing new. was a part of the consultation before many new drugs came on scene. and with their knowledge of physiology and pathology and medicine, seems sensible to professionalise life style advice to some level.

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