Among the many innovations we saw, five stood out for me. The first was the use of technology to improve the quality of care and the experience of people using services. All the organisations we visited had electronic medical records that were instantly available wherever a patient was seen. Patients were able to email their doctors for advice, make appointments online, and access test results. Smart phone apps made these facilities easy to use on the move and had begun to transform the way in which patients interacted with care providers. Catherine’s story is a good example from Kaiser Permanente in San Francisco.
The second innovation that impressed me was the redesign of primary care by Group Health in Seattle. Faced with growing pressures on GPs, and increasing waiting times for patients, this organisation encouraged patients to make greater use of telephones and emails to consult GPs, and drew on the skills of all members of the primary care team. These changes made it possible for GPs to spend more time with patients who really needed to see a doctor in person, with benefits both for patients and for those providing care. One of the consequences was a reduction in A&E attendances because patients were able to access the advice and support they needed much more easily. Primary care redesign also led to improvements in the working lives of GPs, by reducing the pressures on them through increased use of other team members and smarter use of technology.
A third impression was the significant part doctors and other clinicians played in leading change in these organisations. Everywhere we went we were struck by the visibility and commitment of clinical leaders and their obvious passion for quality improvement. To be sure, clinical leaders received valuable support from experienced managers, but a much higher proportion of top leadership roles seemed to be filled by people from clinical backgrounds than is the case in the NHS. This happens because of the investment made in the development of clinical leaders, especially doctors, and a culture that values leadership roles and sees them as attractive career opportunities. I was particularly interested to be reminded of this in light of the recent research report I published with former colleagues at the University of Birmingham which found medical leadership in the NHS remains a minority interest.
The fourth lesson was the benefit of working in an integrated delivery system in which GPs can communicate easily with specialists and provide care in the right place at the right time. Kaiser Permanente has been doing this for almost 70 years and achieves excellent results for its members in the national rankings of health plans. Similar results were evident in the other integrated systems we visited, including Intermountain Healthcare in Salt Lake City which focuses relentlessly on training its staff in quality improvement techniques using a programme the Fund has adapted for the NHS. In this organisation we heard that high-quality care often costs less because it reduces waste and unwarranted variations in care, an opinion that runs counter to received wisdom in much of the NHS.
The work done at Intermountain Healthcare underpins the fifth and final lesson I took from the week, namely the importance of standardising how care is provided when the evidence on good practice is clear. Standardisation does not occur through clinicians being told what to do or being required to comply with externally imposed targets and standards. Instead, it results from their commitment to provide the best possible care within available resources. To return to an earlier lesson, this would not happen without well-developed clinical leadership at all levels, and it works because doctors take responsibility for actively managing the care of patients at all stages.