Dr Steve Allder, Consultant Neurologist at Plymouth Hospitals NHS Trust and Member of the NHS Executive Fast-Track programme, discusses generating a cadre of leaders with the right skill set and taking the data and engaging with the frontline team to deliver transformational change.
How do we consistently find the opportunity to improve healthcare and reduce cost? So in 2003, if you’d have asked me as a Doctor, is it possible to make it better and cheaper, I’d have just laughed at you. So this is my own service with Stroke and we started off in 2008 with high mortality, losing a lot of money per patient with poor patient and relative experience. So I inherited a typical project which had 134 measures from the strategic health authority, someone had started at the top of the Spreadsheet, was working their way down, they got to 20, they ran out of money. So it was like how do we do this in a different way?
So there’s six steps. So the first step is to move from cost control to value creation and what I mean by that is in every service you have activity and you have expenditure and what we do at the moment, even if we kind of do implicitly, is we cut away at the support structures, desperately hoping the clinical services won’t fall over and they don’t immediately but in six months, 18 months they do which is kind of why we’re having the financial crisis that we’re experiencing now.
So what I mean by value creation is you go back to that clinical process and you interrogate it and you find which bits of the clinical process are high cost and low quality. So Four Stroke, even though most of the money should go into primary and secondary prevention (like most conditions in the NHS at the moment), most of the money was going to secondary care, hospital so that if we wanted to make a difference to this ecosystem, we had to deal with the secondary care expenditure.
Step three. How do these patients get into this hospital? And for Stroke, most people have a DE novo stroke, so they come from primary care into secondary care. Once you’ve worked out how they got in, the question was what was happening to them inside. The vast majority of patients were going from the hospital back to primary care and a third of the patients were going from secondary care into community care, but it’s important to understand that the consumption and the cost quality relationship for these streams are very different. So 84% of all the consumption was coming from those patients who had a more complicated discharge, and importantly all of the variation in cost and quality was coming from that ,and worse if you don’t deal with that stream, whatever improvements you make in the two smaller streams will just get washed away. What you need to get to from that stream is you need to find which subgroup of patients are driving most of the variation, and once you found that, which stage of their care? Is it diagnosis, treatment, complications or discharge? And once you’ve got that stage, which step of that is driving the variation?
What we’ve done so far is top down analysis. We now say to the frontline team, “Okay we’ve got this stream of patients that seem to be very high cost, low quality.” We give them this grid and we say, “You fill in for us what you think timely, effective, safe patient centred care would look like across diagnosis, treatments, complications and stability? Go and get some notes and score yourself against them,” and immediately people wanted to do something about it but more than that, it also identified which of those steps was the dominant step and what we found for Stroke was that the dominant problem, the frail patients, really frail, had an Index Stroke and the problem was that the frail strokes that you had a severe stroke, they were dying this terribly unstructured, inhumane death over about 40 days in the hospital. It was just like hidden amongst all the activity.
So with that information, the frontline team redesigned the steps of care. We just went to redesign that pathway for frail patients who had a severe stroke, and this one subgroup was consuming 75% of all of the resource on the unit. So how do you do the redesign? So I found this thing, it’s called a “value proposition canvas,” which is really helpful. So you say to the team, “There’s the segment we’re interested in. How do they get to you?” So for us, it was through morning handover. “What’s the relationship? Now we’re dealing with frail elderly people dying here. What should we actually do? What ideas? And the team just came up with so many ways they could make this better which we distilled into some activities, some resources and some partners and this is what happened. So the time it took to get to the… The Stroke Unit went from two and a half days to half a day, the length of stay dropped from 15 to eight. The number of patients being treated on the stroke unit went to 80% and that meant that we went from having 33 beds in acute trust to 20 and 23 beds to 19.
So that’s a saving of £3,000 per patient and that’s good. But the cool thing for me wasn’t so much this. It was how much better the care was, that’s the first thing, and the other thing is how much better it was for the staff on the ward. Suddenly our ward looked orderly and tidy and conversations were happening that were kind of caring and compassionate. It was amazing. By getting some control to our processes, all of this latent compassion started to emerge and that is how you marry top down, bottom up engagement with staff. It’s all based on understanding that you need a systems approach to the improvement and then the culture changes out of engaging the team in working on the right data, but none of it happens if the leadership team doesn’t create the space for this approach to start being adopted. And I’ll stop there.