Mark Smith: Building an efficient health care system focused on delivering increased value - US perspective

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  • Posted:Thursday 26 November 2015

Mark Smith speaking at our 2015 annual conference about creating a system that is continuously improving in its ability to deliver high value to patients.

This presentation was given at The King's Fund annual conference on 19 November 2015.


In the States, we like to talk about value being an equation characterised by quality divided by cost.

Now of course, in the NHS no-one pays for anything.  That means that the denominator here is zero and I suppose mathematically, at least, that means that the NHS delivers infinite value to its members.

I suspect that’s not the case, but I suspect in part because people don’t pay for things, quality has a different meaning.  The question is; what is quality to our members, our patients, our customers?

And first is clinical quality, the kind of quality we talk about.  Did someone get a beta blocker after a myocardial infarction?  Those things are very important.  But basically our patients aren’t capable of judging those things.

I think to patients, to customers, to consumers, quality is mainly service quality.  Did we communicate with them?  Did we have empathy for them?  Was our service convenient?  Was it personalised?  Was it responsive?  If we think about this being the guide star for how we organise our services, I think we will find our path to much more effective, efficient service as well, because it’s a way to figure out how we’re wasting resources.

Which brings me to the question of efficiency: What is efficiency?  Achieving maximum productivity with minimum wasted effort or expense.  Or what the Japanese would call Moota.  Note, that does not mean just how you make more of something faster.  By efficiency in health care, we should not be talking about how many surgeries we can pump out, because as a famous theoretician of management in the United States, Peter Drucker, once said there is nothing so useless as doing efficiently that which should not be done at all.  It’s a trap.  If you think of efficiency as simply being the production of more units.

In health care in particular the question is: how many units should be produced?  And then talk about doing so efficiently.

Theoretically, health care moves from science to evidence to care.  In reality, science has poor harvesting of insights, the evidence is poorly used in practice and there’s very little feedback of the care experienced to start that cycle again.

That’s what leads to missed opportunities, waste, moota and harm.  That’s the core of the inefficiency in our system.

In our country, at least, a little more mercantile than yours, there’s a curious paradox in that some new techniques, devices and services, particularly those that are financially advantageous to physicians, get adopted so rapidly that we haven’t even had a chance to assess whether they are effective or not.  And on the other hand, the hundred and thirty years after Lister was still trying to get people to wash their hands between patients.

But what are the new tools?  First, computing.  Not only in it’s connectivity, but in it’s power.

Second, systems and process improvement strategies.  LEAN, sick Sigma, modern management techniques that are only now beginning to be applied in health care, there’s a new spirit of entitlement among patients which is part of what we need to overcome some of our problems.

And last, policy levers, namely incentives, transparency, accountability and engagement that provide the context for all of this.

The past half century has seen unprecedented knowledge generation and technical innovation in biomedical science and there’s much more to come, but our systems for choosing, training, deploying and paying the health care workforce and organising their work has not kept up with the biomedical science.

That’s the core problem.

The reason it’s important to put it like this is as we go to our colleagues and tell them they’ve got to change everything they thought they knew about practising their professions, it’s not that they are stupid, it’s not that they’re lazy, it’s not that they were taught wrong, it’s that the modern world has changed dramatically and we have to change the way we work to keep up with the science.

We are a service industry, and the greatest untapped resource for high value care, in my view, is patients themselves with enabling technology.  Remember, we didn’t replace Librarians with just lay people, we replaced them with lay people and Google.  We will replace some of us with lay people and technology that allows them to do things they can do.

So, when I was in training, when some of you were in training, Strepthrough required someone like me, who’d been to school for sixteen years.  Now it can be done by a high school graduate in five minutes for $5 and yet we have professionals, sometimes even doctors, doing this.  The average well motivated mother could do it.

I made that point and then somebody said well that’s simple stuff.  And then there’s a study published from the National Health Service that compares usual care for hypertension, which in the National Health Service I understand is pretty good.  With care where patients not only take their own blood pressures, but titrate their own medication based on the results.  Guess who had better outcomes?

And then someone said that’s just hypertension and then I visited the self-dialysis clinic in Sweden, where patients swipe themselves in to the unit in the morning before the nurses get their, do their e-mail, push the machine to the side and leave.  They have fewer infections, fewer complications, better dialysis numbers than the unit run by the Nephrologists.

Now, am I saying all our patients can do their own dialysis?  I am not, but some can.
If we redesign the machine, like someone redesigned Google, to allow them to take on the responsibility of what professionals are now paid professional wages to do.

So, in my view, the biggest untapped source of value and the cutting edge in the next decade will be enabling people to do more for themselves at lower cost, at much greater convenience and better satisfaction.


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