Matthew Lewis: A view from the front line

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  • Posted:Thursday 06 December 2018

Matthew Lewis, Visiting Fellow at The King’s Fund, speaks at our 2018 annual conference. Hear learning from our report 'Approaches to better value: improving quality and cost' where we heard from staff at three NHS acute hospital trusts.

Transcript

I see wonderful things in hospital. I see wonderful use of resources, wonderful staff who use their time and give more than they should do for looking after patients in their care, but I also see some work that’s misdirected. I see examples of people working in ways that aren’t necessarily meeting the needs of the patients that they’re looking after and perhaps we’ve managed them worse than if they’d stayed at home. 

I’ve lost track of the number of times I’ve sat through a whole afternoon in the outpatient clinic and at the end of it thought, I haven’t actually examined anyone. The reason for coming to clinic was because they needed a conversation and a review of their medication, and a discussion about how we should plan their investigations and their treatment, but all of that could have taken place over the phone and to me value is the essence of this in a way. Value is the best outcome at the lowest cost. 

NHSE’s got a very nice definition of waste, it says anything that improves patient care and experience is adding value, anything else is waste. There’s a quote from David Meates from Canterbury, he says that the biggest waste that we have in our health system is patients’ time. So a lot of the waste that we build into our systems is making patients do things that they don’t need to do. 

The approaches to value are numerous. We’ve got NHS Right to Care, we’ve got Getting it Right First Time, we’ve got Carter Report and Model Hospital, all of those looking at issues of variability, quality improvement initiatives through pathway redesign, looking at end of life care, looking at the way that we manage patients through lots of different pathways. A focus on patient safety which is crucial. We’ve got projects that tried to identify ways of building decisions around care, asking patients whether they’re happy to take risks, what they want in terms of investigations. Sometimes management tools have been used. Lean approaches are very current. So we wanted to have a look at two or three hospitals, Royal Free Group takes the approach of a chain in effect, so working closely with neighbouring trusts to share and understanding about how best to look after patients. The key part of this, in my mind, is the clinical practice groups, so specialities in different trusts working together, to understand which bits of what they’re doing is best practice. 

So if you like, almost comparing the practice between different places and working out who’s doing it best and then making that standardised practice across different trusts. 

Bolton is almost certainly another extreme. The model that they’ve developed is a very small model with two people working in a project management office. People within the hospital are encouraged to come up with quality improvement programmes as a way of delivering better care but also as a way of trying to save money and even small projects, maybe £90 or £100 saving run through this project management office but equally much bigger projects, maybe £100,000 saving go through it and they’ve been able to show quite carefully and quite well that there are strengths in such a small and concentrated resource of people, supporting other people to help make these decisions. 

Bradford’s model is not a big overarching plan. What they found was that they had a pocket of really good practice within their service. They had a ward that was running a virtual ward, so the elderly care ward realised they didn’t need to keep patients in hospital in order to manage their care. They could arrange for some investigations to be done as an outpatient and then they could review the patient virtually by ringing them at home. It’s not a new or a unique model, but what Bradford have done well is they’ve implemented this across their trust and they’ve set themselves the ambition to become a virtual hospital as much as they possibly can. So any services that don’t need to be run with a patient staying overnight in hospital aren’t. 

So looking across the board at these three examples, all of them show benefits, but it’s quite hard to define the end points. It’s quite hard to demonstrate which bits of these service redesign have actually caused the improvements that have been found. Common factors across the three sites, clear strategy, strong stable leadership, commitment to delivering a programme over a long period of time, staff engages is obviously key but more than that, staff need to be trained. They need to be shown how to take on these roles, being aligned with the local health economy is obviously key and having data that’s fresh is obviously key and I hope what we’ve seen with this value programme is ways in which the theories of improving the value are starting to be demonstrated in practice.