I spent time on the west coast of the United States recently, visiting six health care organisations in three cities over five days with colleagues from the Department of Health, NHS England and Monitor. The purpose of the visit was to understand how the US organisations provide high-quality person-centred care and the lessons that can be drawn for the NHS, local authorities and the third sector.
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.
Chris
Excellent article. I followed the link back the research with the University of Birmingham. Two things struck me. Why is it that doctors in leadership/management roles (below medical director but even including most of the national tsars who still spend half their time on clinical work) need to be hands on practicing clinicians, seeing patients, doing on calls, clinics and wards rounds to retain credibility with their colleagues, yet this doesn't seem to apply in the slightest to nursing or therapies, where in most cases leaving clinical practice for good is a prerequisite to "getting on". For my money, this is something that doctors should be proud of and sustain. The more divorced one is from the frontline the harder to be an effective leader.
Second, because USA health care organisations are not managed "top down" by national targets/vital signs/efficiency savings coming from government/NHS England/Regulator etc does this make it easier to move away from "learned helplessness" and "command and control" and enable radical change and vision rather than managerial incrementalism?
Third, is it possible to transplant these lessons readily from a system with markets, completion, spare capacity in providers, permission to fail etc to one where most localities have only one secondary care provider, one mental health trust, one community health service provider and where these can't be allowed to fail because this would leave the local population with no service?
Ultimately, the NHS was created to provide a decent offer of care to the whole population, free at the point of delivery, at low cost, and this it does pretty well. The vagrant mown down on Westminster Bridge will receive the same world class ICU and Trauma care as the cabinet minister. It was not created to enable excellence and innovation for selected groups of the population, in competition with other providers. And being English, the fear of failure is ingrained. So transplanting the lessons not easy. We must also remember that ultimately the US spends twice the proportion of GDP as the UK for generally worse population outcomes, greater inequality in access, less universal coverage, less access to primary care etc. So pockets of true excellence for the few versus half decent care for the many?...
We have long been trying to engage with UK healthcare organisations about the application of evidence based medicine in practice as a means of improving the quality of care, reducing costs and reducing variation.
Whilst clinical leadership is fundamental (as is recognition of the benefits of care standardisation), clinicians also need to be provided with the right tools, support and resources to ensure that changes in practice are implemented and embedded effectively.
We have found that ultimately, these types of investment decisions are ultimately the remit of board level management and subject to lengthy and often prolonged debate as in a time when resources are severely limited, the appetite for investing in 'new' (to the NHS) ideas is low - by which time the clinical will and desire to pursue potentially tranformative change had dissipated.
In addition to clinical leadership development, there is an urgent need for organisations to realise that investment in resources and commitment to quality is a necessity and can ultimately lead to higher quality, more efficent care.
US examples are interesting but KP and Group Health have not tried to reproduce what UK primary care does: free at the point of access care for the whole population. Look at the staffing model for Group Health's pilot of 10,000 patients. UK primary care can only dream of this level of staffing. No wonder they were able to reduce physician burn-out!
Clinicians will never translate into effective managers while the system they are trying to manage is essentially bankrupt. Organizations elsewhere succeed only because they can dump stuff that doesn't pay. Doing this in the NHS isn't an option; trying to merely sets doctors against each other and both sides become demoralized. Medical managers can mostly just nibble round the edges.
Patients are now, more than ever, seeking further information about their medication, measures they can take to avoid further problems , information about their GPs and Consultants . Everyone now "googles" everything only to return to the GP concerned that the ocean of information available to them is overwhelming. One charity in the UK - MAGGIES Centres - now offers "guided websurfing" that is nurse led. Other groups are developing "Libraries and Health" projects . We are not in the USA but we have much loved NHS GP services and much loved Charities and Libraries . More "partnership working" between charities, libraries and GPs might just get us some way towards the
institutional changes we need and the changes in help seeking behaviour that patients and carers pursue. Just a thought !
General practice will forever be a place of excessive stress until 15 minute appointments become standard. Along with a significant minority of other practices we have delivered this for nine years with huge benefits for patients and ourselves.
Beswick et al (Lancet 2008) concluded In their meta-analysis, where they reviewed 89 studies, that a preventive care programme would produce a reduction in number of bed days of institutional care, in hospital referrals and in falls. Physical function was also better in the intervention groups. The five areas discussed in Chris Ham's review: Electron data collection and retrieval by all staff working within the provider setting; Redesign of primary care so that integrated working becomes possible; Clear and accountable Dr leadership; Agreement of what needs to be delivered by both primary and secondary care with good communication and record linkage; Clinical standard setting by those delivering the service: have all been central to the evolving focus on pro-active care for older people such as demonstrated in StayWell75+ see www.bgs.org.uk Stay well 75+ - Integrating community and hospital care. Such programs are not however supported at a high NHS level despite a cost effective programme of integrated care for 13000 people at a cost of £31,000 now at risk from NHS savings. Inaccurate editorials such as that of D'Ouza and Guptha - BMJ 25th Ma y 2013 - draw the conclusion that 'no evidence that managing 'frail elderly' people in the community reduces admissions'. Within the UK the old primary/secondary care rivalries are far from over!
The description of Group Health's model bears close resemblance to that invented by British GPs and described with case studies and research at http://www.patient-access.org.uk/ . No doubt there are differences too, resulting both from a different funding model and the way that innovations take different paths at different times and places. We should compare and contrast the method, the intervention and the way they are measured and further developed.
Comments
Excellent article. I followed the link back the research with the University of Birmingham. Two things struck me. Why is it that doctors in leadership/management roles (below medical director but even including most of the national tsars who still spend half their time on clinical work) need to be hands on practicing clinicians, seeing patients, doing on calls, clinics and wards rounds to retain credibility with their colleagues, yet this doesn't seem to apply in the slightest to nursing or therapies, where in most cases leaving clinical practice for good is a prerequisite to "getting on". For my money, this is something that doctors should be proud of and sustain. The more divorced one is from the frontline the harder to be an effective leader.
Second, because USA health care organisations are not managed "top down" by national targets/vital signs/efficiency savings coming from government/NHS England/Regulator etc does this make it easier to move away from "learned helplessness" and "command and control" and enable radical change and vision rather than managerial incrementalism?
Third, is it possible to transplant these lessons readily from a system with markets, completion, spare capacity in providers, permission to fail etc to one where most localities have only one secondary care provider, one mental health trust, one community health service provider and where these can't be allowed to fail because this would leave the local population with no service?
Ultimately, the NHS was created to provide a decent offer of care to the whole population, free at the point of delivery, at low cost, and this it does pretty well. The vagrant mown down on Westminster Bridge will receive the same world class ICU and Trauma care as the cabinet minister. It was not created to enable excellence and innovation for selected groups of the population, in competition with other providers. And being English, the fear of failure is ingrained. So transplanting the lessons not easy. We must also remember that ultimately the US spends twice the proportion of GDP as the UK for generally worse population outcomes, greater inequality in access, less universal coverage, less access to primary care etc. So pockets of true excellence for the few versus half decent care for the many?...
David
Whilst clinical leadership is fundamental (as is recognition of the benefits of care standardisation), clinicians also need to be provided with the right tools, support and resources to ensure that changes in practice are implemented and embedded effectively.
We have found that ultimately, these types of investment decisions are ultimately the remit of board level management and subject to lengthy and often prolonged debate as in a time when resources are severely limited, the appetite for investing in 'new' (to the NHS) ideas is low - by which time the clinical will and desire to pursue potentially tranformative change had dissipated.
In addition to clinical leadership development, there is an urgent need for organisations to realise that investment in resources and commitment to quality is a necessity and can ultimately lead to higher quality, more efficent care.
institutional changes we need and the changes in help seeking behaviour that patients and carers pursue. Just a thought !
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