Like all public healthcare systems, the NHS is confronted with huge challenges, both operationally and financially. With providers’ deficits rising year on year, achieving statutory service standards and performance targets becomes ever more difficult. Compounding this, commissioners (in England) face unrelenting ‘over-performance’ challenges. Such a phenomenon occurs when more work activity occurs than originally forecast and enshrined in annual plans. In Northern Ireland, Scotland and Wales, local health boards or Trusts plan, budget and deliver services but face comparable challenges.
To surmount these chronic ailments, the NHS and local social care services must operationally evolve to drive efficacy and reduce costs. This hinges on using data intelligently which in turn depends on an acceptance to redesigning systems around patient demand. They must focus on the holistic needs of different cohorts of patients rather than the various range of misguided approaches taken over the years. These include standardising all service and pathway offerings; over-medicalising service responses; functionalising services into system silos and recent attempts to introduce commercial rigour into business operations. In short, we must focus as much on care needs as medical treatments.
This presents a huge opportunity for short, medium and long-term improvement, yet to be realised, requires a fundamental rethink of how we understand our healthcare systems.
Above and beyond activity: understanding patient demand
It begins by robustly and methodically understanding the point of view of the patient ahead of considering work activity and cost. This provides a true understanding of patient demand, allowing for focused operational research techniques that highlight operational performance issues and costs. Further augmentation of this data can be achieved via information management platforms that support improved decision-making leading to better hospital bed capacity and patient flow results.
This new approach to collecting and analysing data empirically challenges long established NHS conventions. Patient numbers, for example, are often reported as rising, yet through this lens they are stable, and contrary to popular opinion, the elderly population are not in fact causing most work activity. The reality is that healthcare economies are instead driven by just 5% of patients. These ‘vital few’ use up a third of resources accounting for: 30-50% of all A&E 4-hour breaches and admissions into observation units, up to 40% of bed capacity and between 70-100% of net operating deficits.
The approach can be applied across all aspects of healthcare organisational and service design. It can be used to understand and improve the array of healthcare sectors; service functions such as A&E; clinical or support services. These include pharmacy and pathology. With the latter, this work revealed for one acute trust serving a population of 300,000, some 15,000 patients were responsible for 250,000 pathology tests.
Learning to improve: reprioritising improvement around patient cohorts
Having a better and more insightful perspective allows for new and innovative thinking on how to improve, not only to reduce patient demand but also to better respond to, and therefore manage, such demand. Again, this requires a departure from typical practice, moving away from analysing activity to standardise pathways in generic fashions and towards understanding true patient demand and customising care for the vital few.
By focusing on the needs of these key patient cohorts, the approach naturally prioritises improvements, and in turn, reduces their disproportionate consumption of healthcare resources, freeing up capacity. Roll out of this is both iterative and staged. Proof of concept pilots for specific cohorts of patients will deliver total cost of care savings between 25-75% and allows for scalability to be achieved more sustainably then conventional schemes.
Even the ‘principle performance challenges’, that a recent report by the BBC recently highlighted are being failed across the board, are successfully addressed by this work. These include the A&E 4-hour breaches; delayed transfers of care (DTOC); and RTT waiting times in cancer and elective care. In the case of one hospital trust, they have consistently bucked the national trend by adopting this methodology, allowing them to improve their performance against the target indicator by over 3% points.
Raising the Bar: The healthcare holy-grail
To meet the mounting pressures on health and care services, the sector must think and act differently. Adopting a systematic patient focus combined with better use of data, design and digital technology is key. Numbers of patients across healthcare systems are stable, predictable and repeatable. It is the disproportionate volume of activity demanded by these vital few where costs are incurred and sustained. We must shift improvement focus from standardised pathways to patient cohorts. We must move from cure to prevention which this approach allows us to achieve. We must humanise healthcare; it’s the business methodology and model to do the right thing.