It is indulgent to allow practitioners to determine their own diagnostic testing based only on personal experience and preference. If we can agree on a ‘recipe’ for a standardised operating system, we can assure reliable service delivery, writes David Dalton
I find it hard to understand why we tolerate the extent of variation in service standards, patient outcomes and efficiency that exists between NHS organisations. If we know what the evidence of best practice is, surely we should be capable of defining our service standards, and then organising reliable delivery?
‘NICE is the envy of the world, yet its outputs repeatedly fall off the conveyor belt onto the floor’
I know it is not that easy but the key leadership challenge is to assure reliable delivery of what we know works for our patients. This means we should spend less time considering what we should do, and tackle the more difficult issue: how we go about doing the right thing.
To be provocative: the National Institute for Health and Care Excellence is the envy of the world, yet its outputs repeatedly fall off the conveyor belt onto the floor. This is not because we cannot produce a “trust policy”, but because we cannot assure reliable implementation or feedback to staff on how well they adhere to protocols.
A success culture
We have organisations in England that have found ways to navigate the complexity of change management. Supporting a success culture should mean we apply these successful systems, methods and organisational behaviours to enable the adoption and spread of what we know works.
I applaud the development of new models of care – but let us not kid ourselves that the NHS is capable of reliable implementation across the country of what may work.
If we are to reduce variation of clinical practice within and across organisations, then what matters is reliable implementation of standards, based on the evidence of best practice.
Surely it is indulgent to allow practitioners and trainees to determine their own diagnostic testing and management plans based only on personal experience and preference, without the ability to either support or audit their decisions?
‘Every chief executive needs to know if their patients are receiving care to standard’
In Singapore, New Zealand, Chicago, Baltimore and other places they are testing and developing new approaches to standardisation and deployment of resources. I do not underestimate the huge challenge and time required to get this right, but should we not do similarly in England?
I believe every chief executive, medical director and nurse director needs to know if their patients, in hospitals, GP surgeries and homes, are receiving care and treatment to best practice standards, at a cost that is affordable.
Change the game
How might this work? Imagine someone attends an emergency department with a stroke, then using an evidence based care pathway on the electronic health record system, the clinician would be advised of the “order sets” - i.e. the tests and treatments to be organised, the algorithms for prescribing, etc. - based on the unique characteristics of the patient.
The system would support clinical decision making and not replace it, with any variances to the pathway being recorded for audit and learning purposes. This system would also enable just-in-time ordering of the consumables required during length of stay.
Most importantly, it could determine in real time the skills and staffing needs based on the assessed dependency of that patient every hour of the day.
‘Matching resources to patients’ needs and standards of best practice would be a game changer’
Let us also suppose that with clever mathematics it could see into the elective list (order book) and accurately predict, six weeks in advance, the resource requirements, including staffing that a hospital would require and the standard arrangements necessary for discharge.
A clinical leader or operational manager could then see on the computer screen all the resource and staffing profiles of their wards/department and agree to deploy staffing to meet the needs of patients (without the extent of recourse to bank, agency or “specialling” staff).
Being able to organise and match resources to the needs of patients and the contemporary standards of best practice would be a real game changer.
Currently, it is as though we all agree the recipe for a good cake, but cannot find a way to help our “bakers” check they are using the right ingredients, or baking at the right temperature. So we produce thousands of different cakes of variable taste, quality and cost.
Standardisation at scale
Using data and applying technology in this novel way is hugely important, but will not, on its own, provide the solution. I know from my work on quality improvement at Salford Royal Foundation Trust, that to succeed we also require the right mindset, leadership behaviours and understanding of human factors to deliver change.
Our best leaders should aspire to create standardised operating systems capable of delivering excellence. If other healthcare systems and industries can agree on the best “recipe” and then replicate it, we should be able to do the same.
‘Having 240 organisations is no longer an affordable way of delivering reliable NHS care’
In short, delivering excellence in a single organisation is not the answer to the challenges of our “national” health service – we need standardisation at scale.
Having 240 organisations is no longer an affordable way of delivering reliable NHS care at lower cost. The NHS is currently perfectly designed to deliver a £22bn deficit in four years’ time. If we want to reduce the variation that exists in our NHS to deliver better outcomes and improved efficiency, we must pursue different approaches.
Last year, the Dalton review identified a number of ways in which we could use new arrangements as a means of supporting change and improvement - the “how” to deliver the “what”. One approach - an operating group - is designed to allow the benefits of standardisation to be achieved at scale.
Do not misunderstand me – I am not saying “bigger is better”.
A new arrangement
A group arrangement is not a merger or acquisition: it is an approach that ensures a number of operating entities (let us say up to six current trusts within a cluster) can consistently deliver clinical services to agreed standards.
FTs could belong to a group, retaining their public membership, but ceding some sovereignty to a group board that determines standardised operating systems and assures they are reliably used.
A group arrangement would reduce management overheads, and consolidate back office and clinical support services. It would allow leaders to design strategic programmes of change, manage complex stakeholder relationships and deliver productivity improvement at scale.
It is said in healthcare that “the problem is moving faster than the solution”. However, companies are investing millions in product development to solve our problems.
I strongly believe that a group would be better placed to create long term strategic partnerships with such companies, in order to apply technologies that accelerate improvements to outcomes and productivity. This approach is often elusive to single organisations.
‘The NHS can prosper, but it will need to adapt’
Another cash releasing prize, just out of reach, is being able to close hospital estate in poor condition.
Each time Salford Royal has undertaken an audit of its inpatients it has revealed that about 20 per cent of patients do not need to be in hospital. Most of these patients have care needs that could be provided at or near to home.
Liberating 200 beds from Salford Royal - or about 2,000 beds if directly extrapolated across Greater Manchester - is worthy of consideration.
Each trust currently plans costly capital programmes to renew or refurbish poor estate, requiring cash for loans and higher asset value to be depreciated. Poor estate is unevenly distributed across hospitals and so organising its eradication across a group of providers makes possible what would otherwise have been unattainable on a single site.
If we do not make some of these changes soon, some patients will continue to receive sub-optimal services and some will lose their lives.
The NHS can prosper, but it will need to adapt.
New approaches are needed and these must include a commitment to reduce variation in services and outcomes through the standardisation of clinical pathways and operating systems. I believe that trusts with a track record of success are best equipped to deliver improvement, at scale, through new group governance arrangements.
Sir David Dalton is chief executive of Salford Royal Foundation Trust