Services are often fragmented across systems and even within organisations, causing waste. True value in healthcare, says Kate Hall, comes from smoothing patient pathways.
NHS services are designed to deliver what we think needs to be delivered. We improve individual services without considering whether there is a more efficient way of overall delivery. We often change services with a view to what would work best for us – either as organisations or individuals.
If we consider radical change we quickly realise that it is complex, challenging and often inconvenient, so we don’t do it. We find reasons why it is not possible or sensible and tinker round the edges instead. Services are, sometimes, built around the people who deliver them.
To ensure a sustainable NHS for the future we need to focus on value. Value in healthcare means health outcomes divided by the resources spent on achieving those outcomes.
At a macro-system level, outcomes are the complete set of patient health results over the entire pathway of care. Cost is the total cost of care for a patient’s condition over the entire pathway. The same principle applies at a micro-system level, but it is limited within an organisation, department or service.
The value concept is universally understood and is relatively simple. Surely the NHS should aim to organise services in a way which ensures as high quality of care as possible within the money available to spend?
Although relatively simple, the value approach is a significant shift from previous thinking. We are not used to considering value in the NHS. To truly achieve value, care needs to be designed, organised and delivered around patient and population needs.
While this sounds a very sensible, logical approach it requires people to set aside personal views, to cease working in professional silos and to become more holistic in approach.
A common goal
A number of organisations have started organising services to facilitate better value and are promoting the concepts around value in healthcare in their strategy and development plans, but many have not started even thinking about healthcare delivery in this way.
Earlier this year, UCL Partners, one of the five accredited academic health science centres, hosted a workshop on value in healthcare delivery, in partnership with foundation trust regulator Monitor and the Health Foundation.
The workshop was led by Michael Porter, a professor at Harvard Business School who has devoted considerable attention to highlighting and promoting the concept of value in healthcare, and Tom Lee, the chief executive of Partners Community Healthcare and professor of medicine at Harvard Business School.
The workshop focused on US and UK case studies from organisations which have adopted a value approach.
The obvious benefit of a value approach is that it aligns the interests of various professional groups and therefore should be a positive message for all involved. Value is a common goal.
Language is important. Value is an understandable term and it is hard to disagree with the concept. Wrightington, Wigan and Leigh Foundation Trust is one organisation where the value approach is being adopted. Chief executive Andrew Foster says: “The idea of outcome divided by cost seems a much more honest expression of what we are trying to achieve.”
Jeremy Rushmer, a business unit director and consultant in anaesthesia and intensive care medicine at Northumbria Healthcare Foundation Trust, reinforces this.
He says: “Clinicians have become inured to the annual requests to improve costs rather than ‘real debate’, which is about how to improve outcome and reduce costs.
“What is needed is information about patient outcomes, the real cost associated with those outcomes, and a continual desire to improve the value that clinical systems deliver. Presenting cost and effectiveness information data and asking clinicians questions about value is more credible and is most welcome”.
Professor Porter highlights the benefit of integrated practice units where care is organised around a medical condition rather than distinct services and co-produced between clinicians and patients.
UK services are fragmented across systems but, worse, services are often fragmented within organisations. We seem good at creating hurdles for patients, even within organisations where there is no reason for a hurdle to exist.
Removing hurdles is a key characteristic of an integrated practice unit, creating convenience for patients and improving patient involvement. These units are patient focused and enable resources to be better spent on coordinated patient care rather than individual components of the care pathway.
Redesigning systems will not be quick. Transformational change, across traditional boundaries and where behaviours are entrenched, can take years. This does not mean it is impossible or that it shouldn’t be considered.
Four components of the value approach
Professor Porter of Harvard Business School emphasises that achieving a significant improvement in value requires a fundamental restructuring of healthcare delivery, not the incremental improvements that we are used to. He highlights four basic components to ensuring a value approach is successfully adopted:
- defining what we mean by value and measuring it;
- deporting quality and cost together, not separately;
- organising the system around value;
- setting aside historical boundaries and creating stable teams, which collaborate and seek to continuously improve value.
Great Western Hospitals Foundation Trust is also adopting a value approach. Until 2009 its maternity unit ran a traditional service with consultant named antenatal clinics. The unit was well regarded; in 2008 the Healthcare Commission highlighted the service as in the top six “best performing” maternity units and it achieved the top clinical risk rating.
Despite this, consultant gynaecologist and lead obstetrician Harini Narayan felt the antenatal service for patients with high risk pregnancies could be improved. Dr Narayan believed the service was fragmented, which was confirmed by a local audit. It found a substantial number of women with high risk pregnancies were seen almost entirely by non-consultant grade doctors, with varying degrees of experience and without direct consultant input. There was little continuity of care and sometimes conflicting advice.
Additionally, a 25 per cent rise in birth rates over five years and increasing complexity of pregnancies meant the service was overstretched, with demand exceeding capacity. It was recognised that there was waste and duplication in the system.
Dr Narayan starting thinking about the service she would want as a patient. This led to the creation of a virtual model of care which enabled her to discuss her vision for redesign with colleagues across professional boundaries.
Dr Narayan’s virtual model turned into reality after a two-year transformation process starting in 2008. There were four stages:
- creation of evidence based individualised guidelines and algorithms (for care pathways) to move away from the inconsistent opinion based care;
- consultation with staff and patients;
- service design;
Eleven new condition based clinics, with specific referral criteria, replaced the 16 consultant based clinics and are now led by a consistent team of senior doctors and midwives. A coordinating midwife oversees the process and a new system is in place to facilitate appropriate referrals to each condition based clinic, improving information flow between doctors and midwives in primary care and the hospital.
Each condition based clinic is jointly led by two senior clinicians and a midwife and follows a condition specific pathway. In each clinic there is one consultant with relevant expertise in the particular area of high risk obstetrics, and a senior clinician who covers the clinic when necessary.
Clinicians from other specialties are involved in the clinics, helping the overall coordination and enabling a rapid referral when needed.
The reconfiguration project did not involve any capital or set-up costs (or ongoing additional running costs) but significant amounts of time and effort were given by the project leads. The results are as follows:
- decrease in unnecessary antenatal follow-ups;
- decrease in inpatient admissions from antenatal clinics;
- unnecessary interventions, such as inductions of labour, have been reduced;
- significant increase in direct consultant-delivered care;
- 13 antenatal beds have closed, enabling the creation of a co-located birthing centre;
- out of area referrals have increased by 33 per cent, which although significant is manageable because additional capacity was created as a result of the redesign;
- patient satisfaction has improved: 52 per cent of patients rated overall maternity care as “good” in 2008-09 and 90 per cent of patients rated the service as ‘good to excellent’ in 2010-11;
- overall running costs of the service have been reduced by about 6 per cent despite more new patients being seen.
Other maternity units are now considering a similar system. A significant benefit is that they do not need to start at the beginning. There are also opportunities to look at general outpatient and community services through a similar lens, as many principles are transferable.
Healthcare professionals have to discover the benefits and ideally drive the change themselves. The clinic transformation at Great Western Hospital was driven by clinicians in direct response to feeling the service could be improved. There will always be sceptics. Often those who moan the most about services are the ones who seem unable to see the way forward or expect necessary changes to happen around them. Change on this scale takes time and energy.
Outcomes and patient experience are at the heart of the NHS reforms. Sometimes we have to take incremental steps towards a significant change. Sometimes the steps seem too small or the mountain just too big so we feel it is not worth it, but we will improve quality of care, outcomes for patients, efficiency and professional satisfaction by focusing on value at both a macro and micro level.
We make choices in our everyday lives about value. A value approach is definitely achievable but will only work if people and organisations think differently.