Hamish is an independent management consultant and improvement coach with expertise in systems thinking, service design and customer service in the public services.
Hamish Dibley
Consulting DirectorThe NHS currently faces unprecedented challenges. NHS system convenors and organisational providers are struggling to meet constitutional service standards and performance targets whilst addressing the backlog of waiting lists that were exacerbated due to the coronavirus pandemic.
‘Rising demand’ in emergency and urgent care settings, together with the need to make post-pandemic productivity improvements in elective care, are seen as the principal causes of the current NHS malaise. Conventional analysis lends itself to activity management and unit cost analyses.
Adopting a Different Mindset
There is a better way to conceive and act on the current problems facing the NHS. I have evolved a novel, empirical and pragmatic approach to successfully understand and improve the operational and cost performance of healthcare services. I call it Humanising Healthcare®.
This approach begins by studying healthcare systems from the patient, not activity, perspective. By understanding patient demand, it is possible to deploy a range of research and improvement techniques that will allow you to understand the causes of operational performance issues and total costs.
Understand Patients before Analysing Activity
Analysing patient demand reveals that it is more stable, predictable and repeatable than assumed. However, the activity on stable numbers of patients is rising. Relatively few patients consume a lot of healthcare, and I refer to these as the ‘vital few’. It is they who require a genuinely integrated service provision.
These are small numbers of patients typically less than 5% of the hospital population who boomerang around local healthcare systems, consuming disproportionate activity and resources. 50% to 66% of such patients are below 65 to 70 years of age. Many of them have common chronic conditions but these are not the reason behind their high consumption of services.
These patients are behind up to 50% of all A&E breaches of target performance; 50% of admissions (often into assessment units); a similar proportion of emergency beds capacity; the lion’s share of hospital mortality rates; and between 40% to 90% of hospital deficits. A positive impact on small numbers of such patients has a significant impact on overall service and system performance and budgets.
The diagram below illustrates the ‘vital few’ patients relating to a large teaching hospital with a geographical population of 700,000 people. The hospital patient population was 230,000 unique people who every year the hospital would see in either urgent or planned care. The hospital’s performance challenges rested on 12,935 ‘vital few’ patients who were responsible for 20% of all work activity and 30% of total costs.
The Pyramid of Healthcare Consumption
The performance phenomena to tackle in elective care centres on ‘planned care tippers’. These are ‘vital few’ patients with genuine medical needs who, because our core support processes and systems are broken and fragmented, tip into urgent care and consume a lot of acute (and beyond) services. The pandemic exacerbated this phenomenon due to the stop-start-stop cancellations that have occurred in elective care.
This work reveals service design (including referral) problems, which need to be tackled. It is with these planned-care patients that hospitals create their own unnecessary work and costs that can be prevented.
Conversely, in urgent care, we see people whom the system fails these are ‘pinball patients’ they are people who have social, psychological, emotional and environmental problems. These patients end up in the only part of the healthcare system that is designed to fix them but cannot help them address or manage their non-medical needs the emergency departments (ED).
Patient Cohort Improvement
The focus of improvement work changes from creating arbitrary standardised ‘pathways’ to designing more effective service responses for patient cohorts. These include the ‘vital few,’ urgent care or planned care medical specialties.
It is about redesigning services (including roles, measures and budgets) to work for distinct types of patients and is based on studying and understanding their needs and how they currently consume healthcare resources. Understanding patient needs and their journeys, together with how the processes and systems currently work and need to change, is vital.
Proof of concept prototypes (with the broader control group) are initiated, and services are designed differently to ‘learn how to improve and improve to learn’. Continuous improvement comes through this learning and the resulting expanding of the work.
Prototyping Performance Improvement
This approach can be deployed to any service function (ED, bed provision, discharge etc.), sector (ambulance, acute, community, mental health, primary care, social care) or medical specialty. It is about studying patient demand, analysing the nature of that activity that this demand generates and achieving sustainable cost savings through eliminating wasteful activity that does not meet patients’ real needs.
Humanising Healthcare®: A Better Way to Work
This approach is centred upon adopting a person-centred perspective to healthcare performance challenges. We need to adopt a different approach to achieve the holy grail of healthcare: better service experienced by patients, at less system cost.
Most patients do not require extensive care integration: they simply require effective hospital and healthcare processes and for systems to work as they are intelligently designed.
But for small numbers the ‘vital few’ we need to customise their care and design service responses around their needs. The results will be better outcomes and cheaper system-wide costs.
The approach requires a collaborative effort, linking clinicians with management. It entails an unremitting focus on intelligent operational research linked to operational performance improvement, with the patient firmly at the centre of the work.
It is time to humanise health and civilise care.