Data sharing between NHS organisations will help drive clinical efficiency and enable better decision-making as fiscal and demographic pressures come to bear, says Peter Osborne of LOC Consulting.
The introduction of the new NHS structures in April this year transformed the way patient health services in England are commissioned. Replacing Primary Care Trusts (PCTs) with Clinical Commissioning Groups (CCGs), they place clinicians at the centre of the commissioning process, base payments on quality of care, and give GPs more responsibility for managing budgets.
CCGs are tasked with using their knowledge of patient pathways to drive efficiency and eliminate functions that fail to meet patients’ needs. They are now responsible for commissioning the majority of secondary healthcare services – about 60% of the annual budget. They also have the freedom to ‘buy, build or share services’ via any provider meeting NHS standards.
The priority now is to drive further savings and improve clinical efficiency, arguably the greatest challenge facing the NHS. With budgets ring-fenced and allocated on a ‘flat-cash’ basis, rising patient demand means annual cost savings of some £5bn must be found. At the same time, standards of care are under intense scrutiny following publication of the Cavendish, Francis, and Keogh reports, while A&E is said to be reaching breaking point.
Given that pay accounts for approximately 70% of NHS trusts’ costs, the obvious saving is to cut staffing levels. But with the political debate ramping up, the NHS can ill afford further negative headlines around failings in care or cuts to front-line staff. A much better approach is to deploy this cost in a more effective way. This can be achieved by identifying instances where there is duplication or inefficiency at primary and secondary care level, and by optimising the flow of patients between them.
Lack of visibility
CCGs have already identified the benefit of working together with commissioning services across boundaries. Providers are also working more closely to attract as many patients as possible to ‘choose’ their services. However, competition between providers based on quality and not price has created barriers to commissioning integrated services. With CCGs, clinical support units (CSUs), and secondary care providers each operating as separate entities, managing their own budgets and costs, the result is a non-joined up approach.
For example, a patient arrives at a primary care facility; a clinician examines them and, if required, sends them to a secondary care facility where they are re-examined and provided specific treatment if needed. The patient is then discharged, but if they have to make a repeat visit, the whole process is replicated – with all the associated costs. Looking at this scenario as a cost driver would suggest that the patient in question should be treated differently.
Ironically, restructuring itself has driven operational inefficiency into the commissioning system, due to the complexity of the buy, build, or share model, and the fact that doctors and clinicians tend not to be experienced in forecasting, management, and co-ordinating budgets or resources. The separation of commissioning and provisioning also makes it harder to allocate cost on a per-patient basis, since there is no end-to-end view of the necessary data. Without visibility across the two, it is much harder to drive further cash releasing or operational efficiency savings.
Identifying the real costs
Managing data on an incident-by-incident basis gives cost per outcome. But without the ability to look at a range of cost drivers, it is not possible to identify efficient or inefficient interactions in the front end or back end. Handoff’s between services is particularly vital to understand. For example, where one service is using another as a front-end facility, changing the behaviour of the services involved could reduce cost for both in the longer term.
At a macro level, it is relatively simple to identify cost drivers. The difficulty is in breaking them down to a level that allows organisations to understand the drivers of cost and then to implement change. Many medical consumables such as bandages and syringes for example, are purchased in bulk using agreed payment scales, but although the trust benefits from a discount, there is the potential for wastage if they are not used before their ‘use-by’ date.
Without the right data, it is difficult for trusts to employ logic over procurement protocol without wastage becoming a cost driver. Inflation has been another key challenge, with clinical supplies and service costs reported to have risen by 8.7% in 2011-12. One of the impacts of this was highlighted in recent HSJ research, which revealed acute trusts were disproportionately targeting non-pay budgets in this year’s savings plans in the wake of the Francis report, while the Department of Health has announced that the NHS is looking for a saving in procurement of £1.5bn by the end of 2015-16.
Lessons can be learnt from the manufacturing supply-chain, where there is a need to assess the cost to produce, aligned wastage, the cost to expedite and the desire to achieve a just-in-time delivery. Much of this thinking could be transferred to the health sector, with pathways seen as an integrated process. Information on the costs of treating individual patients provides a much more detailed understanding of the real costs of care incurred, enabling more informed management decisions. It also has the potential to engage clinicians by making clearer the link between clinical decisions and aspects of efficiency cost-drivers and cost-effectiveness.
Time for action
Adopting a more joined-up approach to healthcare data across NHS organisations could provide nurses, doctors and clinicians with greater insight, as well as improving the quality of care and optimising capacity and consumables. Core to the requirement of CCGs is the understanding and manipulation of national datasets, trust datasets and the commencement of data capture to fully understand the costs of services.
Today, many trusts consider data collection a burden imposed on them by external parties, and are often unwilling to collect data to support their own decision-making process. In other words, they tend to collect it to meet the measure rather than seeing it as a potential value-add. The vast majority of trusts are going to have to raise their game, recognise the value of disciplined data collection and consolidation, and then use thorough analysis to make better decisions.
Although there is no single solution to achieving benchmarking and cost apportionment, both commissioners and providers have the opportunity to realise further operational efficiencies through the data and information available to them. There are also opportunities to achieve dramatic improvements in the quality of data and information they collect, and the way in which it is collected.
Following the warning from NHS England’s chief data officer that “only a handful of trusts” are likely to meet the new data requirements from April 2014, it is certainly time for action. Only with the necessary data at their disposal can NHS organisations cast off the mistakes of the past decade, where budget has been spent in the wrong areas, to target those where real value can be added instead.
Steve Williams is the Managing Director of Qmatic UK - the world leader in patient flow solutions.
The NHS is under enormous pressure to provide an improved quality of care to more patients, while coping with limited available resources. Hospitals in particular can be stressful locations for patients and staff alike, as an individual’s care will often be administered from multiple departments, each with their own nuances, processes, queuing systems and waiting lists. The sheer number of resources and departments involved in patient care inevitably leads to bottlenecks, and in an organisation the size of the NHS, bottlenecks soon mount up to costly inefficiencies and inadequate patient care.
Qmatic conducted independent research among 100 senior IT decision makers and department heads within the NHS, to investigate the main reasons why inefficiencies and bottlenecks arise. The results show that issues tend to arise in three main areas:
Unnecessary administrative burdens
Non-clinical tasks were found to take up a substantial proportion of NHS nurses' time. From the survey, it was found that on average, 18% of nurse’s time is spent arranging follow-up appointments, 14% is spent explaining to patients about waiting times and 10% is spent helping lost patients. This means an average total of 42% of nurses' time is being spent on activities other than nursing – a significant misuse of a valuable resource. Much of this wasted time can be better managed with the right systems and technology in place to keep patients, nurses and admin staff better informed.
Reception staff too can be inundated with unnecessary enquiries. General enquiries (64%), asking for directions (63%) and patients being in the wrong department or building (52%) are the most commonly observed behaviours at reception - all of which could be reduced dramatically with accurate signposting, information points and self-check in.
The biggest issue cited by NHS staff is that not all patients read the signs available to them (observed by 59% of respondents). This can be a particular problem for patients who need to visit more than one department and who may not be following the logical flow of the hospital from entrance to destination. As a result, patients experience increased frustration, staff receive a greater number of navigational enquiries and the number of late or missed appointments increases.
Perhaps as a precaution, in case patients get lost, the next observation made by NHS staff is that patients often arrive very early for their scheduled appointments. As a result, the demand on seating increases, particularly during peak times when capacity is at a premium.
Under-utilisation of resources
Under-utilisation of clinics was identified as another structural challenge for the NHS; on average, the percentage utilisation of NHS clinics is cited at 66%. The top three reasons for this under-utilisation are consultants taking ownership over specific rooms (43%), rooms not having the correct equipment (38%) and rooms not being properly cleaned/maintained (28%).
Inconsistency in terms of seating has also been noted. More than three in five respondents (63%) believe they do not have adequate seating in all their departments throughout the day, yet nearly three quarters (72%) claim that while there might be no free seats in one department, another department will still have seats available, suggesting that better utilisation of the resources available could remedy the problem.
Senior decision makers within the NHS acknowledge that better patient management is the way forward. In fact, in Qmatic’s survey 62% said that improving queuing and waiting in their department is a priority that needs to be looked at and 97% of NHS staff firmly believe that improving patient flow will have a positive influence on patient behaviour and reduce the number of complaints and aggressive incidents.
Many hospitals are adopting the use of digital solutions such as digital kiosks, tablet devices, electronic/automated triage and queue management information systems. Of those departments which have development projects underway for reception, 56% are working on digital kiosks to help with choice and self-service right now, up from 36% in 2011.
Managing the flow of patients is the core engine of the NHS – it is the one function that touches every single patient at every stage of their treatment. If just one cog stops turning, then the whole machine starts to stall, undermining the ability of the NHS to deliver the high quality of healthcare that it is known for. A full audit of patient flow management can help hospitals gain a clearer picture of a patient’s entire hospital journey. As a result, hospitals are better able to deliver significant efficiencies and cost savings to the NHS through the use of technology and more efficient workflow.
Qmatic is world leader in queuing, waiting and patient flow solutions that increase productivity, efficiency and patient satisfaction while reducing costs for the NHS. Its software, hardware and consultancy helps hospitals such as Birmingham Children’s, The Christie and St Thomas’ to value time within the physical patient experience and derive real-time business intelligence (BI). This BI drives room and resource utilisation as well as patient routing to improve appointment keeping and burdens on clinical staff. It also determines department layout and design, employee training, job satisfaction as well as patient behaviour and satisfaction. Reporting against targets, real-time problem resolution, efficiency and cost control factor too. According to a new survey, poor signage and administrative burdens hold back the world’s largest public health organisation significantly.
Headquartered in Sweden, Qmatic operates out of 120 international locations. Its solutions have been successfully deployed in 51,000 sites across 122 countries. It is estimated that more than two billion users; a quarter of the world's population, pass through Qmatic’s systems every year. See www.qmatic.com/uk.
Qmatic UK is based at Derwent House, University Way, Cranfield Technology Park, Bedford, MK43 0AZ. Phone: 01234 757 110. Twitter Qmatic_UK.
Mark Pilgrim is the Vice President of EMEA at NComputing and joined the company in February 2012 to develop its reach in virtual desktop solutions in markets across EMEA. Mark has worked in customer and partner facing roles within the global technology industry for over 25 years. Prior to starting at NComputing he held a number of senior roles, including Regional Director of Sales in the UK and Ireland at Quest Software and Managing Director at Teligent Ltd.
The UK Government recently confirmed plans for smarter use of IT in healthcare. The goal of digitising patient records is to save £5billion a year while improving the quality of patient care by making it easier for medical staff to share and access records. Tight deadlines mean new infrastructure will need to be deployed rapidly and with minimum disruption or delay.
But this kind of project comes with huge risks. The NHS deals with over one million patients every 36 hours and the experience of developing and deploying the IT infrastructure to support the service has been troubled. The most recent project to create a centralised database was scrapped in 2011 after costing taxpayers over £6 billion.
So the decision of the current government to focus on supporting local schemes that roll-out healthcare IT improvements in accordance with national standards seems sensible. In seeking to bring the benefits of digital medicine within tight spending budgets, this should encourage the NHS to consider how desktop virtualisation can offer a more affordable, scalable and flexible platform for enabling NHS staff to access and share patient records.
Next generation virtual desktop environments are ideally suited to address these requirements. The technology allows you to re-purpose old equipment, add mobility and widen access through new low cost and low power devices. In fact, these state of the art non-PC devices are ideally suited to the sensitive clinical environments into which computing could be extended under this plan. They have a smaller form factor, thus freeing up valuable space in a ward or treatment room, and are very easy to keep clean because they have no fans to retain or disperse bacteria or dust. Add to this lower sound and heat emissions and you can envisage how they can seamlessly be part of any clinical setting.
The Government’s announcement doesn’t go into the details of what platform will be used – this is a decision that will be made at a local level. But given the scale of this project and the determination for best value for the money, it would be natural for NHS organizations to take virtual desktops and apps more seriously because of the potential capital and operational savings, and significantly better end user experience for both patients and staff. And what is being discussed in the UK has parallels in other parts of Europe and beyond.
Belinda Miller, Director of Insight and Context at marketing company, Corporate Culture, explains what the best way of getting men over 50 to get checked for skin cancer is.
Persuading men of a certain age to get skin cancer signs checked out is no mean feat. For many people, it’s easier to ignore the warning signs than bother the GP with a seemingly minor ailment. But research shows that men aged 50+ are particularly reluctant to come forward early, which explains why skin cancer deaths are highest among men of this age, even though more women get the disease.
This is a key problem for the health sector because later-stage diagnosis of skin cancer makes it more difficult to treat people and save lives. The rewards for successfully changing these behaviours and encouraging more men aged 50+ to present early are obvious but critical: the sooner they come the more likely they are to be referred and treated successfully; and the treatment itself will be more cost-effective because it’s cheaper to treat early-stage than late-stage skin cancer - the annual cost of skin cancer is estimated at more than £100m in England alone.
We have been working with Cancer Research UK and the Department of Health on cancer campaigns for many years. In all initiatives aimed at changing a specific type of behaviour, it’s important to understand who you’re targeting, what factors are behind their current activity (or lack of action) and what the motivation would be for them to change. These theories are put into practice in our ongoing work for CRUK which has proven to effectively generate awareness of the early signs of skin cancer among older men across four different cancer networks.
To build the knowledge base, CRUK was keen to understand which type of approach to engaging patients was the most cost effective at driving early presentations. This meant testing three different intervention approaches, using proven collateral in a campaign covering areas of Dorset Cancer Network. In Weymouth, residents were targeted with community outreach using a roadshow vehicle which offered skin checks at key periods. In Christchurch, ‘hit squad’ street teams were deployed to meet people in their own environment and talk one-to-one. Thirdly, direct mail packs featuring a personalised letter and fold-out advice leaflet was sent to men in North Dorset. In all cases, patients were given information on skin cancer signs and a prompt to visit their GP if concerned.
The results were then evaluated. Traditionally, ‘big noise’ tactics and community interventions have been deemed the best way of changing attitudes towards making a GP appointment by many in the NHS and cancer charities alike. This time, however, direct mail was the clear winner. Not only did the mail pack have a much lower cost per engagement, and ultimately cost per referral, than the other two methods, its prompted recall was the highest of all three channels. Tellingly, it provoked significantly more presentations. The marketing campaign was considered successful, and the direct mail tactic is already being rolled out to other areas of the country, including Avon, Wiltshire and Somerset, Peninsula and Greater Manchester, where we are now evaluating the impact of targeting female influencers as opposed to men directly.
The Dorset campaign is an example of how setting the wheels of behaviour change in motion can lead to quick gains for health commissioners looking to make long-term savings from sustained alterations in attitudes and understanding. By persuading more men over 50 to check themselves for possible signs of skin cancer, what may appear to be simple marketing tactics has begun to change the way in which this vulnerable age group thinks about and acts on melanoma. To facilitate this, Cancer Research UK and the BAD (British Association of Dermatologists) have also developed a skin cancer recognition toolkit for GPs which is available at www.doctors.net.uk/skincancer.
By Jane Lewis
Trained by “the co-creator of positive deviance (PD)”, Jerry Sternin, Jane Lewis then created and led the UK’s first organisational PD project, which delivered significant social work time savings for Hertfordshire County Council. She also has led successful community projects with Gosport Borough Council and is working with the Home Office to test the application of PD to difficult community safety problems.
The NHS and its partners are facing a programme of colossal change to the structure and processes with which they work. Over the coming years, much hard work will be undertaken to initiate this transformation and the success of this agenda will very much depend on the changing behaviours of the community and changing the culture, leadership styles and relationships in organisations. Sustainable change must be delivered and the way in which this is done is critical for success.
The Traditional approach to transformation has limitations
Traditionally change is imposed from outside consultants, or from top-down management. In these situations, staff can resist that change, viewing it as negative and feeling they are being criticised. The outcome is often that new policies, practices and structures are not adhered to for long and frontline staff become demotivated.
To overcome this negative trend it is important to realise that the skills, capabilities and wisdom needed to address the transformation agenda, and many of the seemingly intractable problems within the NHS successfully, can be found internally. Frontline staff know the culture inside-out and many already have easy-to-implement, cost efficient and extremely effective ideas of how to reach the desired change, such as placing the patient at the heart of the process. These people, who are already addressing the problems effectively – even when faced with the same challenges as their colleagues – are known as Positive Deviants.
Positive Deviants have a big role to play in the NHS
Positive Deviance is an innovative, inspiring, low cost and proven way of helping frontline staff help themselves. It is a group facilitation process that requires skills rather than money. It is not a top-down or a business consultant-led approach, which often comes with a hefty price tag and is met with resistance. The ‘community’ i.e. the staff, become the process owners and look to the practices and strategies of Positive Deviants, which are then disseminated throughout the organisation using practical activities. The ‘community’ owns the measuring and recording of the process providing positive change, reducing resistance and often creating a needed boost to morale.
It creates behaviour change by ‘acting your way into a new way of thinking’ and works well in complex organisations, like the NHS. Internal hidden wisdom is unlocked and used to address change. It has the power to change relationships between patients, service users and agencies, providing greater productivity.
Positive Deviance in action
The VA Pittsburgh Healthcare System in the USA used PD to advance their ‘Getting to Zero MRSA Initiative’. By engaging every person in the healthcare environment, including the frontline hospital staff, from janitors to consultants, it was possible to find positive deviance practices that reduced the spread of infection by up to 62%.
A very interesting example of PD practices comes from one particular hospital - the Albert Einstein Medical Center - where a patient escort developed a unique method of disposing of his soiled gloves and gown. The escort worked out that by quickly sliding out of the gown, inverting it, folding it tightly and precisely stuffing it into a medical glove, he was able to compress the potential biohazard into a wad the size of a cricket ball prior to proper disposal. This eliminated the threat of the virus spreading and the technique has since been circulated throughout the hospital.
This change was easy, cost effective and because the change was determined by a staff member – not a top down instruction – it has resulted in lasting change. The solution to the problem was already within the hospital and using the staff’s internal wisdoms has had a huge impact.
For more information, visit: www.woodward-lewis.co.uk