I have had two curious experiences as a digital citizen this week. It all started with a rather depressing article I read in BMJ last weekend. It was a ‘yes/no’ debate (a common format in the magazine) on the question of whether GPs should allow patients to email them. I found it depressing for two reasons 1) I found it astounding that we should be debating the ‘question’ at all 2) The implication that e-mail might be even a remotely sensible tool for digital access to health care.

Even Digital Doctors Don’t Change

The debate continued on twitter – it appeared to me as a casual observer – that the argument against (apparently the overwhelmingly held view – even of GP twitterers) distilled down to the following:
- GPs are inundated with patients in their surgeries so how could they possibly have time to answer e-mails from them. (The doctor as victim argument)
- Face to Face consultation is a sacred rite of healthcare delivery – any qualitative diminishment of this is a disservice to patients. (The ‘I’ve been trained to do it this way I can’t believe it could possibly be done by a machine’ argument)
- Patients will ask silly or trivial questions and we would be swamped by the worried well. (The ‘We know whats best for patients’ argument) .
- What evidence is there that on-line access reduces demand any way? (The ‘If there isn’t a randomised controlled trial I’m not going to change’ argument)
I was appalled by the narrow perspective, lack of self awareness and how patronising and patriarchal the medical profession still is in 2014. I, rather inadvisably, said so on twitter – and was hit by a ‘twitter storm’ (more of an angry gust if I’m honest) of protest from doctors – what would I know, I’m just an anaesthetist!

Patients Doing it for Themselves

So that was my first experience of an online ‘trolling’ – an important rite of passage as a digital citizen. My second curious experience I’m glad to say was more uplifting. I received an unsolicited invitation from the King’s Fund to take part in a round table discussion about ‘The Art of the Possible’ in a digital future for healthcare. This took place on tuesday night – there were a variety of people – CEOs, MDs, Academics, Community, Mental Health, Industry, DoH (HSCIC) and Patient representatives.

The session started with the absolutley captivating story from Katherine Cormack. She spoke unwaveringly of her experiences of childhood and adolescent mental health problems, the inadequacy of the services provided to treat them and of her attempts to create a solution from the inside (she worked for the NHS for a while trying to set up online help forums for teenagers with mental health issues – but had to give up because of the barriers to change) and eventually joined a social enterprise which has developed an online tool called BuddyApp which creates an online regulated self-help community for patients and therapists.

A long and fascinating conversation ensued – which I can’t divulge because we were operating under ‘Chatham House Rules’. However the messages I took away were the following:

1) There is a desperate desire from users of the health service for it to enter the digital age – they feel ‘locked out’ and rebuffed by an un-listening and un-reformable system.
2) The world is innovating around us – the NHS is being left behind
3) The NHS is a jealous guardian of patients health information and cannot see a way through the mire of data protection, confidentiality and competition law to release it back to them – although in fact there are no reasons why these should be barriers
4) The NHS is incapable of disrupting itself – it cannot release cash from things it is currently doing in order to invest in doing things differently – this was implacably conveyed by the man from HSCIC
5) Yet it is only technology enabled patient self care that has the potential to relive the inexorable rise in demand for NHS services
6) There is a stark asymmetry between the value we (the health service) think we add compared to what patients think we add
7) The NHS has the long history and deep seated culture of a public service organisation that thinks it knows best – this patriarchal culture suffuses the organisation from its civil servants and managers to its frontline clinicians.
8) Those on the inside with insight and the desire to change it are a definite minority – but they are passionate and are seeing and implementing solutions, albeit in small pockets of the service.

Some Myths about Digital Patients

The other strong message that came through is that there are some strongly held beliefs of health professionals about digital healthcare that are simply not born out by the evidence.

Myth 1 – ‘Technology is the preserve of the young and the elderly would be excluded’ – Smartphone market penetration has exceeded 90% in the UK and the fasted growing sector is the over 65s
Myth 2 – ‘The elderly struggle to use or understand modern information technology’ – It is not uncommon now on our wards to see patients young and old using this technology intuitively and effectively. I have seen patients on our elderly care wards ordering their supermarket shopping in preparation for their own discharge.
Myth 3 – ‘Handing out devices to patients will result in them being stolen’ – this is simply untrue – devices have been used in solutions for the homeless and drug addicted with no or minimal loss
Myth 4 – ‘Digital healthcare is a poor substitute for face to face and hands on consultation’ – There is a very large element of health seeking behaviour which is simply looking for trusted advice and reassurance, patients value the continuous access that digital health affords compared to the limited hours and inconvenience of primary care or the appalling experience of A&E.

A Coalition of Radicals

The most uplifting part of the evening was being able to meet and network with developers of solutions for digital healthcare (like BuddyApp), professionals from the health service that have put them to use and representatives from patient groups that have been campaigning for greater patient autonomy and self care through access to their own health record. They are a weary tribe of campaigners because they get little audience from the service they are trying to improve. However there was a clear shared vision and enthusiasm for digital access to healthcare and evidence of real progress from some innovative developers.

It is clear to me that it is this tripartite coalition – patients, third party developers and willing clinicians that will deliver the digital future of health. The only change from inside the health system that is needed is the release of patients own information back to them – and that should cost nothing. Its time to campaign for your right to access your own health information. This innovative disruption will change the NHS from the outside for ever.

We had an ill child in our A&E for over 20 hours yesterday. Read that again – yes its true – 20 hours in an inner-city A&E – on a Friday. Actually she isn’t a child – according to half the professionals that saw her, but was according to the other half. Conveniently for each of them they were able to define her in a way (wrong side of of her seventeenth birthday) that meant neither had to take responsibility for her. A definitive safe place of care was eventually found at an adolescent mental health facility over 100 miles away. Throughout this whole episode she was suffering an acute psychiatric illness.

Fragile Minds

After toddlerhood – adolescence is the most active phase of brain development. It is a critical period during which personality, skills and traits are developed that set the patterns of mind, thought and behaviour for the remainder of adult life. It is a crucial phase of transition from childhood to adulthood – a period of ‘finding ones place in the world’ apart from the security of parents and family. It is an intensely psychologically vulnerable time – one of which we all have memories of our own we would probably rather forget. It is also the commonest period of life for mental health issues to first develop – by some estimates up to 20% of adolescents and young adults are experiencing some degree of mental illness and over 40% of adult mental illness commences in the adolescent period. The combined assaults of alcohol, drugs, sex hormones and dramatic changes in life circumstances on a fast developing brain have unpredictable consequences – which for a growing minority include breakdown, psychosis and the roots of devastating life long mental illness.

When your world falls apart

Psychosis is the most terrifying symptom of disease. It is the awakening of primal fears – normally locked away by evolution and civilisation. Psychosis is the manifestation of every self doubt and vulnerability we harbour, a total loss of security. The very ground you stand on loses its solidity, the certainties of perceived reality evaporate. Paranoia is intense, everyone is against you, every sound becomes the whispering taunting voices – undermining and aggravating self doubt.

During this potentially lethal psychological experience – our service finds it most appropriate to leave the sufferers sitting in A&E cubicles, overseen by security guards and witnessed by the drunken fray that make up the core clientele of A&E on a friday night. Meanwhile professionals play ‘pass the buck’ – skulking guiltily in the background too nervous to engage with a ‘difficult teenager’ – the behaviour surely being noticed and fuelling the paranoid beliefs of the patient ‘for whom no-one cares’.

Why do we do this? Why do we let down such a vulnerable group in such a catastrophic manner?

Too Special to Touch

Throughout my career I have witnessed, and been exasperated by, the phenomenon of medical super-specialisation. This is the process by which small groups of sub-specialists – usually based in well resourced centrally located university hospitals – develop standards of care for a sub-set of a population with a branch of a disease that produce significantly superior outcomes for those patients. This isn’t a problem in itself – this is how the frontiers of medicine move forwards. The problem arises when this standard of care – attainable in the rarefied environment of the academic centre – becomes the expected standard in all healthcare settings. A process of centralisation of care then ensues – as ‘good enough’ becomes the victim of ‘perfection’ – standard care in general settings is discredited. Generalists are stripped of the right to provide certain aspects of care – patients are diverted to diminishing numbers of ever distant specialist centres – as the skills for providing even ‘good enough’ care at local centres evaporate.

One of the most striking areas of medicine where this has happened is children’s services. Most paediatric services are now provided by centrally located children’s hospitals – these highly specialist tertiary centres do a fantastic job – but to survive they have had to grow their business ‘down the value chain’ to the point where they now also provide the bulk of standard secondary care. This has resulted in the shrinking of paediatric services in district general hospitals to below critical mass levels – many paediatric services have closed – many others are teetering on the edge of viability, even in quite large general hospitals. It is reaching a point where in many hospitals it is just unsafe to be a child – and the doors are simply closing on them.

This march of progress wouldn’t be a problem if wasn’t for the fact that very sick children – whether physical or, as in our story above, mental – still come to A&E expecting life saving treatment. Our doctors, with dis-credited general skills, diminished exposure and experience – are not only discouraged but actively criticised for trying to provide good enough care. So they have stopped – and patients languish in A&E awaiting transfer to over subscribed specialist centres – not receiving immediate care they need that might prevent harder to treat long term conditions. Meanwhile the generalist tiptoes around them – too terrified to touch.

A Relentless Epidemic

Childhood and adolescent mental health is very special indeed. Most ordinary doctors are scared of mental illness – this is hived off very early in training – and even more scared of children. Yet the story of our seventeen year old in crisis is becoming more not less common, what was a handful a year presenting to our A&E has become dozens a month. We don’t know why – but the wide availability of cheap alcohol, potent cannabis, met-amphetamines, and other ‘legal’ highs along with the as yet un-evaluated impact of the psycho-social complexity of a life lived ‘on-line’ must all be playing a part. And this is a drama that is being played out in emergency departments across the NHS – daily.

There is an urgent need to find a solution for delivering safe ‘good enough’ care for these patients – at the point of presentation – until a place of definitive care can be found. The needs are not complex – but they do transcend organisational boundaries – the ability to provide safe dependable holding treatment in an urgent mental health situation – is a good test of health system integration. The care of the intoxicated, potentially physical injured patient that is in the throes of a mental health crisis requires professionals that normally work in isolation (traditionally somewhat distrustful of each other) to come together and meet the physical and psychological needs of these patients.

Above all this needs system leaders to come together, organise their services to deliver and demonstrate that – yes, we do care about this calamity – we care very much.

**** URGENT PRESS RELEASE****

A shocking revelation today exposed the collusion between a national newspaper and an independent health information manipulator to be based on flawed data and groundless inference.

A Perfect Business Model

Dr Bluster Insinuation Ltd is a private company that uses freely available public information about hospital activity and applies sophisticated statistical analysis to it in order to draw inferences about the quality of care provided by the NHS. A spokesman for Dr Bluster said – “Our clever tools can literally turn garbage data into pure gold” – “We take this free public information, make a big fuss of it and then sell it back to the public sector and to national newspapers”.

Accounts filed with companies house for 2012 show that Dr Bluster Insinuation Ltd turned over £22 million. Another spokesman said “Its alright though, one of our major shareholders is the government – so the public sector profits from our profit really – no honestly”

Making a Meal of it

It was revealed today that Dr Bluster has a covert relationship with the Daily Meal – using this national platform as publicity for its services – exploiting the paranoia of the readership about public services and the NHS in particular. “Its a perfect partnership” said an insider “we feed them stories based on pure inference and they jump to the conclusions they want to – its a great way to sell papers”. It was revealed through our investigation that Dr Bluster has been releasing embargoed reports to the Daily Meal before revealing them to the Hospitals about whom they are making the groundless insinuations. “Its quite entertaining watching hospital spokesmen trying to respond to our allegations when they haven’t even seen the report or our analysis” – “By the time they get the reports and work out that our allegations are not supported by the data everyone else has got bored and moved on”

Data Undermining

The Daily Meal made the following statement:

“Our mission is to undermine public confidence in the NHS because we believe in the private provision of healthcare – Our readers would deservedly benefit from this because they are wealthy and pay taxes where as the poor don’t”

The Daily Meal claim that the NHS costs too much and isn’t very good – even though independent international comparisons of healthcare systems made by the Commonwealth Fund (A United States healthcare think tank) rate the NHS as the best value healthcare system in the World and ranks it second for health outcomes amongst Europe, United States, Canada, Australia and New Zealand.

“We don’t report stuff like that because our readers don’t want to know” said the Daily Meal.

In an unguarded moment Dr Bluster said the following:

“We are experts in ‘Big Data’ – we mine the huge volumes of data that come out of the NHS for stories we can sell – I suppose you could call it gold digging”

A Knight in Shining Armour

Professor White (Knight in Shining Armour) – a clever man who works in public health – has said that it is a scandalous misuse of statistics to make these claims. If you look at mortality data through a PRISM you can see that there is absolutely no correlation between the numbers and the actual quality of care provided to patients. If we really want to improve the care of patients in the NHS you have to look at every case and learn from the mistakes we make. One of the biggest mistakes we make is to deny people who are inevitably dying access to palliative care.

Authors Note

I hope you enjoyed this piece of fiction. I do not take any responsibility for any conclusions you may jump to about persons or organisations existing being referred to in this blog. The views mis-represented here are entirely my own and have nothing to do with my employer

Over the next 2 years many NHS Hospitals will be replacing electronic health record (EHR) systems as the contracts born out of the national program for IT (NPfIT) come to an end. They are doing so amid a noisy revolution in healthcare informatics – which is demanding that we completely reframe not just our ideas about the EPR itself but also the nature of healthcare delivery and the traditional medical model.

I have previously talked about the cumbersome desk bound IT systems that have been as much an impediment to the process of care as a source of misery for the users of these systems. Why is there such a mismatch in expectations of healthcare staff and the developers of the tools supposedly there to help them? I don’t believe we can blame the developers of the systems – or for that matter the users of them. I believe that it has come about because we have all failed to understand the true nature of modern medicine and it has taken the social media revolution to wake us up to the fact.

Transactional Healthcare

All our current systems – IT, contracting, measuring, counting and operational delivery – are designed around the notion that healthcare is a series of individual transactions, each transaction taking place under the auspices of an individual clinician (e.g. the finished consultant episode – FCE). The overriding assumption of this model is that healthcare is episodic, that between episodes we have no contact and no need for contact with the healthcare system and that each episode is presided over by a clinician that has, if not control, then at least knowledge of what is happening. It also assumes that of the information required to manage an episode of care only a proportion of it is of relevance to future episodes – and that episodes of care have largely self contained information needs.

Notwithstanding this, what a typical patient might consider a single episode of healthcare actually consists of large numbers of individual transactions often with several different organisations and several different parts of the same organisation (GP, Outpatient department, Radiology, Pathology etc.). The ‘system’ has fragmented itself – for its own purposes – and has at the same time failed to provide a reliable mechanism for the sufficient sharing of information between its different parts to give any sense of continuity – let alone impression of competence – to the hapless patient.

20131226-221457.jpg

The NHS far from being a single organisation is an aggregation of large and small institutions, thrown together in a pseudo-market notionally in competition with each other – with strict rules that prevent them from collaborating (competition law) and sharing information (data protection). It is designed to fail to meet the continuity challenge and the expectations of patients. It is also unsafe – with manifold opportunities for vital information communication failure, a common root cause of critical incidents and serious complaints.

This transactional model has developed out of the medical model that assumes patients have singular diagnosable diseases that are amenable to technological intervention (pharmaceutical or surgical) and that life long cure is the outcome. This is certainly the case in a proportion of healthcare interactions – but medicine and patients are changing. The vast majority (in excess of 70%) of healthcare delivery is for the multiply co-morbid patient with conditions that they will live with for the rest of their lives. There may indeed be episodic deteriorations in their condition, that result in (expensive) episodes of highly technological healthcare – these are however often both predictable and avoidable manifestations of a long term condition for which there is a continuous healthcare need.

Social Healthcare

A new medical model – that fits the needs of 21st century patients – is emerging in the era of social networking. Social Healthcare – this model assumes that the patient has a continuous need for health intervention and that this is delivered by a network of providers that the patient invites in to their ‘health space’. A long term condition demands a multitude of interactions over a sustained period of time with many providers. Our current system fails to ensure that those providers interact with each other over the same patient using the same information as it cannot guarantee that they ever have access to the same information (or even know that they are looking after the same patient). In the social healthcare model the patient is the guardian of all information about themselves. Their information sits in ‘the cloud’ but they hold the key to its access. Over time they build a personalised health care team who have access to their cloud data and can ‘talk’ to each other about the patient through his or her ‘health space’. The patient can source information about their condition, ask advice or consult through the portal to their health space at any time of day or night. The portal allows for direct consultation through a skype like interface. Even more powerfully the patient can consult with other patients who have the same conditions. A self supporting community emerges that can provide advice, support and shared experience – on a continuous basis. “It’s like having a waiting room conversation with 1000 other people – just like me”.

20131226-221511.jpg

This new model has the potential to have a powerful enabling impact on patients. It subverts the traditional hierarchy in the health transaction, puts all providers on an equal footing below that of the patient – who becomes the master of their own information. Networks of expert patients start to generate new kinds of knowledge about the nature of disease and the impact of interventions – crowd sourced evidence creating medicine. Patients have the power to choose who contributes to their health space – based on the value they add to them as individuals.

Preparing to be part of the Crowd contributing to the Cloud

What does this mean for providers of health care that are in the process of renewing their informatics systems? What does this mean for me as an individual doctor? The truth is the system described above doesn’t yet exist – there is nothing yet that will force me as a doctor to change my clinical practice in such a way as to make myself available through the cloud to individual or groups of patients on a continuous basis. There is nothing yet that will force the hospital that I work for to make available all the information it holds about patients to patients through a cloud portal – or share that information with other providers of that patient’s choosing. Nothing yet – but it is coming…

Third party providers of patient centred health portals are are emerging – from a variety of premises and care models – but are converging on something that looks similar to the ‘social healthcare’ system. Patients like me, Patients Know Best, Health Fabric and Skype Health are all examples of emerging technologies that will deliver the vision. And they are selling their wares not to doctors, healthcare institutions or commissioners – they are selling them to patients.

20131227-190745.jpg

What this means then is that the systems we purchase or develop will need to have the ability to talk to these providers, transfer information, support voice and video links. We will have to think through how the information outcomes of healthcare transactions will be recorded in a way that can meaningfully sit in a patient’s cloud – shareable with other providers and understandable by patients.

What this means for doctors is a shift from practicing intermittent transactional healthcare – to developing a personal online continuous relationship with our patients and being part of and interacting with the crowd of providers that are also caring for them.

Welcome to the future of medicine – are you ready?

20131227-190826.jpg

For as long as there has been healthcare we have struggled with developing economic models for its delivery. The variety of models that exist across the world – from the raw market seen in many developing countries; through various degrees of private / state sponsored insurance; to the pure state funded provision we enjoy in the NHS – attest to the fact that there is no ‘right answer’ to this conundrum.

The Funding Paradox of Healthcare

Most healthcare systems in one way or another attempt to resolve the inevitable paradox that in the majority of cases those in most need of healthcare are also the least likely to be able to pay for it. As a result most systems are a manifestation of a ‘collective bond’ between society and the individual – ‘We’ will pay for your healthcare when you need it as long as ‘you’ contribute what you can when you don’t.

Different systems manifest the bond in different way – Through direct taxation, private or state subsidised insurance. Even the least developed systems, that rely on direct payments for care have a degree of economic re-distribution built into them, with wealthier clients overpaying to subsidise the poor and charitable donations making up the difference.

Does the funding mechanism affect the amount of money the ‘collective’ is prepared to spend on healthcare? Interestingly it appears not to be the case – the biggest determinant on how much is spent is the wealth of nation, but the relationship is geometric one i.e. the wealthier a nation the greater the proportion of GDP is spent on healthcare. The graph looks like this:

20130721-194548.jpg

Justice and Equity

Where systems do differ significantly is ‘in what way’ and ‘on whom’ the money is spent. The lesson from international healthcare system comparisons is that, in general, the greater the involvement of the state the better are the measures of ‘Universality’ i.e. distributive justice and equality of access.

Universality is not the only outcome we want to achieve from our healthcare funding system though – there is no point in having universal access to a system that is no good. Universality is ultimately, like funding model, a policy decision. It is a decision by the collective on how it would like to distribute the healthcare funds it has decided it can afford – both are the product of culture, politics, history and national character. But neither universality nor funding model alone determine health outcomes. Changing either of these is unlikely to improve the quality of care or the cost of its provision.

Is the NHS Any Good?

So, the NHS is funded to the level we would expect for the size and wealth of the nation – it scores pretty well (one of the best) on universality, although we lose points because we do tend to ration care by putting people into queues (but that is part of our national character). How do we know if we are getting the healthcare we are paying for? How do we know if the NHS is Good Value? To answer this question we have to understand the notion of value in healthcare.

Value is a fundamental function of any free market economy – it is an equation all of us reconcile, either consciously or unconsciously, every time we part with money for goods or services. We all make a calculation as to whether a particular good or service is ‘worth’ the amount of money we are about to part with. The solution to the value equation is always a very personal one – it varies enormously between individuals and even within the same individual at different times and in different contexts (most of us are prepared to pay more for a glass of wine to accompany a meal in a restaurant than we are for one when watching TV at home). Value drives market economics – it drives quality up and costs down – it improves quality of life and increases wealth – it is the triumph of market capitalism. But – it only works as long as the reconciliation of value (Worth/Cost) takes place within the same individual or entity. You cannot reconcile value if you are spending someone else’s money.

Let me tell a story to illustrate the point…

A Bitter-Sweet Motoring Tale

Just over two years ago I finally got around to replacing our family car after 8 years of neglecting the task. Having not thought about it in all that time I was for a period gripped by a frenzied interest in the family car market. After browsing the internet, buying the magazines, and even stepping into a car show room for the odd test drive – I ultimately had to come to a decision between 3 car types (having already decided that I wanted a medium sized family estate). These types are essentially ‘Low-End’ (cheap and cheerful e.g. Citroen, Seat, Fiat), ‘Mid-Range’ (Popular Reliable e.g. Ford, VW, Skoda) and ‘High-End’ (Designer, Classy, Expensive e.g. BMW, Audi, Lexus). In terms of cost low-end were in the range £12K – £15K, mid-range approximately £5K more than that and high-end another £10K on top of that and in excess of twice the cost of low-end. Having previously experienced the catastrophic residual value loss associated with the low-end of the market and been persuaded (conscience and wife in equal measure) that I couldn’t afford to go down the high-end route I settled (like many do) for a mid-range model and became the proud owner of a Skoda Octavia Estate. My personal ‘value journey’ has resulted in a car I am delighted with at no more cost than I was prepared to spend, and I am pleased to say the residual seems to be holding up nicely! My delight has only been tempered by the extraordinary hike in the cost of insuring it compared to the old car…

I was, unfortunately, involved in a car accident not so long ago – no one injured thankfully – but the car was off the road for several weeks. My positive motoring experience continued though – the insurance company appeared eager to help me out, arranging immediate retrieval of the vehicle, replacement with a hire car personally delivered to my front door, insistence that I put forward any personal injury claim (there was none). My car was returned to me weeks later in an immaculate condition having undergone repairs approaching half the cost of the original purchase price. The whole ‘accident experience’ was really no inconvenience to me at all, and I am told that the quality of repairs these days means that it will have no impact on residual value either. All great – but at what cost?

The car insurance market in recent years has undergone phenomenal price inflation – at times exceeding background inflation by a factor of ten. The introduction of ‘claims management companies’ ‘Personal injuries claim farmers’ ‘Professional body shop repairers’ ‘Replacement car hire’ etc. – have inflated the cost of motoring accidents massively. Everyone involved in the car accident ‘value chain’ appears to to be exceptionally eager to please and also appear to be profiting handsomely – in fact the whole trade was recently investigated by the OFT for profiteering. How has this runaway inflation been allowed to happen? It is a consequence of the fact that the value equation has become ‘de-coupled’ – whilst benefit is experienced by the individual the cost is shared out amongst the pool of the insured. I have contributed a small amount to overall inflation in the cost of insuring cars against accidents – had I been paying directly for the consequences of my accident would I have chosen such a high cost route to resolution? The fact is the system is locked into an inevitable inflationary spiral as no-one is controlling costs.

The market in new cars is a healthy market – it has delivered incredible improvements in the quality of cars over many years and at the same time kept costs down – the value equation is always resolved by the purchaser. The car insurance market is broken – delivering runaway inflation and ever diminishing value.

Delivering Value in Health

I am sure you will have realised that I believe that healthcare ‘markets’ share more in common with car insurance than they do with car manufacturing. That is why marketisation of healthcare has failed to deliver value.

The value equation in healthcare is on the face of it simple but is nuanced and complex – it looks like this:

VALUE = (Quality + Outcome) / True Cost of Delivery

The equation is reconciled rather uneasily within the ‘triumvirate’ of Patient, Provider and Payer. The providers are profiting (in this context by profiting I mean existing) from being fragmented, with no incentive to prevent costs being passed along the ‘value chain’, and plenty of incentive to do more at more cost to the payers. The patient experiences the quality and the outcome (often at some significant distance in time from the transaction) but has no notion of the cost. The payers are faced with irreconcilable demands for increasing scope and quality, limited levers of control of costs and under-developed measures of quality and outcome. All of this fuelled by the easy altruism of the providers spending someone else’s money.

Marketising Integrated Care

How can we yield the incredible power of a well functioning market to deliver increasing quality at reducing cost but not at the same time create a runaway self inflating market? Where in the system can we bring together the quality and outcome (as experienced by the patient) with the true cost of delivery (as experienced by the payer) in order to create value?

The answer, ironically enough, is coming from the US healthcare system. This has experienced the kind of runaway inflation described above and led it to becoming the most expensive healthcare system that has ever existed delivering aggregated health outcomes little better than systems costing less than a quarter per head of population. Yet the payers (in this case private insurers) have spotted the flaws in the market – the fundamentally self inflating structures of healthcare that incentivise primary care to refer, secondary care to receive and over diagnose problems for which they profit from treating. Their solution has been for the payers to move into the provider space – creating integrated healthcare systems. In doing so they have incentivised ‘doing less earlier for a better outcome’ – incentivised prevention, incentivised early accurate diagnosis, incentivised the creation of ‘activated patients’ and incentivised best value treatment. ‘Payer-Provider’ healthcare systems in the US such as Kaiser Permanente, Veterans Affairs and others are profiting from integrated care. They are deconstructing traditional silos and re-building delivery systems organised around whole value-chains – delivering end-to-end care for dramatically less cost. The market is moving from a market of healthcare providers to a market in integrated care organisations – providing whole life cycle care.

Time for a New NHS?

We want a better value NHS – one that delivers more and higher quality care for the same or less cost. This is a reasonable objective. We won’t achieve it by meddling with funding model or universality – these are predetermined and would require a re-negotiation of the collective bond, and would not deliver better value. We won’t achieve it by fragmenting the provider market – that will create a runaway self inflating system of passing the cost up the value chain. We might achieve it by integrating providers around whole cycles of care. We have been talking about integration in various guises for years but have delivered little as we remain in a purchaser provider split and a primary secondary split all locked in self preserving stalemate. What has been missing is the incentive to integrate and that comes from integrating payers and providers. This is for the NHS the slightly awkward lesson coming to us from over the Atlantic.

I have just finished reading the astonishing book by Daniel Kahneman ‘Thinking, Fast and Slow’ – it is a book that takes you on a journey of thirty years of discovery in psychological science. Once you read it you will never ‘think’ about yourself the same way again. The central tenet of the book is particularly salient to the conversation in the health service about mortality and the statistics relating to it following the recent publication of the findings of the second Francis report.

Judgements, Biases and Heuristics

Kahneman describes three dichotomous concepts – Firstly two types of thinking ‘System 1′ (Fast, intuitive, associative, innate and effortless) and ‘System 2′ (Slow, analytical, calculating, learning and effortful); Secondly two types of people ‘Econs’ (rational, consistent, logical, ideal economic agents that always make the ‘right’ choice) and ‘Humans’ (reasonable but subject to biases of their thinking such as priming, framing, narrative fallacy, imabalanced attitudes towards risk of loss and gain, excessive weighting to ‘available’ evidence, relatively blind to statistics and the ‘external’ view); Thirdly two ‘Selves’ the experiencing self (the person reading this blog here and now) and the remembered self (the person your mind has created through the narrative stitching of remembered events and experiences). For more details – go and read the book…

What is particularly interesting about his research is that he has demonstrated unequivocally time and again that being an ‘expert’ in any field, be it healthcare, economics or even psychology itself, does not protect you from these innate biases of human thinking – even when you know they exist they still influence you, and in fact being an expert simply puts you in a position where these biases are more consequential (your biases harm other people as well as yourself). He does, however, describe a number of strategies that organisations can adopt that defend against the consequences of individual judgment bias, strategies that need to be adopted systematically and deliberately. He gives examples of spectacular corporate failure, through group think, where these strategies had not been adopted.

The Statistics of Death

Why is this all relevant to us following the Mid-Staffs crisis, Francis report and the renewed scrutiny of hospitals with ‘outlying’ mortality figures? In the pantheon of spectacular corporate failure the events in 2007 at the Mid-Staffordshire NHS Foundation Trust must rank prettily highly, and of course the principle theme of the second Francis report is that this was an NHS corporate failure, not just a hospital failure. One of the central themes of the crisis centres on the role, meaning and response to mortality statistics for the hospital at the time. It is worth, therefore, taking a little time to understand how mortality statistics are generated.

At the time there was a single statistical measure routinely used to compare mortality in hospitals across the NHS – Hospital Standardised Mortality Ratio (HSMR). HSMR is calculated by taking the observed death rate and dividing it by a calculated figure for an ‘expected’ death rate. The expected death rate is essentially the death rate in hospitals for the whole of the UK with a number of adjustments made in order to compensate for differences in case mix (the diagnoses patients are admitted with), age, co-morbidity and social deprivation. The ratio is multiplied by 100, so if your observed death rate is the same as the expected then the ratio is 1.0 and the HSMR would be 100. When observing mortality in a population it is important to recognise that over time mortality will always increase (we all have to die eventually) – therefore when comparing mortality in different populations we have to know over what time period mortality has been counted (usually 30 days, 90 days, 1 year or 5 years). One of the weaknesses of HSMR is that it does not specify the time period – it is simply the time spent in hospital – therefore a hospital with a longer than average length of stay will tend to have a higher mortality. Another weakness of HSMR is that it does not have a diagnostic category code for palliative care. The provision of out of hospital end of life services across the UK is at best patchy, where provision is poor patients are admitted to hospital to die, HSMR does not adjust for these expected deaths and so hospitals in this situation will have a higher than ‘expected’ HSMR. As a result of these statistical biases, HSMR is being replaced by a newer indicator – Standardised Hospital Mortality Indicator (SHMI). SHMI is very similar to HSMR but differs in two important aspects. Firstly it expands the number of diagnostic codes against which case mix adjustment takes place from 56 to 140, including one for palliative care. Secondly it fixes the number of days over which mortality is measured to 30 days after discharge.

The other important thing to recognise about mortality statistics – is that they are just that; statistics. As such reliability depends on sample size and confidence intervals. As a rule of thumb a condition with an expected mortality rate of 10% needs a sample size of about 200 cases before the confidence interval falls to a point where a doubling (or halving) of the observed rate can be explained by anything more than random chance. This is best illustrated graphically by the ‘funnel plot’ an example of which is below – and explained simply in this article here.

20130401-174202.jpg

Two Stories About Mortality

Hospital A is a medium size district general hospital in a provincial town of the midlands. It is more than 30 miles from the nearest city and serves a relatively fixed population, bounded by open countryside, which is below the threshold for sustaining a comprehensive range of hospital services. It has recently successfully achieved foundation trust status by importing a new board that have railroaded a controversial savings program through that has helped make the long term finances appear sustainable. Many staff have been made redundant and staffing ratios on the wards have been reduced. Morale is low and sickness rates are high, the wards are busy with large numbers of elderly dependent patients. The hospital has always struggled with attracting high quality medical staff because of its geographical location, tenuous affiliation with a university hospital, low numbers of doctors in training and an unexciting specialty portfolio. There have been a number of recent complaints from relatives unhappy about basic standards of care on the wards – two of these have been reported in the local newspaper, with the suggestion that neglect of care was a contributing factor in the deaths of patients. The HSMR for this hospital is 127, the second highest in the country.

Hospital B is a large university trust in a major city in England. It has a number of highly specialised tertiary services for which it has a national and international profile. One of these is complex paediatric congenital heart surgery, for which it is one of only a dozen centres in the country. The unit is celebrated locally and has a loyal following of patients and their parents who have received treatment there. The surgeons often having taken on cases others have refused and in doing so averting what would have otherwise been certain death. The unit has been threatened with closure as a result of a national consultation on re-configuration of paediatric cardiac surgery – aiming to concentrate services from eleven to seven centres. The local newspaper is outraged and has rallied support from local and national celebrities and politicians to keep the unit open. The staff are highly motivated and capable and the surgeons have published acclaimed original research in international journals. The standardised mortality ratio for paediatric heart surgery at the hospital is 200, the second highest in the country.

Beside ourselves jumping to conclusions

Death is a powerful word – just reading it on the page is likely to result in both a physiological response (increased heart rate, blood pressure and dilated pupils) and an emotional one (fear, disgust and aversion). These responses are usually rapidly attenuated by the rational part of the brain (system 2), however the alertness brought on by the physiological and emotional response will have activated system 1 – your innate, intuitive, fast thinking brain will be in overdrive (primed to deal with the ‘threat’) as will all of its biases.

So what are you thinking about the two (completely fictional) hospitals above? At whom is your outrage directed in each of the stories? Would you allow your grandmother to have her fractured hip treated at hospital A? Would you recommend a friend have their child with VSD be operated on at hospital B? Are you angry with the hospital or the system that is trying to close it down?

Before you answer those questions it is worth taking some time to reflect on how your thinking may be being manipulated:

  • First of all – Priming – the stories I have written have a ring of familiarity to them, you have made an association with a previous experience for which you know the outcome, however hard you try to avoid it, this will be influencing your thinking in both situations.
  • Secondly – Framing – I have (rather clumsily from a literary perspective) set the scene in both stories in a way that influences your thinking, I have told you what some other people think about those hospitals and I have given you some limited facts that probably make you like or dislike each of them.
  • Thirdly – Narrative Fallacy – I have told a compelling story that ‘explains’ the numbers. We all like stories and are primed to discern patterns in randomness – there is a multi-billion pound industry built on this tendency, its called professional sport and is hilariously exposed on a regular basis by Daniel Finkelstein
  • Fourthly – Availability Bias – this is also variously known as positive reporting bias and / or economy with the truth. It is ruthlessly exploited by the pharmaceutical industry through the suppression of non-supportive evidence for the efficacy of drugs. They are by no means the only culprits though, most published academic research is subject to this bias as well. Even though you ‘know’ I haven’t told the whole story in both cases and can easily entertain the idea that there may be other facts, unreported, that could change your view of the situation – your view is firmly anchored by what I have told you so far and new evidence can only move you from this position.
  • Finally – Statistical Blindness – the fact is that whilst system 1 thinking is life saving, allowing you to act quickly, decisively and intuitively in almost all everyday situations – and many non-everyday situations – it is designed to jump to conclusions, to abide by rules of thumb, accept evidence, particularly statistical evidence, at face value. As much psychological weight is given to a statistic based on a handful of cases as many thousands even when there is no mathematical justification for doing so.
  • This last point is particularly pertinent to my two stories, because they both have one thing in common – they are both ‘small’ – one is a small district general hospital, the other is a small highly specialised unit. Their outlier status is almost certainly more to do with their smallness than their quality of care, although this should not be ruled out of hand either.

    A Prejudice Fuelled by a Bias

    Buried within the shrill, insistent and pervasive criticism of the Mid-Staffordshire Hospital Trust is a deeply held prejudice amongst leaders and policy makers within the health service; big is good small is bad. This prejudice is affirmed and re-affirmed on a regular basis by the apparent evidence of poor performance and outcomes – the smaller you are the more likely you are to find yourself at the top or bottom of a league table. The fact that this phenomenon is a mathematical inevitability is either not recognised or overlooked because it suits ‘the system’, it provides supporting ‘evidence’ that not only are small services expensive they offer poor value as well.

    Big of course is not inevitably good either – one of the advantages of being a large institution is that you experience the converse of the ‘small outlier’ phenomenon in your outcome statistics, you are generally a ‘large average’ institution, you routinely find yourself (reassuringly) ‘in the pack’. Reassured you shouldn’t be though – hiding in every large institution’s aggregated outcome statistics will be some great performance and some dreadful. Some of the shrillness of the commentary will be disguising the fear that every leader holds – that within their own institutions are lurking little bits of Mid-Staffs.

    The mortality figures at Mid-Staffs were probably the least surprising and least relevant part of the story. A great deal did go wrong at the hospital – particularly at board level where there is much evidence that it was the victim of ‘group think’ – almost all of the pre-requisites and risks were present and it would appear none of the defences. A topic I think I will come back to in a future blog.

    Outcome Statistics – A Health Warning

    As an intensivist I have lived and breathed outcome statistics (I’ve even written a book chapter on that subject as well). They are incredibly useful tools, but they take time to become useful, it took the intensive care community a good decade to start to understand the meaning and utility of the statistics produced by ICNARC. What is absolutely certain is that they can never tell the whole story, and in fact when constructing a story about the quality and safety of a service they should simply act as pointers for further and deeper investigation. There are many nuances even to the apparently binomial outcome of mortality that have to be unpicked and understood before coming to any meaningful conclusion. I thoroughly welcome the fact that mortality as an outcome has found the spotlight – it used to frustrate me immensely as a clinical director that I was held to account more for my financial balance than the number of deaths on my unit. But in finding the spotlight it has been picked up, sensationalised and put to political use – not just by the press but by people within the health service that should know better.

    The conversation about mortality in hospitals needs to be held in an intelligent, un-frenzied, non-political and unprejudiced environment – we risk doing immense harm to fragile services if we don’t.

    When thinking about mortality it is vital that we think slow.

    As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

    Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

    Prerequisites for Organisational Learning

    We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

    There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

  • A Learning Environment
  • A Team Based Learning Infrastructure
  • A Compelling Vision Delivered Through Leadership
  • I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

    Two Key Barriers to Organisational Learning in Hospitals

    Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
    20130120-132457.jpg
    We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

    The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

    Leading Learning for Patient Safety

    So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

  • Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)
  • This makes it hard to articulate
  • The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure
  • The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision
  • The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort
  • The task will never be finished
  • If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

    Second Order Problem Solving and A Team Based Learning Infrastructure

    Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

    Blame Free Culture Vs Accountability – A Balance that Creates ‘Psychological Safety’

    Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

    But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

    20130120-213610.jpg
    This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

    Blameworthy Acts – the Boundaries of a Blame Free Culture

    Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

  • Reckless behaviour
  • Disruptive behaviour
  • Working significantly outside your capability
  • Disrespectful behaviour
  • Knowingly violating standards
  • Failure to learn over time
  • Failure to work as a team
  • Covering up
  • No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

    I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

    There is a solution to all the problems in healthcare – it is a simple one, it has a successful track record in many high risk industries and it is one that is acceptable to all stakeholders in the health transaction – Professionals, Patients, Payers, Politicians and Managers. It also saves money – lots of it…

    The solution has been called different things in different industries, it has been adopted in various styles at different points in history by these different industries – but is essentially the same thing. Health is probably the last high risk industry to adopt this solution and is doing so rather slowly, grudgingly if at all – for one simple reason: The harm that healthcare causes does not affect either the payers or the providers of the service.

    The airline industry was an early adopter – because it discovered pretty quickly that not adopting it would be fatal to themselves and their customers. There was also pretty effective self selection of non-adopters as heroic, buccaneering individuals and organisations literally crashed and burned. The oil and gas industry followed somewhat later when they discovered that adopting it made them money – lots and lots of it – with safety being a welcome side effect.

    The solution has created a world where it is safer to fly than it is to drive to the airport. Where more people are killed by petrol in their own garages than in the entire global petrochemical processing industry. Where we enjoy astonishing improvements in quality, safety and utility of the products we consume at either the same or diminishing cost (think of the mobile phone you use now compared to ten years ago).

    The solution is a culture, a state of mind and a way of doing things – it is a committed, system wide and systematic approach to reliability.

    The commonest argument used against the proposal to adopt a reliable approach to delivering healthcare goes along the lines of – ‘Patients are not widgets’; ‘Jumbo jets are more reliable than patients’; ‘There is so much uncertainty in medicine’; ‘This constrains my freedom of practice’ etc. Blaming patients for unreliable healthcare is, however, a highly disingenuous argument. Patients are unreliable, they do present us with enormous problems of variance and deviance from the expected, medicine is difficult – but that is their nature, that is their right. Putting them into an unreliable healthcare system produces variance on variance – which, I have said before, is the definition of chaos. Unreliable healthcare results in unsafe medicine, uncertain and poor outcomes, errors that are destined to be repeated (like history) all of which, not withstanding the human misery, costs. It has been estimated that nearly half of all health care costs are related to failures in the delivery of care.

    What is Reliable Healthcare Delivery?

    The trite (and not very helpful) answer to this question is the familiar ‘Doing the right thing and doing things right’. This particular definition ignores the rather large zone of uncertainty that exists between what we know is the right thing and what we know is the wrong thing. If we were to pause and reflect on the state of medical knowledge and draw a diagram representing each of these three zones – what we know is right (white), what we know is wrong (black), where there is room for argument (grey) – how big would we draw each of the zones? What strategies would a reliable healthcare delivery system adopt in the three different knowledge zones?

    20120910-221331.jpg

    The White Zone – Doing the right thing the right way

    The truth of the matter is we have a huge amount of medical knowledge – there are very many areas of medicine where we know what the right thing to do is and how best to do it. The medical knowledge base is vast and increasing exponentially (see graph below) and there are swathes of medicine where the important unanswered question is not ‘What is the right thing to do?’ but ‘Why (IGN) are we not doing it?’. One of the main barriers to deploying medical knowledge appears to be the shear volume of new information – over 1 million original medical papers were published in 2010 alone. However we have allies to help us – there are expert groups, royal colleges, specialist societies, NICE, Map of Medicine, Bandolier, national and international consensus bodies who are systematically collecting, sifting and grading the evidence for us and telling us what we should do.

    20120910-215345.jpg

    Yet as McGlynn et al. discovered we still don’t do it nearly 50% of the time (see table below). Why? There are healthcare organisations that do take a systematic approach to doing the right thing – Intermountain Health in Utah USA is one of the most outstanding high performing healthcare organisations in the world. Their outcomes for most common medical and surgical diagnoses are way above their peers – their mortality from sepsis is 9.3% compared to a US average of 25% – 40%. They are one of the few organisations in the US that makes a return on Medicare and Medicaid reimbursements. They invented the care process model – of which more later.

     

    There will be doctors reading this (most of them) that are convinced that they are practicing to the highest and most up to date standards, and able account for that standard of care they provide. Yet the outcome from their institutions will come nowhere near those of Intermountain. Whilst they may account for their own practice they will undoubtedly be a little more taciturn on their colleague’s practice, and perhaps a little more vocal about what they perceive the standard of care provided to patients before they arrived in their care and maybe after they left as well. And there is the rub – for to deliver outstanding outcomes we have to do the right thing every step of the way on the patient’s journey – for every patient.

    A good outcome is the aggregated marginal gains of multiple inputs by many professionals. Reliable healthcare is a team sport and as Atul Gawande put it in his tour-de-force ‘The Checklist Manifesto’ we are still practicing the medicine of the heroic individual – we are only just emerging from the buccaneering age of medicine, equivalent in the airline industry of when aircraft routinely fell out of the sky. Unlike buccaneering pilots though doctors don’t die with their mistakes.

    The problem with doing the right thing is that it is rather mundane. It involves being told what to do, it involves following checklists, care bundles, protocols and pathways. It also involves agreeing with your team ‘how we are going to do things here’; that inevitably involves negotiation and compromise, going along with the consensus because doing so is for the greater good. Heroic doctors are not very good at doing those sorts of things. It also takes a lot of collaborative effort to get there.

    There is still plenty of scope for the heroic doctor though. To paraphrase Atul Gawande again ‘Checklists are there to get the 80% of mundane stuff right so that the mind is freed to do the heroic 20%’. It is vital to get the 80% right – otherwise our heroics become expensive futilities.

    The Black Zone – when it goes wrong

    Understanding and managing medical error is a huge topic in of itself – which I will undoubtedly expand in future posts. I am though in a hurry (for a change) to move on to the bit I am interested today which is the grey zone. Suffice to say for now that you cannot be a highly reliable healthcare organisation if you do not manage medical error well.

    The Grey Zone – Learning from uncertainty

    This is where it starts getting very interesting. In our daily practice as doctors our patients constantly present us with dilemmas. Situations where doing the right thing seems to be the wrong thing, or where doing the right thing for one problem is definitely the wrong thing for another. As our patients get older and compound multiple pathologies these dilemmas increase all the time. Each time we are presented with these situations it feels as though we are solving the problem for the first time over and again for each patient – we are faced with the huge and overwhelming variance in presentation and response to treatment.

    The traditional medical model for dealing with these situations is the ‘iterative care process’ underpinned by the ‘experienced clinician’. This care process involves a combination of medical detective work (history and examination), Diagnostic hypothesis (differential diagnosis), Diagnostic tests or a ‘Diagnostic Therapeutic Trial’ (we’ll give antibiotics and see if they get better…). Experience helps by being able to ask the right questions, come up with a feasible and manageable list of diagnostic hypotheses and also design a diagnostic prescription that does the minimum to confirm or refute the hypothesis. Patients will often go through several cycles of this process (either because it doesn’t solve the problem or because the patient has moved to a different team) – with escalating intensity and invasiveness of investigation – until either a diagnosis is made and correct treatment started or the progress of the condition outpaces the process and the patient succumbs (or they get better despite us).

    There are several reasons why this model is problematic and fails to deliver reliable care. The first is that the operating model of the modern hospital (the process by which patients move through the organisation) is not aligned to the iterative care process. The second is we are not very good at it any more – we don’t have enough experienced clinicians to see and review patients progress through the care process in a timely or frequent enough way. Thirdly it is slow, expensive and unreliable. Finally it does not deliver learning at anything other than an individual level – hence the very real sense in which we feel we are re-solving the same problems day-in day-out without seeming to make much progress.

    The complexity of modern medicine and modern patients, the dissolution of traditional medical teams and their replacement by the transitory, multi-professional, socially complex, modern alternatives – means we need a new model for delivering care.

    This medical model needs to achieve several things:
    1) Reliable delivery of care that we know is right that does not depend on the location of the patient, or the presence or absence of a particular professional.
    2) Keep up-to-date with the ever expanding body of medical knowledge
    3) Generate ‘Team Learning’ from variance in presentation and response
    4) Generate ‘Team Learning’ from medical errors
    5) Use that learning to modify and adapt the care process

    The ‘Care Process Model’ invented by Intermountain achieves all of these things. On first glance it appears to be a set of protocols – and many subsequent implementations have deployed it as such. However seeing it as such is missing the point – the content of the protocol is much less important than the process by which it comes about and the way that it is used.

    The diagram below shows the essence of the care process model development and more to the point continuous improvement through organisational learning.

    20120910-231035.jpg

    The essential components are:
    1) An expert team that crystallise the current state of medical knowledge into detailed guidance
    2) Clinical senate that simplify and standardise to a deployable protocol across the whole system
    3) An operating system that reliably delivers elements of the CPM at all points of the pathway – the protocol is the record
    4) A reporting and monitoring system of deviance from the pathway – an expected deviance of 20% is built in – but all deviance is reported and analysed including medical error
    5) Outcomes are monitored
    6) Information is fed back to the clinical senate that adjust the CPM

    You will see that this generates organisational learning – the system gets smarter – and that it does so using three distinct knowledge types – The global medical knowledge base generated by original research, knowledge of its own patient group through analysis of unexpected response and outcome, knowledge of itself through analysis of medical error and non-compliance.

    In my next post I will discuss the pre-requisites in culture, structure and process that are required to create organisational learning and how rare they are in the NHS.

    The sea reflected the almost unblemished sky with a dark, angry meridian blue. Only the slate-grey streak above the horizon belied the otherwise benevolent August day. The rocky outcrops, punctuated by deep black caves and lightly rusted with seaweed and lichen, glistened like tarnished silver in the midday sun. The mineral white surf thrashed with frenzied futility against the oblique buttresses of rock, throwing up foamy spray that blew about like a midsummer blizzard. Occasionally it would drift up over the cliff edge to the vivid green fields capping the headland, dotted with sheep chewing with bucolic nonchalance, oblivious to the seething battle only feet beneath them.

    The Atlantic rollers were splendid, coming with just the right periodic regularity, energised by the residuum of a distant hurricane reverberating it’s destructive existence from across the ocean three days before. Standing with my surfboard each wave announced it’s arrival at first with a powerful sucking force, dragging sand, seaweed and debris painfully around my legs. It would then rear up, a sandy turquoise colour latticed with submerged foam, darkening suddenly as it tipped into a breaking roller. If I timed it right it would pick me up and accelerate me forwards dangerously, exhilaratingly, thrilling in a way no cosseted roller coaster ride could possibly ever achieve.

    They just kept coming and I couldn’t drag myself away – addicted to the reliable adrenaline rush with each wave I caught. I must have not stopped to look around for some time because all of a sudden the sun winked out, engulfed by the dark grey blanket that had scudded in from the horizon. The mood of the waves turned from playful energy to menacing power and my anticipation became tainted with anxiety.

    I staggered with the drag as the water level dropped from mid chest to below my knees. This wave really towered, it was clouded with the churned sand in it’s turbulent core and seemed to suspend itself above me whilst I decided whether to dive through or try and catch it. Of course it was playing with me, laughing at me, as I decided a fraction of a second too late to try and catch it. I felt the weight of the water first – it crushed the air out of my lungs – before picking me up and turning me over feet first, tearing the surfboard from under me and snapping the wrist tie. I was submerged and tumbling, the force of the water pushing me face first into the gritty sand, before changing direction and picking me up again. I couldn’t breath and sandy salt water was forced into my nose and throat. It kept me under, shaking with contempt my rag doll attempts at swimming, long enough for the panic of imminent drowning to start rising from my solar plexus. Just as I began to think I couldn’t get out of this it dragged me front first into the shallow shore, sand filling the front of my wetsuit. The water hissed as it retreated away from me over the rippled sand, as if to dare me to try this again.

    I limped up the beach with my broken surfboard flapping forlornly, bruised, grazed and my head spinning slightly. I lowered myself on to the picnic blanket to a welcoming sweet biscuit and strong coffee as the light summer drizzle began to fall.
    “How is the surfing today darling?”
    “Brilliant – absolutely brilliant…”

    20120827-131859.jpg

    In a book chapter I wrote on the subject of information management in critical care, I concluded that one of the most important challenges for this generation of doctors is the transfer of clinical information management from paper to electronic systems. So far we have failed that challenge, the vast majority of clinical information is still being recorded and managed (rather poorly) on paper. Those parts that are managed electronically are, in general, still cumbersome, bespoke systems that serve functions other than the delivery of clinical care far better than the needs of doctors, nurses or even patients. As a result a lot of these systems are at best grudgingly tolerated, often despised and sometimes even avoided altogether. The majority of doctors, with the exception of the minority enthusiasts, have withdrawn from the conversation on development of information management systems (or even been left out altogether) because it has been seen as a technological challenge rather than a clinical one. This is wrong and has to change because the way we manage clinical information is a crucial enabler for radical change in health care delivery. If doctors fail in this challenge we will find ourselves marginalised and obsolete in an ‘innovatively disrupted’ health economy.

    Early Adopters

    There is, of course, some history here which partly explains our current situation. Electronic clinical information systems have been in existence for over twenty years. The early years of the development of these systems was dominated by the technological challenges. The sheer volume and complexity of information that is collected in the course of delivering clinical care was a challenge when the cost of electronic storage was high and networking infrastructure not well developed. Taming the complexity of the information – codifying it and structuring it so that it could ‘fit’ in a conventional database – was not only difficult but also met with resistance of professionals as it constrained practice and the PC / workstation became a barrier between doctor and patient. Despite these challenges there are examples of hospitals and hospital systems that showed the world how it could be done (Burton Hospital being a notable example in the NHS) and also how it could go wrong.

    The Lost Decade

    If the nineties was the pioneering decade for clinical information systems then the first decade of this century can only be characterised as the ‘lost decade’ – whilst the Internet flourished and the age of distributed, personalised, world-in-your-pocket computing dawned – hospital IT systems remained desk-bound, cumbersome, inflexible, centralised systems. The need for information sharing was misinterpreted as a need to provide a single solution for all. A strategy that has cost billions, failed to deliver and diverted funding and more importantly the engagement of the medical profession (it was often doctors with IT skills that where the pioneers of the early adoption period) away from user and patient centred solutions.

    A Tablet Ushers in a New Era of Medicine

    Technology is no longer the problem – storage is cheap and abundant, networks are reliable and fast and devices are powerful, intuitive and mobile. Data management has transformed as well. XML allied to sophisticated search algorithms means less taming of information is required, the structure of the ‘database’ need not trouble the user any longer. Cloud technology means that information can be kept absolutely secure whilst not compromising the freedom of permitted users. The technology really has come of age and has surpassed the specification required to deliver clinical information management that truly serves the needs of patients, doctors and managers. Mobile devices like the iPad can give doctors both tools for information gathering and the tools to access it when it is needed without the technology getting in the way of the transaction with the patient.

    Paper, Paper Everywhere!

    But we are still using paper – tons of it. Medical records are stuffed with cardboard folders bursting with, mostly useless, pieces of paper. The information is locked away, unstructured and inaccessible – every request for information (and there are lots) is a mountainous struggle, consuming hundreds of man hours to extract it. The functions of the paper medical record as care coordinator, communicator, clinical process manager, monitor and legal witness are all conflated and result in an extreme precautionary approach to the retention of information which completely subsumes the probably more important function as informant almost as important (and often more informative) as the patient themselves.

    It’s the Information Stupid

    It’s time for the conversation to move from the technology to the information. We must focus on the type of information we gather, how we gather it, what we need and when we need it in order to deliver safe effective care. So much duplication and iteration and re-iteration of clinical information has evolved as a defence against the in-accessibility to information. Most patients I have met are astonished at the number of times they are asked the same questions over and over again even within the same clinical episode – they see the duplication and fragmentation that we as professionals miss.

    The care we give our patients is complicated and messy – partly because our patients are complicated and inflict on us huge variance in presentation, severity, comorbidity and response to treatment. That is the nature of medicine and what makes it so all consumingly interesting. But we make life exponentially more difficult for ourselves by imposing our own variance in practice and reliability on this already unpredictable background. Doing it differently every time, sometimes even changing our mind half way through results in variance on variance which is the definition of chaos. Chaotic medicine results in unpredictable, usually poor, outcome and huge waste – and is bad medicine.

    There is an answer to the information problem which also solves the chaos problem and results in not just better care but dramatically better care. Healthcare organisations that adopt this solution are not only better than their peers they are exponentially better. The solution is the key to delivering reliable care and it is the Clinical Process Model. This will be the subject of my next blog.