I have read two stories this week.

The first was written in an interesting, contemporary literary style – you know the sort – short sparse sentences almost factual, leaving lots of ‘space’ for your own imaginative inference, not making explicit links between facts and events but leaving you to do that for yourself.  It was a love story, rather charming and quite short, describing a familiar narrative of boy meets girl, invites her to the cinema and they fall in love (probably).  It could be described as Chandleresque in style – though it isn’t that good – in fact it could have been written by an 11+ student.  It wasn’t though – it was in fact written by a computer using a form of artificial intelligence called natural language generation with genuinely no human input.  You can read how it was done here.

The second story I read is a description of a falling out of love – of the medical profession with the IT industry and the electronic patient record.  This one is very well written by Robert Wachter and is a warts and all recounting of the story of the somewhat faltering start of the digital revolution in healthcare.  It is called ‘The Digital Doctor’ and I would highly reccomend you read it if you have any interest in the future of medicine.  It is not the manifesto of a starry eyed digital optimist, nor is it the rantings of a frustrated digital skeptic – he manages to artfully balance both world views with a studied and comprehensive analysis of the state of modern health IT systems.  His realism though extends to understanding and articulating the trajectory of the health IT narrative and where it is taking us – which is a radically different way of delivering medical care.  I won’t use this blog to precis his book – its probably better if you go and read it yourself.

From Data to Information to Understanding

The falling out that Dr Wachter describes really is quite dramatic – this is the United States the most advanced healthcare system in the world – yet there are hospitals in the US that advertise their lack of an EPR as a selling point to attract high quality doctors to work for them.  Where has it gone wrong?  Why is the instant availabilty not only of comprehensive and detailed information about our patients but also a myriad of decision support systems designed to make our jobs easier and safer to carry out – not setting us alight with enthusiasm?  In fact it is overwhelming us and oppressing us  – turning history taking into a data collection chore and treatment decisions into a series of nag screens.

The problem is there is just too much information.  The healthcare industry is a prolific producer of information – an average patient over the age of 65 with one or more long term conditions will see their GP (or one of her partners) 3 – 4 times a year, have a similar number of outpatient visits with at least 2 different specialists and attend A&E at least once.  That doesn’t include the lab tests, x-rays, visits to the pharmacy, nursing and therapy episodes.  Each contact with the system will generate notes, letters, results, reports, images, charts and forms – it all goes in to the record – which, if it is a well organised integrated electronic record, will be available in its entirety at the point of care.

Point of care being the point – most health care episodes are conducted over a very short time span.  A patient visiting his GP will, if he’s lucky, get 10 minutes with her – it doesn’t make for a very satisfactory consultation if 4 or 5 of those minutes are spent with the doctor staring at a screen – navigating through pages of data attempting to stich together a meaningful interpretation of the myriad past and recent events in the patient’s medical history.

How it used to be (in the good old days)

So what is it that the above mentioned hospitals in the US are harking back to in order to attract their doctors?  What is the appeal of how it used to be done when a consultation consisted of a doctor, a patient and a few scrappy bits of paper in a cardboard folder?  Well for a start at least the patient got the full 10 minutes of the doctors attention.  The doctor however was relying on what information though?  What the patient tells them, what the last doctor to see them chose to write in the notes, and the other events that might have made it into their particular version of this patient’s health record.  This gives rise to what I call a ‘goldfish’ consultation (limited view of the whole picture, very short memory, starting from scratch each time).  We get away with it most of the time – mainly because most consultations concern realtively short term issues – but too often we don’t get away with it and patients experience a merry go round of disconnected episodes of reactive care.

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When I used to still practice intensive care medicine one of the things that occupied quite a lot of my time as ‘consultant on duty for ICU’ was the ward referral.  As gatekeeper of the precious resource that is an intensive care bed my role would be to go and assess a patient for their suitability for ICU care as well as advise on appropriate measures that could be used to avert the need for ICU.  My first port of call would be the patients notes – where I would go through the entire patients hospital stay – for some, particularly medical patients, this might be many days or even weeks of inpatient care.  What I would invariably find is that the patient had been under the care of several different teams, the notes would consist of a series of ‘contacts’ (ward rounds, referrals, escalations) few of which realted to each other (lots of goldfish medicine even over the course of a single admission).  I soon ceased to be surprised by the fact that I, at the point of escalation to critical care, was the first person to actually review the entire narrative of the patient’s stay in hospital.  Once that narrative was put together very often the trajectory of a patient’s illness became self evident – and the question of whether they would benefit from a period of brutal, invasive, intensive medicine usually answered itself.

Patient Stories

The defence against goldfish medicine in the ‘old days’ was physician continuity – back then you could  expect to be treated most of your life by the same GP, or when you came into hospital by one consultant and his ‘firm’ (the small team of doctors that worked just for him – for in the good old days it was almost invariably a him) for the whole admission.  They would carry your story – every now and then summarising it in a clerking or a well crafted letter.  But physician continuity has gone – and it isn’t likely ever to come back.

The EPR promised to solve the continuity problem by ensuring that even if you had never met the patient in front of you before (nor were likely ever to meet them again) you at least had instant access to everything that had ever happend to them – including the results of every test they had ever had.  But it doesn’t work – data has no meaning until it is turned into a story – and the more data you have the harder it is and longer it takes to turn it into a story.

And stories matter in medicine – they matter to patients and their relatives who use them to understand the random injustice of disease, it tells them where they have come from and where they are going to.  They matter to doctors as well – medical narratives are complex things, they are played out in individual patients over different timescales – from a life span to just a few minutes, each narrative having implications for the other.  Whilst we don’t neccessarily think of it as such – it is precisly the complex interplay between chronic and acute disease, social and psychological context, genetics and pathology that we narrate when summarising a case history.  When it is done well it can be a joy to read – and of course it creates the opportunity for sudden moment when you get the diagnostic insight that changes the course of a paient’s treatment.

Natural Language Generation

Turning the undifferentiated information that is a patients medical record – whether paper or digital – into a meaningful story has always been a doctor’s task.  What has changed is the amount of information available for the source material, and the way it is presented.  A good story always benefits from good editing – leaving out the superfluous, the immaterial or irrelevant detail is an expert task and one that requires experience and intelligence.  You see it when comparing the admission record taken by a foundation year doctor compared to an experienced registrar or consultant – the former will be a verbatim record of an exchange between doctor and patient, the latter a concise inquisition that hones in on the diagnosis through a series of precise, intelligent questions.

So is the AI technology that is able to spontaneously generate a love story sufficiently mature to be turned to the task of intelligently summarising the electronic patient record into a meaningful narrative? Its certainly been used to that effect in a number of other information tasks – weather forecasts and financial reports are now routinely published that were drafted using NLG technology.  The answer of course is maybe – there have been some brave attempts – but I don’t think we are there yet.  What I do know is that the progress of AI technology is moving apace and it won’t be very long before the NLG applied to a comprehensive EPR will be doing a better job than your average foundation year doctor at telling the patient’s story – maybe then we will fall back in love with EPR? Maybe…

  
On the 14th April 2003 biomedical scientists achieved the medical equivalent of the 1969 apollo moon landings – The first entire gene sequence of a human was published.  This was a phenomenal achievement and was the culmination of 12 years of intensive research – it was announced by the US President with great fanfare along with excited promsises of revolutionary advances in medicine.  We all waited with anticipation – and we waited.  Rather like the dawning of the space age – that first momentous step seemed to be followed by a quite a prolonged period of rather disappointingly mundane achievements (where are the moon colonies, hotels on mars?).  My entire medical school training and early career was filled with promises of the genetic age of medicine.  And whilst without doubt the technology of genetics has transformed our understanding of disease and created many therapeutic opportunities – the revoloution seems to have been largely confined to the laboratory and some very rare inherited genetic disorders.  The impact on most doctors (and patients) has been marginal to non-existent.  I do believe this is about to change though.

The First Two Ages of Modern Medicine

I am defining modern medicine as the era in which it becam possible ‘to do’ something to alter the course of disease and suffering.  It largely coincides with the medical profession’s mastery of pain and conciousness – allowing for the explosive development of modern surgery, and its mastery of infection – through vaccination, asepsis and antibiotics.  These triumphs of the late 19th and early 20th century brought about a rather (possibly justifiably) hubristic ‘doctor knows best’ attitude of the profession and a transformation from cynicism (just read the literature to find out what the victorians thought of their doctors!) to profound trust of society in the capabilities of the profession.  I will call the first age of modern medicine the ‘Paternalistic Age’.  Of course we eventually discovered that doctors don’t always know best, and that when confered with unreasonable trust – like all humans – doctors sometimes betray that trust.

The second age came about with the realisation that individual experts do not have privileged access to knowledge – and that true knowledge comes about through scrupulous collection of evidence, and when that process is bypassed serious harm can result.  This is best exemplified (but not exclusively) by the Thalidomide tragedy.  Another example of the consequences of unchecked, unjustifiable trust would be Harold Shipman.  Whilst the foundations of trust in the profession have not been completely undermined – there is now a healthy wariness of the claims of the profession.  The second era of modern medicine is the one I have been brought up in – it is perhaps best described as the ‘Evidence Based Age’.  It has been characterised by the ‘standardisation’ of medical care, the medicalisation of health (primary prevention – statins), increasing specialisation and a subtle shift in the powerbase in the consulting room to one of patient as consumer of medical care and doctor as informant and provider.  It has also been characterised by an proliferation of regulation as well as litigation and the practice of defensive medicine.

The two ages overlap of course – by a considerable margin – even as the third age dawns there are still doctors with unfounded self belief and patients that simply submit themselves unquestioningly to their fate at the hands of the profession.  It is also not entirely certain that the second age is always an improvement on the first.  We struggle with ‘evidence’ – it seems to change its mind, and our method of gathering it is expensive, laborious and many of the problems we need solving don’t seem to be amenable to the standard methods of evidence gathering.  This has resulted in the evidence being biased significantly towards therapeutic intervention with drugs – because that is where the evidence gathering resource lies.  We are over regulated – to an opressive degree – and we have managed to instil in our patients both very high expectation and complete dependence.  We are also conflicted – when the evidence (that we sometimes doubt) tells us one thing, our instinct tells us another and our patients have unreasonably  high expectations for something else – it can feel like we don’t have the license to do the right thing.  We end up bewildering our patients by showering them with evidence, risks and benefits – and then saying ‘over to you’ knowing full well that our patients are ill equipped to decide.

There must be a better way – and there is – but it requires the confluence of three revolutions to bring it about.

Three Revolutions

The first of these is one I have written about extenisvely – it is the information revolution as it applies to medicine and healthcare.  The revolution in gathering, processing, decision making and redistribution of medical information is just about getting under way.  However it has not even started to realise its full potential yet.

The second revolution is one I have also previously alluded to – which is the patient empowerment revolution – also just about getting underway if a little slowly.  This not just places the patient at the centre of care, it places them as master of their destiny through empowerment and education.  The medical professional task is primarily one of teaching self care backed up by judicious, co-comissioned intervention.

The third revolution I haven’t written about before – mainly because I have only really just learnt about it.    Whilst I have possibly been dimly aware of the concept of genomics – the reality of it has emerged into my conciousness in the last month as a result of two events.  The first of these was our very own consultant conference at which we were introduced to the launch of the 100,000 genome project.  The second – allied to this – was a meeting at the Institute of Translational Medicine in Birmingham where we were helping NHS England formulate a strategy for ‘Personalised Medicine’.

The Genetic Revolution Begins

So has it finally arrived – the age of genetic medicine – that I was promised as a medical student (blah years ago)?  Well not quite – and of course I don’t think that the third age of modern medicine is the genetic age that was promised.  However genetics – or more specifically Genomics – does form the third pillar of the dawning of our new age.

Returning to our space age metaphor – the 100,000 Gemone Project is the equivalent to the first manned mission to Mars.  The 100,000 people that enter the project are the equivalent to the 200,000 volunteers that have put themselves forward for that mission.  Notwithstanding that we don’t know who they are yet – they will be the pioneers of the third age of modern medicine.  They don’t quite know what they are letting themselves in for, or where in fact they are going.  What is certain is that the journey is most definately one way.

The first human genome sequence cost the US taxpayer $3 billion and took 12 years – technology has advanced somewhat since then and it now costs less than £300 and takes a couple of hours.  Thats little more than the cost of an MRI scan.  You can buy your genome sequence online – don’t ask your doctor what the result means though, they won’t know.  In fact you would be hard pressed to find anyone that can interpret the vast amount of information that is your genome.  This is where the 100,000 genome project comes in – the aim of the project is to give all that information some sort of meaning.

We are more than our genes – we are the manifestation of our genes but with a context and a history.  It is the interaction of our genes with the environment over a sustained period of time – plus the impact of pathologies and the attrition of time on our DNA that makes ‘us’.  A genetic sequence has no meaning until it is interpreted in that context.  The true power of genomics will be realised when we know how people ‘like us’ respond to environmental, therapeutic and pathological influences and the impact that genetic variance has on that.  To achieve that we have to ‘cross reference’ the vast data base that is the genome with an equally vast database that is the ‘phenome’ i.e. everything else.

The 100,000 genome project will start with recruiting people with conditions for which we know there is a genetic component either of the disease itself or the response to currently available treatments – this includes a variety of cancers and a (quite long) list of other rare diseases.  It will collect the ‘phenotype’ of these people i.e. comprehensive and structured information about individuals, their history the environment in which they grew up and live, their response to treatment and their outcomes.  It will probably do the same for their families.  It will process huge amounts of data – and it may not even directly benefit our 100,000 pioneers – much of the significance  of this information will only become clear after time and many more individuals have been recruited.  

This is a new paradigm in bio-medical research – it is the science of ‘discovery’ rather than the more familiar cycle of hypothesis testing through randomised control trial.  It imposes a discipline on the way we practice medicine – in particular the way we collect information.  It makes every health transaction an evidence creating one.  It is a model of continuous learning.  What is really exciting is that it is happening right here in the diverse, metropolitan beating heart of the country – Birmingham.

Where will it end?  From what I can see it certainly won’t end at the 100,oooth patient.  It is quite a long way to Mars…

Interpreting the Future

So the third age – is it the ‘Genomic Age’? No – although I believe the aims and design of the 100,000 genome project epitomise third age medicine.  I am going to call the third age of modern medicine the ‘Interpretive Age’.  By this I mean the future of medicine will be personal.  We will need doctors that can interpret the large amounts of information from genomics, phenomics, proteomics, theranomics and infonomics (only the last one is my invention) relating to individual patients and interpret them in a way that has meaning for the patient – and that starts with listening to the patient and understanding their context, their wants needs and aspirations (psychonomics? socionomics?).

In many ways good doctors already do this.  Are the GPs that don’t give statins to patients with a 10% risk of heart disease in the next 10 years (see Times Thursday 29th October 2015) – denying patients best evidence based care or are they practising personalised medicine?  Is it right to call someone only at risk of disease a patient?  Genomics is really simply another tool that gives an unheralded level of precision to the decision making we can make with our patients for what is best for them.  There are many tools in that box – some of them listed above – are we equipped to use them though?  I am certain that when we have have ‘precision personalised medicine’ brought about through detailed interpretation of genetic, therpeutic, informatic data, we won’t be giving 3.5 million healthy people statins.

Are you an ‘Interpretive Doctor’?
  

Over recent months there has been an emerging consensus – articulated in reports from the Royal College of Physicians (The Future Hospitals Commission) and David Greenaway’s report for the GMC (The Shape of Training) – that it is time to put into acute reverse the socio-professional trend of the last 30 years of ever increasing medical super-specialisation. In their own ways these reports identify that the needs of a health system in which 70% of the activity is ongoing health maintenance of increasingly aged patients with 3 or more coexisting long term conditions, is not an army of doctors each of which can treat only one thing.

They also identify that the key specialties for managing this population – Emergency Medicine, Acute Medicine, Elderly Care Medicine and General Practice – are all ‘shortage’ specialties, i.e. there are more jobs available than people willing or able to do them by a considerable margin (8% – 22% vacancy factor [source:BMJ Careers May 2013] and that’s before you take into account the demographic time bomb of the mass retirement of a generation of GPs that started their careers during the last big expansion of the specialty in the 70s and 80s). If you move down the training hierarchy the fill rates are even more dismal – with 50% of higher specialist training posts in emergency medicine not being filled.

The ‘solution’ to the problem that is being proposed appears to be to increase exposure to these specialities earlier on in young doctors careers – make them do these types of jobs for longer – and at the same time make access to more specialised training (like cardio-thoracic surgery or neurology) much much more difficult by decimating the number of training places for them, in the hope that more of them will stick with the front line specialties rather than flood into the popular ‘super’ specialties (as they currently do – and always have). This apparent solution however seems to be completely ignoring the fact that a young doctor when faced with the choice of not getting access to the training in the specialty they want would rather up sticks and settle in Australia than to stay in the UK in a specialty that doesn’t interest them. Which is exactly what they are doing – in droves [Source: The Times, Saturday March 7th 2015].

So why is it that young doctors are eschewing the ‘Semi-differentiated’ specialities (my term – referring to the specialities listed above and to which I would add my own specialty of critical care – albeit not a shortage specialty)? What is it about the intellectual, practical and emotional challenge of providing care to patients with multi-system disease, in a psycho-social context that requires the corralling and coordinating of multi-professional multi-agency teams that puts them off? What is it about integrated care that is just so difficult?

Both the reports cited above home in on training as the issue – we are just not training our doctors right – and they propose some really quite radical changes to post-graduate medical training to address this. Whilst this is necessary, I do not think it is nearly radical enough – to really address the issue we need to go back to medical school and examine – who we are selecting; what we are teaching them; the skills we are equipping them with; and the attitudes they are possessed of when leaving medical school.

I have had cause to visit a number of university open days – not their medical schools but their engineering departments (I’ll leave you to guess why that might be). Engineering is a profession that requires the acquisition of at least as much if not significantly more technical skills and knowledge as medical training – the courses are just as intense and nowadays just as long (typically 4 – 5 years with a year in industry). Competition to get in is just as stiff and the bright young things wanting to do it are as possessed of the same desire ‘to make a difference’ as that which motivates those who enter a medical career. What has struck me though is that every engineering course I have looked at not only emphasises the knowledge and technical skills required (The maths!) but also have very large parts of their curriculum given over to the acquisition of non-technical skills – leadership, team work, collaboration, project management, business skills – all of which are required to be a successful engineer.

They are required to be a successful doctor as well – but we don’t teach them. You are selected for medical school on academic performance at the age of 18 – pass through 15 years of undergraduate and post graduate training and emerge as a highly knowledgable, very skilled technocrat – a heroic doctor – any non-technical skills acquired along the way more by accident than design. It is not just the non-technical skills they teach engineers that doctors need either. Becoming a doctor in an integrated care system requires many of the technical skills associated with engineering as well. Understanding complex adaptive systems, industrial process design, informatics and information technology (amongst many) are all skills we require of doctors if we are to ‘industrialise’ modern medicine.

We need to train a generation of doctors that are able to command and corral the multiple professions, agencies and technologies required to support the complex interaction of social, psychological and physical pathologies that represent the disease burden of our patients. We need a generation of specialists too – but specialisms built on a foundation of whole systems care. We need a generation of doctors that recognise that its not good enough just to be brilliant at one thing.

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As a medical director of a large acute hospital trust, how people die in our care occupies quite a lot of my waking thoughts (and quite a few of my sleeping ones too…). I thought I knew quite a lot about this subject – coming into the role from a background of critical care (where death is common). I have found though that my experience, whilst a useful primer in the topic, has demanded significant additional learning on my part – this post is my attempt to share some of that learning.

People Die in Hospital – That’s what they do

There is a curious symmetry in the social changes that have occurred at both the beginning and the end of life. The realisation over the last half century or so that many of what were believed to be inevitable tragedies at the beginning and end of life were in fact amenable to technological intervention and thus avoidable – and the change in the medical profession from overseer and commentator of natural tragedy to intervener and preventer of such – has driven these life events from a home based setting managed by community based services into a hospital setting managed by doctors, nurses and midwives.

This is largely a good thing – more mothers and babies survive the traumatic vagaries of child birth than ever before and people live longer healthier lives than ever before.

There is one rather stark asymmetry though – whilst death and tragedy in child birth is now a very rare event indeed – death at the end of life is still ultimately inevitable. As a society, even though we know we have to die eventually, we still haven’t worked out how we should die. This means that the majority of people end up dying in hospital (over 50% of people – thanks to Shaun Lintern and Craig Stenhouse for correcting this for me!) with doctors and nurses trying to stop them from doing so even when death is inevitable.

This is not a good thing because dying with someone trying to stop you with all the technological weapons of modern medicine (however well meaning) is not a good way to die.

The alternatives – provided by the heroes of the hospice movement – remains a cinderella service, patchily provided, reliant on charity and sparsley funded by public money.

Avoiding the Unexpected

So, people die in hospital – in our two hospitals that is about 1600 people a year (about 1 in every 75 admissions or put another way 4 or 5 admissions every day don’t make it home alive).

When these deaths are studied they can broadly be categorised into three groups according to whether they are expected or unexpected deaths and avoidable or unavoidable deaths.

Category 1Unavoidable expected deaths. This is overwhelmingly the largest category of deaths in hospital. People reaching the end of their natural lives, where their frail bodily systems have reached a point where they provide no defence against otherwise modest insults such as a fall, a urinary tract infection or the flu. Dying in hospital, as I alluded to above, has become the natural order of things in modern Britain (and many other developed health care systems in the world). Also included in this category are the deaths that we would recognise as ‘palliative care’ where even 21st century medicine genuinely has no response – terminal cancer or devastating neurological disease.

Category 2Unavoidable unexpected deaths. These are the genuine tragedies that punctuate life in a hospital. The relatively rare, but affecting cases that litter the landscape of a professional career. These are the maternal deaths from catastrophic amniotic fluid embolus, the brain haemorrhage from an unsuspected cerebral vascular anomaly, the tragically successful suicide or the disastrous major trauma from a road traffic accident (sadly I could go on). These deaths are often met with heroic efforts on the part of hospital staff to prevent them and are followed by dismay and soul searching when unsuccessful. When deconstructed at a later date there is often some learning (we can always do better) but just as often there is little to be learnt – bad things just happen.

Category 3Avoidable unexpected deaths. These are the ones where we got it wrong. Where lapses, incompetence, inexperience, neglect and system failure succeed in lining up in a single case to either actually cause death or prevent avoidable death. These are the cases that stay with you (believe me). This is the missed diagnosis because of a failure to follow up a test result, the failure to act on the deteriorating patient, the unacceptable delay in life saving intervention or the failure to take responsibility for a situation. They are thankfully rare (and overwhelmingly the smallest category of death) – not because the lapses and system failures are rare – they are not – but because (other than in exceptional circumstances) it takes several in a row to have such a devastating outcome, the good old Swiss cheese effect.

I suppose in theory there is a fourth category of avoidable expected death – that feels like a contradiction to me and I can’t conceive what it might be.

The ‘management’ task here is to attempt to assign every death to one of the three categories. That is not a trivial task – and it is not one for which you can take a statistical short cut, however compelling a notion that might be. Not least because in every category there will be deaths where on review there is identified a lapse of care – yet how many lapses does it take to move a death from either of the first two categories to the third?

Lies, Damn Lies and Mortality Statistics

Regular readers of my blog will know that I have been here before in my earlier post: Thinking about Mortality – Fast and Slow. I am not going to rehearse the arguments of the weaknesses of case mix adjusted, risk modified mortality statistics. Suffice to say that the reported ‘dramatic improvement’ in HSMR of the 11 Keogh Review hospitals will have had as much to do with scrutiny of their coding practices as the quality of care they provide.

Professor Nick Black through the PRISM (and soon to be published PRISM 2) study has shown little correlation between quality of care and HSMR (or SHMI or RAMI or any other way of measuring institutional mortality rates). I am trying not to be cynical about these – because they are in fact very useful tools, and cannot be ignored. However one has to be very careful in interpreting them because they tell you as much about what type of hospital you are and what type of patients you treat as they do about the quality of care you provide.

I can tell you without looking that:

Small provincial district general hospitals with proportionately large elderly care, stroke and fractured neck of femur services will have high mortality ratios (however well risk adjusted).

Large urban inner city general hospitals with relatively young transient populations will have low mortality ratios.

Tertiary Centres that carry out high risk care on relatively young patients (like liver transplants or major cancer surgery) will have high mortality ratios.

A Recipe for Managing Mortality

So where does this leave us? We can’t trust the stats and identifying the deaths where we got it wrong, sufficiently to have at least been a causative factor in the death, requires painstaking review of very large numbers of deaths and the judgement of Solomon.

Here are my tips:

1) Don’t ignore the stats – have a committee that looks at your death rates in all specialties and diagnostic groups – identifies the variances, the outliers and the alerts and investigates them even if CQC or Dr Foster don’t notice. You will learn a huge amount about how care is delivered in your hospital and how patients are moved about within it. You will also learn quite a lot about coding.

2) Have a system in place that reviews every death in the hospital. Some have chosen the Medical Examiner solution to this – paying a recently retired doctor to review the notes of every death and extract learning and identify those where more scrutiny is required. We have gone down a variant of the trigger tool methodology – every case is assessed against a set of criteria by a consultant not involved in the care of that patient, if enough triggers are present in one case it gets a table top review.

3) Have a method of sharing the learning – particularly with the consultants doing the screening (in our case that’s all of them), it is laborious work and it has to feel worthwhile. We are not so good at this yet – we have a news letter that goes out, we could and should do more.

4) Don’t trust Dr Foster – they are a commercial organisation that profits from scare stories. Don’t ignore them either.

5) You will find that 70% of patients that fall into category 3 are due to sepsis – invest in physiological track and trigger, sepsis screening tools and implement the sepsis 6 bundle and critical care outreach. Your avoidable mortality will fall.

6) You will also find that acute hospitals provide dreadful care to the majority of patients for whom death is unavoidable and expected (Category 1). The fortunate minority that find themselves under the care of palliative care doctors will get excellent care, the majority that don’t, won’t. Invest in end of life services – this has to be the greatest single priority for the NHS. We are about to publish our ‘Last Year of Life Audit’ – an investigation into the care provided in that critical period of a persons life. It will show that we admit to hospital on average three times in the last six months and start ‘supportive care’ on average 24 hours prior to death.

7) Finally – keep the politicians out, they don’t get it and never will and will do a great deal of harm meddling with stuff they don’t understand. You wouldn’t let them meddle with airport safety would you? why would you let them meddle with hospital mortality…?

We set a new precedent yesterday in one of our A&E’s. Over 400 patients attended and we admitted over 60 patients in one 24 hour period. This is unheard of – a normal ‘take’ in one of our hospitals is 25 – 30 patients from 200 attendances – yet for the last few weeks we have been routinely admitting in excess of 100 patients a day across our two hospitals.

We set another precedent this week as well – we discharged over 200 patients in two days. That is an astonishing number. Of those 200 discharges how many might you think were discharged to the care of social services? The answer is zero – because those two days were over the weekend shortly after the New Year bank holiday. In the same period the number of ‘delayed transfers of care’ has risen to 70 and the number of ‘medically fit for discharge’ (patients no longer requiring medical care but not safe to go home for other reasons) is another 20 or so on top of that. That’s three (unfunded) wards full.

We are under intense pressure – our staff are performing a herculean task – admitting and caring for the sick – shepherding them through the system – and organising safe and efficient discharge – and keeping the floor in A&E safe – just about. That task involves over 60 different professionals for one patient from the triage nurse at the front door through to the community therapies staff that in-reach into the hospital to pull through patients into our intermediate care facilities via the typically three or four different medical teams that might care for one patient during a hospital stay (A&E team, Acute Medical Team, Medical specialty team, MFFD team) – Not forgetting the critical care team that receive the 5% sickest patients on the way.

Yet we are coping. Whilst we have hit ‘Level 4’ at one or other of our hospitals on a few occasions over this period of ‘crisis’ we have never considered ‘closing our doors’ as some others have. And I am convinced I know why.

Synchronous Coordinated Action

Our hospitals march to the drum beat of the two hourly bed meetings. These are brief (less than 15 minutes), always at the same time (8,10,12,14,16,18,20:00 hrs), teleconferences, involving representatives of every part of the pathway from the front of the hospital to beyond the back door, consistent – run to a script, informative – everyone knows what they need to know and leaves knowing what they have to do (discharge 6 patients, 2 before lunch!). A nurse in charge of a community ward will know what the wait times are in A&E. All the time actions are followed up by the operations centre staff – our ‘air traffic control’.

Control of our Outflow

Just over two years ago our Trust took the strategic decision to – ‘move down the value chain’ – we run community services for over half our population and have developed intermediate care facilities in community locations around our catchment area. We are ‘in control’ i.e. have direct access to nearly 100 community beds – including ‘medically fit for discharge wards’ closely co-located but separate from the hospitals and run by GPs.

This has saved our bacon this winter. Its not been plain sailing – it has taken several weeks to get the ‘drum beat’ working consistently and reliably and there have been times when the acuity of admissions have been such that discharges haven’t happened for the ‘right’ reasons and this has threatened to overwhelm us. We have panned the 4 hour target like everyone else – but we’ve done alright for our patients. I am intensely proud of how well our Medical, Nursing, Therapies, Operations and Community staff have pulled together to pull it off.

Its not an A&E Crisis

A&E waits are a symptom of a failing health and social care system. A&E is the only point of care that is consistently available 24 hours a day. Everyone knows where it is, that its always open, that there will always be a doctor there and that you will get free treatment if you need it. People vote with their feet – other parts of the system are either not trusted or simply not available when needed.

The ‘A&E crisis’ is a consequence of un-restrained inflow and significantly constrained outflow. Neither the ‘inflow’ nor the ‘outflow’ is incentivised or held to account for the demands it places on the hospital. It is being in control of at least some of our outflow that helped us weather this particular storm. And therein lies the solution to the problem – if we want hospitals to ‘succeed’ then they must be in control of the resources of ‘outflow’ services and probably ‘inflow’ services as well.

At the moment the philosophy (if organised thinking is a suitable way to describe it) behind the Better Care Fund (The pooling of health and social care resources) is moving in diametrically the wrong direction on this. BCF is moving resources out of health into social care – on the face of it in order to prevent admission to and promote discharge from expensive hospital care. It will not work – however well meaning – it just won’t. Whilst depleted resource in social care is an issue (and a worsening one) fundamentally the issue is one of accountability and control. As long as the services that provide care before and after hospital experience no cost or consequence for sending a patient to or keeping a patient in hospital then they will continue to behave as they always have done. And as these services gradually fail medical takes in hospital of 60 or more will become the norm not the exception.

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.

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.

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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”.

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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.

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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?

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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:

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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.

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?

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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.

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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.

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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.

It is interesting to reflect – now that the PFI bonanza has come to an end and we all have to hunker down and work out how to pay for it for the next 30 years – on what we have spent all the money on and consider whether what we have thrown up around the land is actually what we need.

This paper by the think tank Reform The Hospital is Dead Long Live The Hospital is an eloquent exposition of Clayton Christensen’s ‘Innovator’s Prescription’ within an NHS context. The essential conclusion of both of these is that Hospitals need to move from being ‘A place where sick people go’ to becoming ‘An organisation that keeps people well’. This re-framing of purpose prompts the question – what does a hospital that keeps people well look like? I suspect it is not a large building with lots of beds in it (or clinic rooms for that matter).

Interestingly the specialty of Intensive Care Medicine underwent a similar re-framing of purpose over ten years ago as a result of the comprehensive critical care program in response to a lack of intensive care beds. The outcome of this process was the introduction of critical care outreach teams (or medical emergency response teams) linked to a system of population surveillance (MEWS track and trigger) and an expansion of lower acuity beds (high dependency). There were almost no additional intensive care beds commissioned or provided. The result has been intensive care units have been able absorb ten years of demand growth, almost eliminate the need for inter hospital transfer for capacity reasons, reduce futile care, contain costs and improve outcome.

How do we replicate this operating model at the scale of the hospital within a health economy (as opposed to an intensive care unit in a hospital)? The essential elements are:
1) Knowing the population you are caring for – a disease registry
2) Knowing how they are – a simple method of measuring disease status
3) A response team that averts crisis when a trigger threshold is reached – a specialist community team
4) An escalation pathway that includes rapid access to specialist input – specialty hubs
5) Lower acuity beds for step up or step down care – intermediate care beds
6) Alternate pathways for those that acute care is inappropriate – end of life services
7) Acute beds for those that genuinely need it – closely linked to an intensive care unit!

This distributed model of care does still need buildings – but what it needs more is intelligent information and communication systems used by a workforce that understands the need to keep patients other than those in genuine need away from hospital. It also needs an operating system that measures its impact, analyses unexpected pathway deviance and learns from system failure.

Eliminating the huge waste in the system of inappropriate and futile hospital care (both inpatient and outpatient) will not only deliver cost savings it will improve quality of care and outcomes and create the capacity we need for the growth in demand we know is coming.

The hospital is no longer a building it is a healthcare delivery system. We should be investing in the infrastructure that makes it possible – And that is not bricks and mortar…