Nigel Edwards presents some initial thinking and findings from a consultation on redesigning care in the NHS.

1. © Nuffield Trust17 March 2016
Redesigning care
Nigel Edwards
Chief Executive, The Nuffield Trust
Honorary Visiting Professor
London School of Hygiene & Tropical Medicine

2. © Nuffield Trust
Starting point
Every system is perfectly designed to achieve the results it gets
So to change the results it is necessary to change the design
rules that under pin it
Some of our current design rules are not very good…..

3. © Nuffield Trust
Odd design rules
• Organise around
• Medical disciplines not patient problems
• Individual events not patient journeys
• The sickest patients see the most junior doctor
• Store patients until you are ready to see them

4. © Nuffield Trust
Outpatients in the 1920s

5. © Nuffield Trust
New design principles
Some that already apply:
• Standardise where possible
• Centralise where necessary, decentralise where possible
• Safety as a system property

6. © Nuffield Trust
New design principles: Purposeful design
Purposefully focus on the design and improvement of the system:
• Remove unnecessary complexity
• Focus on continuous improvement and develop skills and
leadership to support this
• Apply improvement science approaches to system design

7. © Nuffield Trust
Population health management
Understand the population’s health needs and match services to
patient/user characteristics based on need and risk. :
• Registries
• Shared assessment processes
• Proactive care to anticipate need
• New ways to target and work with different populations (e.g.
different models for highly mobile populations or ethnic groups
with different expectations of how to use services)

8. © Nuffield Trust
Match need to services
Develop the capability to deal with the complexity of patient needs
and match these to services:
• Multidisciplinary teams including social care and mental health
• Capture the benefits of generalists and specialists
• Providing specialist advice more widely across the system – for
example by the use of technology
• Reduce care coordination challenges and hand-offs by multi-
skilling professionals and care workers

9. © Nuffield Trust
Flow
Focus on flow
• Align the approaches of different parts of the system and the pace at
which they work
• Match capacity to demand
• Separating different types of process flow from each other.
• Focus on the interfaces, the transmission of information and
standardisation of processes, equipment, communication, etc.
• Availability of senior decision maker at the front end of the process
with access to alternative service choices
• Plan for every patient – make & execute decisions

10. © Nuffield Trust
Hospitals: Specialisation and generalism
Treat the whole patient
Escalate quickly where necessary
Rebalance specialism and generalism

11. © Nuffield Trust
Networks
Networks as a key organising principle
• Staff working across organisational and sector boundaries
• Shared approaches to patient management
• Tiered services based on need and risk and easy transfer
between parts of the network
• Focus on knowledge sharing and QI across the network
• Clear accountability for outcomes
• Focus on relationships more than structures
• Back up with technology

12. © Nuffield Trust
Measure outcomes that matter
This requires:
Different methods of data capture
Goal based care
Shared decision making
Patient activation

13. © Nuffield Trust
Shared decision making
1
3

14. © Nuffield Trust
Fully deploy digital technology
1. More systematic, high quality care
2. More proactive and targeted care
3. Better coordinated care
4. Improved access to specialist
5. Engaged patients
6. Improved resource management
7. System improvement and learning

15. © Nuffield Trust
Changing the nature of interactions

16. © Nuffield Trust
Design systems where staff can flourish
Control and mastery
Manageable workload
Human scale organisations
Functioning teams
Feedback on performance
Tools to improve services

17. © Nuffield Trust
Staff: skills and work
Break down barriers between physical and mental health
Multiskill to reduce hand-offs
Create systems that allow staff to work at the top of their licence
(without burning them out)

18. © Nuffield Trust
Plan for environmental sustainability
Carbon
Water
Communities

19. © Nuffield Trust
Communities
Work with the resources of the wider community
• Help the wider community to build its strength, inclusivity and
resilience
• Community development approaches
• Don’t try and control it
• Don’t use it to do things statutory services should be doing
Be honest about what we can actually deliver

20. © Nuffield Trust
Technical
• Problem is well defined
• Solution is known can be
found
• Implementation is clear
Adaptive
• Challenge is complex
• To solve requires transforming
long-standing habits and deeply
held assumptions and values
• Involves feelings of loss,
sacrifice, anxiety, betrayal to
values
• Solution requires learning and a
new way of thinking, new
relationships
• Triggers avoidance of
uncomfortable issues
What sort of change

21. © Nuffield Trust
Three implications
A capability gap
Having the right change model
Creating a the time and space to develop and apply these