The document discusses several issues facing healthcare systems and proposes a new paradigm is needed. It outlines problems with the current system including harm from overuse, inequity from underuse, waste, and failure to prevent disease. Additional future challenges mentioned are rising expectations, increasing need, financial constraints, and climate change. The document argues that more of the same approach is not the solution and that a new system needs to be designed instead of just improving the current one. It emphasizes the importance of population health, systems of care, culture change, and personalized medicine.
1. The last forty years in
healthcare have been terrific
Sir Muir Gray
Keynote presentation at NIHR CLAHRC East Midlands launch event,
14 February 2014, Loughborough
2. Progress in the last 40 years has been amazing but
all health services, everywhere, still face 5 major
problems one of which is unwarranted variation
which reveals the other four
•
•
•
•
HARM, from overuse even when quality is high
INEQUITY, from underuse by groups in high need
WASTE OF RESOURCES through low value activity
FAILURE TO PREVENT DISEASE &DISABILITY
And new, additional, challenges are developing
•
•
•
•
RISING EXPECTATIONS
INCREASING NEED
FINANCIAL CONSTRAINTS
CLIMATE CHANGE
Variation in utilization of health
care services that cannot be
explained by variation in patient
illness or patient preferences.
Jack Wennberg
3.
4. More of the same is not the answer ,
not even better quality, safer, greener
cheaper of the same.
We need to design, plan and build a
new paradigm.
5.
6.
7. Allocative value
Between Programme
Marginal Analysis and
reallocation is a Board
responsibility with public
involvement ; the aim is
optimal allocation ie you
cannot get more value
by shifting a single £
Cancer
Respiratory
Gastrointestinal
8. Between Programme
Marginal Analysis and
reallocation is a
Mental
Health
commissioner
responsibility with public
involvement
Cancer
Respiratory
Gastrointestinal
9. Many people
have more than
one problem ;
GP’s are skilled in
managing
complexity
Mental
Health
Cancers
Respiratory
Gastrointestinal
10.
11. Within Programme,
Between System
Marginal analysis is
a clinician
responsibility
Cancers
Respiratory
Gastroinstestinal
Asthma
COPD
(Chronic
Obstructive Apnoea
Pulmonary
Disease)
14. Within System
Marginal Analysis is a
clinical stewardship
responsibility with
patient involvement
Cancers
Asthma
COPD
(Chronic
Obstructive Apnoea
Pulmonary
Disease)
Respiratory
Gastroinstestinal
Triple Drug
Smoking
Therapy
cessation
O2
Rehabilitation
15. The law of diminishing returns
Benefits
Investment of resources
16. Harmful effects increase in direct proportion
to the resources invested
Harmful or
Side effects
Of care
Investment of resources
17. After a certain level of investment the health
gain may start to decline;
the point of optimality
Benefits
Benefits - harm
Harms
Investment of resources
18. The values this patient
places on benefits &
harms of the options
and on risk taking
Evidence,
Derived from
the study of
groups of
patients
Choice
The clinical condition of this
patient; other diagnoses, risk
factors and their genetic profile and
in particular their problem, what
bothers them psychologically and
socially
Personalised and Stratified Medicine
Decision
19. As the rate of intervention in the population
increases, the balance of benefit and harm
also changes for the individual patient
BENEFIT
HARM
Necessary
High value
appropriate
inappropriate
Low value
futile
Negative Value
20. NHS or nHS?
• Is epilepsy care in Leicestershire better than epilepsy care in
Derbyshire?
• Who is responsible for the service for people with bipolar
disorder in Lincolnshire?
• Did the service for people who are breathless in Rutland
improve last year?
• Is the service for frail elderly people getting better in
Nottinghamshire, is it better than in Northants, and who is
responsible for it?
• How many asthma services should there be in the East
Midlands and is that different from the number of services for
inflammatory bowel disease or rheumatoid arthritis ?
BetterValueHealthcare
23. Population healthcare focuses primarily on
populations defined by a common need
which may be a symptom such as
breathlessness, a condition such as
arthritis or a common characteristic such
as frailty in old age, not on institutions , or
specialties or technologies. Its aim is to
maximise value for those populations and
the individuals within them
24. Ban old language
PrimarySecondaryAcuteCommunityManagerOutpatientHubandSpoke
Introduce new language
A SYSTEM is a set of activities with a common set of objectives and outcomes; and an annual report.
Systems can focus on symptoms, conditions or subgroups of the population
(delivered as a service the configuration of which may vary from one population to another )
A NETWORK is a set of individuals and organisations that deliver the system’s objectives
(a team is a set of individuals or departments within one organisation)
A PATHWAY is the route patients usually follow through the network
A PROGRAMME is a set of systems with ha common knowledge base and a common budget
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25. From archipelago to system
People receive care that is co-ordinated around their needs
and supports them to live the lives they want to lead
Super
Specialist
Community
services
General practice
Specialist
Generalist
Hospital care
Mental healthcare
Social care
Informal care from family
and voluntary help
Self-care
26. This is an example of a national service set up as a system
29. Dr Jones is a respiratory physician in the Derby
Hospital Trust and last year she saw 346 people
with COPD and provided
evidence based, patient centred care, and to
improve effectiveness, productivity and safety
30. Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and
a population based audit showed that there were 100 people who were not
referred who would benefit from the knowledge of her team
31. Dr Jones is given 1 day a week for Population Respiratory Health
and the co-ordinator of the South Derbyshire COPD Network
and Service has responsibility, authority and resources for
Working with Public Health to reduce smoking
Network development
Quality of patient information
Professional development of generalists, and pharmacists
Production of the Annual Report of the service
She is keen to improve her
performance from being 27th out
of the 106 COPD services, and of
greater importance, 6th out of the
23 services in the prosperous
counties
32. “Culture…the shared tacit assumptions of a
group that it has learned in coping with
external threats and dealing with internal
relationships.”
Schein, E.H (1999) The Corporate Culture Survival Guide
“Leadership …and a company’s culture
are inextricably interwined.”
Morgan, J.M. and Liker, J.K. (2006) The Toyota Product Development System
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33. Two national public health projects
• The stroke and vascular dementia (SVD)
prevention project – improving health through
population and personalised care for people
with atrial fibrillation – 25th march
The Falls and Fragility Fracture (FFF) prevention
project – improving health through population
and personalised based systems for people at
risk of falls and fragility fractures -27th March
34. New Knowledge
• An understanding of all issues related to value,
including the ethical issues such as accountability for
reasonableness; and the work of Amartya Sen and
Norman Daniels
• Understanding allocative efficiency and relevant
writings, such as the workings of Thomas Rice
• Systems and network development with familiarity
with other work of people such as Manuel Castells.
• Concepts of population accountability for clinical
services including the work of Thomas Friedman.
35. New skills
•
•
•
•
•
Understanding and Increasing Value
Designing and building Systems of Care
Creating the Right Healthcare Culture
Delivering Population-based Medicine.
Designing and delivering Patient Centred and
Personalised Care
36. Map of Medicine - COPD
Work like an ant colony; Neither markets
nor bureaucracies can solve the challenges
of complexity
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Editor's Notes
Use local data from the atlases of variation http://www.rightcare.nhs.uk/index.php/atlas/atlas-of-variation-2011/
This is the link slide to the new paradigm,
You can point out that even small and straightforward health challenges , like deafness in children have four different types of commissioner involved
This is the approach to healthcare that complements the institutional approach Ask participants to work in pairs to agree what they understand by the meaning of the term population; different perspectives will be given by people working in hospitals and those responsible for commissioning or in the public health service At this stage in the workshop ask participants to turn to their neighbours and discuss for two minutes what they mean by the term population, each has to give the other an example of what they mean by the term
Here are the new terms Acute and community implies the hospital is not part of the community Primary and secondary ignores the point that A&E is for many people their primary port of call Out patients is a 19th century term Hub and spoke implies a power relations hip; in a network all the constituent elements are nodes
This is only one way of depicting a system the next pptshows another
The network is the set of individuals and organizations that delivers the system to the populations. It is useful to go through the hierarchy of the 20th century to the network of the 21st century, with the patient at the centre “professor, specialist and GP, with the patient invisible”In the 21st century all the professionals, all the nodes in the network are of equal importance with t he patient in the middle
“now we need to think of the implications for clinicians, here is how we see specialist clinical practice at present . Here is a picture of clinical practice as it is at the moment , DRJones is an example of an excellent clinician in the world as we know it at present but we want drjones to take a different perspective and the first step to think about the whole population
The old style of thinking is for dr Jones to put in a bid for more resources to expand her out patient service but Dr Jones1 THERE IS NO MORE MONEY 2 out patients is a 19th century concept . We want you to practice in a different way, even pone day a week to develop a population based service to tackle the problems such as those shown in the next ppt
Askparticipants to adapt this to a problem they know about
