Great innovations of the first and second healthcare revolution

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Great innovations of the first and second
healthcare revolution
The First
The Second
Broad Street - John Snow

• MRI and CT scanning
• Statins
• Antibiotics
• Coronary artery bypass graft surgery
• Hip and knee replacement
• Chemotherapy
• Radiotherapy
• Randomised controlled trials
• Systematic reviews

Gower Street - Doll Hill
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- At the beginning of the 21st Century 5,
problems of health and healthcare remain

• SAFETY -Errors and mistakes
• QUALITY - sub standard clinical practice and poor
  patient experience
• FAILURE TO MAXIMISE VALUE
• Waste
• Overenthusiastic adoption of interventions of low
  value and failure to get new evidence into
  practice
• INEQUALITIES
• FAILURE TO PREVENT DISEASE

These need a third revolution, and one is already
underway driven not by scientists and managers
and clinicians but by
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Citizens
Information Knowledge
Technology
The Drivers of the Third Industrial Revolution
(Manuel Castells)
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At the beginning of the 21st Century new
healthchallenges emergeObesityHIVPopulation
Agingrising expectationsClimate change
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Need Demand
Amount
Resources
Time
The 4 problems from the 20th Century the new
problems of the 21st C create a crisis This
crisis needs urgent action and courageous
leadership and a third revolution fortunately
the 3rd Healthcare revolution has already started
but it is not driven by experts
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UNDERSTANDING THE MEANINGS OF VALUE
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The 2 meanings of value

• A value is a statement of principle shared by all
  who work in a health service eg This service
  values the right of patients to decide what
  treatment they want
• Value is a measure used to appraise the balance
  of benefits and harms resulting from the
  investment of resources eg The use of aspirin to
  reduce the risk of a second heart attack is a
  high value intervention

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Value
Waste
Value
Waste
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• The aim of
• Commissioning is to decrease the proportion
  of the budget spent on low value activities
  either
• Low value interventions or
• Patients unlikely to benefit from high value
  interventions
• High value interventions performed at low quality
  or high cost

PCT Budget
Low Value
High Value
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PCT Budget
Exceptional cases
Unplanned Creep of low value
High Value Interventions of high value offered
to patients most likely to benefit, at acceptable
levels of quality
High Value Interventions of high value offered
to patients most likely to benefit, at acceptable
levels of quality
PCT Budget Planned
Actual

(may be planned)
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PCT Budget
THE SECOND ANNUAL POPULATION VALUE REVIEW
Mental health
Breast Stomach
Cancer
CVD
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3 types of generalisable knowledge
Knowledge from research - Evidence Knowledge
from measurement of healthcare performance-Statist
ics Knowledge from experience-Of patients and
clinicians
2 types of particular knowledge
Knowledge about this patient Knowledge about
this service
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The values of the population served
Choice Decision
Evidence
The other needs of the population (opportunity
costs revealed by needs analysis)
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What is the best structure for financing and
organising healthcare for the 21st C ?
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• A business organisation should have a
  nonhierarchical, self-organizing structure
  working in tandem with its hierarchical formal
  structure..As business organisations grow in
  scale and complexity they should simultaneously
  maximise both corporate level efficiency and
  local flexibilitythe most appropriate name is
  the hypertext organisation
• Ikujiro Nonaka and Hirotaka Takeuchi
• The knowledge creating company
• OUP 1995

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Shared objectives
Hypertext organisation
Bureaucratic Organisation (Nonaka Takeuchi OUP
1995 The Knowledge Creating Company
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We need networks, not hub and spoke all
organisations are of equal importance
Networked Information Economy Yochai Benkler
(2006) The Wealth of Networks Yale Univ Press
Hub and Spoke
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The Oxford Healthcare System
Objectives Criteria Standards
Performance
Minimal Achievable Excellent in Annual
Report
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The Oxford Healthcare System

• A healthcare system is a set of activities with a
  common set of objectives an example of a set of
  objectives, for a rheumatoid arthritis healthcare
  system is set out below
• To diagnose rheumatoid arthritis quickly and
  accurately
• To show the process of the disease is effective
  and safe treatment
• To help the individual afflicted adopt to the
  challenges
• To control symptoms over the effects of
  disabilities
• To involve patients, both individually and
  collectively, in their care
• To make the best use of resources
• To promote and support research
• To support the development of staff
• To report annually to the population served

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This is an example of a national service set
up as a system
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http//www.communities.idea.gov.uk
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• www.theclimateconnection.org

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If you were to ask all the clinicians Derbyshire
who manage services to write down the difference
between the meanings of efficiency and
productivity what would they write?
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21st C leadership

• Rely on citizens - The Revolutionaries
• Manage knowledge as though it were money Develop
  systems, not institutions
• Develop the culture

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WWW.NHS.UK
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20th Century knowledge flow
informs
Is given
Patient
Clinician
Knowledge
21st Century knowledge flow
discusses
Is given
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most patients were not given clear information
about the survival gain of palliative
chemotherapy in most (26/37) consultations
discussion of survival benefit was vague or
non-existent

• Audrey S et al (2008)
• What oncologists tell patients about survival
  benefit of palliative chemotherapy and
  implications for informed consent
• BMJ 2008 337a752

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21st C leadership

• Rely on citizens - The Revolutionaries Manage
  knowledge as though it were money
• Develop systems, not institutions
• Develop the culture

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Knowledge is the enemy of disease - the
application of what we know will have a bigger
impact than any drug or technology likely to be
introduced in the next decade
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Generalisable Knowledge
Explicit Tacit
From research Evidence
From data Information or statistics
From experience
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Generalisable Knowledge
Explicit Tacit
From research Evidence
From data Information or statistics
From experience
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evidence from recent trials, no matter how
impressive, should be interpreted with
cautionclaims for made in 45 highly cited
reports were subsequently contradicted (n7) or
weakened (n7) for 14 of the interventions

• Ionnidis JPA (2005)
• Contradicted and initially stronger effects in
  highly cited clinical research
• JAMA 294 218-228

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Research Reports

• NICE
• Guidance

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Someone on the Board of every healthcare
organisation,someone directly responsible to the
Chief Executive, will be given the responsibility
of acting as Chief Knowledge Officer
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Who is responsible for 1. What a new GP in
Hinckley knows about indications for referral
when there is a hoarseness?2. What a citizen in
Beeston knows about PSA screening?3. What a Year
1 SpR in geriatrics in Chesterfield knows about
fracture neck of femur?4. What a teacher of
children in Lincoln with learning disability
knows about epilepsy?
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Citizen involvement 1

• How do we get citizens engaged in resource
  allocation?
• Patients with knowledge v citizens without
• Dunno!
• NEDs, OSCs, where are the people on the streets?
  Neighbourhood fora a start
• Individual budget holders users as Cer
• NOT one size fits all tailor to each type of
  citizen

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Citizen involvement 2

• Evaluate what you do
• Engagement, empowerment, involvement
• How to get the right people involved?
• Use local media, use websites
• How do you make people want to get involved and
  want knowledge?
• Best v most popular

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Citizen involvement 3

• Celebs
• Hard to scratch surface with tiny resource each
  has
• Hard to get engagement in disinvestment

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www.phlab.org
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The unintended consequences of CPOE are
widespread and important
Ash JS et al (2007) The extent and importance of
unintended consequences of computerised physician
order entry JAMIA 14 415-423
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The campaign for greener healthcare
www.knowledgeintoaction.org
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The law of diminishing returns
Benefits
Investment of resources
BVHP The Better Value Healthcare Programme
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Harmful effects increase in direct proportion to
the resources invested
Harmful or Side effects Of care
Investment of resources
BVHP The Better Value Healthcare Programme
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After a certain level of investment the health
gain -the difference between benefit and harm-
may start to decline
Benefits
Benefits - harm
Harms
Investment of resources
BVHP The Better Value Healthcare Programme
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After a certain level of investment the health
gain may start to decline
Optimality
Benefits - harm

Value decreasing
Investment of resources
BVHP The Better Value Healthcare Programme
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The law of diminishing returns
Benefits
Investment to improve quality or safety
BVHP The Better Value Healthcare Programme
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• The aim of leadership for better value
• is to decrease the proportion of the
  budget spent on low value activities either
• Low value interventions or
• Patients unlikely to benefit from high value
  interventions
• High value interventions performed at low quality
  or high cost

Budget
Low Value
High Value
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Programme Budgets
Mental health
Cancer
CVD
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The management of chronic serious health problems
such as epilepsy or breast cancer is too
complicated for any bureaucratic solution
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• A business organisation should have a
  nonhierarchical, self-organizing structure
  working in tandem with its hierarchical formal
  structure.the most appropriate name is the
  hypertext organisation
• Ikujiro Nonaka and Hirotaka Takeuchi
• The knowledge creating company
• OUP 1995

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1y
1y
1y
2y
2y
1y
1y
Primary Secondary (hospitals) Tertiary
Tertiary
2y
2y
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The Oxford Healthcare System

• A healthcare system is a set of activities with a
  common set of objectives an example of a set of
  objectives, for a lung cancer healthcare system
  is set out below
• To prevent lung cancer
• To diagnose lung cancer quickly and accurately
• To provide effective and safe treatment
• To help the individual afflicted adapt to the
  challenges
• To control symptoms and the effects of
  disabilities
• To involve patients, both individually and
  collectively, in their care
• To make the best use of resources
• To promote and support research
• To support the development of staff
• To report annually to the population served

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The Oxford Healthcare System
Objectives Criteria Standards
Performance
Minimal Achievable Excellent in Annual
Report
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Primary Secondary (hospitals) Tertiary
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Breast Lung Colon Stomach Asthma
Epilepsy Ca Ca Ca Ca

Prevention Screening Primary Secondary (hospita
ls) Tertiary
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With systems in place it is possible to improve
quality and safety
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21st C leadership

• Develop systems, not institutions
• Rely on citizens - patients and the public Manage
  knowledge
• Develop the culture

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www.nhs.uk
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21st C leadership

• Develop systems, not institutions
• Rely on citizens - patients and the public Manage
  knowledge
• Develop the culture

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21st C leadership

• Develop systems, not institutions
• Rely on citizens - patients and the public Manage
  knowledge
• Develop the culture
• Make carbon your third currency

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Questions for leaders

• What is the difference between leadership and
  management ?
• What proportion of the ten most common and
  expensive conditions have explicit systems ?
• What were the principal concerns and complaints
  of the last 100 patients who had elective surgery
  ?
• What proportion of new drugs and diagnostic tests
  procured for the first time in the last year had
  systematic review evidence that they provided
  good value for money?
• When was the last time that there was a
  discussion with staff to ascertain how the
  actual culture related to the mission statement?
• What is the carbon footprint of your service and
  who is responsible for reducing it by 15 by 2015
• Can you describe your service in 2018 ?