Challenges in healthcare: solutions from improvement science?

Dr Jennifer Dixon

Chief Executive

The Health Foundation

2

Challenges seeking solutions

3

Funding (NHS in England)

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Funding (NHS in England)

Period Years Average annual real growth in NHS spending:

Entire NHS history 1949−50 to 2010−11 +4.0%

Last Labour government

1996−97 to 2009−10 +6.4%

Last Conservative government

1978−79 to 1996−97 +3.3%

Previous governments 1949−50 to 1978−79 +3.5%

Tightest 4 year period 1950–51 to 1954–55 –2.4%

Tightest 4 year period in last 50 years

1975−76 to 1979−80 +1.3%

Reform (NHS in England)

Health and Social Care Act 2012

‘So large you can see it on Google Earth’....(CEO NHS (England))

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Demand

– Rising burden of ill health (demography < long term conditions, dying)

– Consumer expectations (eg shared decision-making, access to specific treatments)

– Population expectations (eg fairness in access, at least minimum standards)

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Value

– More than minimum standards

– Internationally comparable outcomes

– Preventive care, person centred

– Population health, building community assets

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Value

9

Supply side ‘rigidities’– Growth of hospital care (technology/expectations,

degree of specialism, political power of hospitals/professionals)

– Poor integration with primary care, community services, and social care

– Lower interest in complex and behavioural over simple and scientific

– Professional autonomy/low scrutiny

– Workforce contracts

– Payment mechanisms

– Public health...

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– Challenges seeking solutions– Responses

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P

Policy ecosystem

Provider/care system

P P

P

P

P

Communities

.. and individuals...

Improvement efforts

12

Policy ecosystem• Incremental change (but ‘punctuated equilibrium’ (Tuohy))• Historical focus on demand side solutions > tackle provider interests• Devolution to regions or other subnational units and frustration with national

control• Payment reform• Control of input prices (pharma)• Market mechanisms: competition and choice• Regulation • Central directives/command• Information policy• Managed care (LTC): risk based accountable care organisations• NICE-like replicas• Defined benefit package• Co-payments/insurance• Social care

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Communities

Local government

Community groups

Voluntary sector

Local business

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Provider care system

Collaborations and networks

- hospital

- primary care

Competition (some)

GP practic

esCommunit

y servic

esSocial care

Other provid

ers

Hospital

Collaborations and networks

Payers

Capitation-based £Risk adjustedRisk and outcome based

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Lead provider contracting, alliance contracting

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Provider care systemCollaborations and networks are developing

Quality improvement capacity limited

Quality improvement interventions

- Differing (and developing) interventions

- Differing improvement tools

- Differing implementation intensity

- Differing context

- Differing evaluation methods

- Evidence base...(ROI)

Spread and scalability is a challenge

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What does the research tell us?

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Reduction in effectiveness from applying the same fixed-intervention in different contexts

Innovation sample

Evaluation sample

Immediate wide-scale implementation

Parry GJ, Carson-Stevens A, Luff DF, McPherson ME, Goldmann DA. Recommendations for Evaluation of Health Care Improvement Initiatives. Academic Pediatrics. 2013.

Effectiveness may be maintained if we can learn in

what contexts the intervention can be amended to work

Learn which contexts it can be amended to work in as we move from Innovation to Prototype to Test and Spread

Innovation sample

Parry GJ, Carson-Stevens A, Luff DF, McPherson ME, Goldmann DA. Recommendations for Evaluation of Health Care Improvement Initiatives. Academic Pediatrics. 2013

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– Challenges seeking solutions– Responses– Evidence and evaluation

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Hierarchy of evidence

Source: Davies A and Newman S (2011). Evaluating telecare and telehealth interventions. WSDAN briefing paper. Available from: http://www.wsdactionnetwork.org.uk

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Evaluation of service change

Arrived

Adapting

Early

InterventionMethods

Case study

Formative

Summative

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Evaluation of service change

Method

Case study

(Early)

Formative study

(Adapting)

Summative study

Example intervention

Clinical team piloting a change to service delivery: a one stop clinic in urology outpatients

Six organisations developing and implementing a model for self management support in chronic care

Comparative study of 20 obstetric departments that implement a programme for team-based patient safety training compared with 20 departments not doing the training

Complex interventions

Evaluability tests

Early Adapting Arrived

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Evaluability assessmentAlso known as ‘exploratory evaluation’

Needs to be used more:

- provides rapid feedback about how the intervention is working

- helps to develop realistic objectives for the project/programme

- examines the feasibility of implementation and adaptability

- informs the design of a full evaluation to gain useful information

Our best shot?

Improvement

support

Implementation

Formative evaluation

Real timeAllowing course correction

Techniques eg PDSALogic modelsStatistical process control

With internal evaluation

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– Challenges seeking solutions– Responses– Evidence and evaluation– Future research directions

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Future research directions

• Informatics to support improved quality of care

• Health economics at system level to clinical team level

• Big data to direct the focus for new systems of care

• Evolution of evaluation techniques

Outpatients DayCase Elective AENonelective

Time (weeks)

Big data and linkage (NHS)

Area level Person level

Big data and linkage (NHS and social care)

Big data and risk stratification

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P

Policy ecosystem

P

P

P

P

P

.. and individuals...

Improvement science

Improvement science research can show which are the most promising solutions

Research could also demonstrate if they are cost effective

Improvement science is about understanding how solutions work, in what context and how to adapt for new settings

Provider

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The role of evidence

Opinion / ideology

Reasoned argument and experience

/ public

Evidence

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Health policy

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