Challenges in healthcare: solutions from improvement science? Dr Jennifer Dixon

Chief Executive

The Health Foundation

2

Challenges seeking solutions

Funding (NHS in England)

3

Funding (NHS in England)

4

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))

Demand

6

– 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)

Value

7

– More than minimum standards

– Internationally comparable outcomes

– Preventive care, person centred

– Population health, building community assets

Value

8

Supply side ‘rigidities’

9

– 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...

10

– Challenges seeking solutions

– Responses

11

P

Policy ecosystem

Provider/care system

P P

P

P

P

Communities

.. and individuals...

Improvement efforts

Policy ecosystem

12

• 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

Communities

13

Local government

Community groups

Voluntary sector

Local business

Provider care system

14

Collaborations and networks

- hospital

- primary care

Competition (some)

GP practices

Community services

Social care

Other providers

Hospital

Collaborations and networks

Payers

Capitation-based £

Risk adjusted

Risk and outcome

based

15

Lead provider contracting,

alliance contracting

Provider care system

16

Collaborations 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

17

What does the research tell

us?

18

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

21

– Challenges seeking solutions

– Responses

– Evidence and evaluation

Hierarchy of evidence

22 Source: Davies A and Newman S (2011). Evaluating telecare and telehealth interventions.

WSDAN briefing paper. Available from: http://www.wsdactionnetwork.org.uk

Evaluation of service change

23

Arrived

Adapting

Early

Intervention Methods

Case study

Formative

Summative

Evaluation of service change

24

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

Evaluability assessment

26

Also 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 time

Allowing course correction

Techniques eg

PDSA

Logic models

Statistical process

control

With internal evaluation

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– Challenges seeking solutions

– Responses

– Evidence and evaluation

– Future research directions

Future research directions

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• 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

Person level hospital cost profile over a year (NHS)

(50+ year old male, total annual cost > £35,000)

Outpatients DayCase ElectiveAE Nonelective

Time

(weeks)

Big data and linkage (NHS)

Census Member file

NHS use

Inpatient Cost

Outpatient Cost

A&E Cost

GP

Community

Social care use

Nursing home

Cost

Domicilary care

Cost

Area level Person level

Big data and linkage (NHS and social care)

Big data and risk stratification

34

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

The role of evidence

35

Opinion / ideology

Reasoned argument and experience

/ public

Evidence

Health policy

36

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