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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• WASTE OF RESOURCES through low value activity • INEQUITY, from underuse by groups in high need • 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

More of the same is not the answer , not even better quality, safer, greener cheaper of the

same run by more tightly regulated and inspected bureaucracies

we need to design, plan and build a new paradigm to adapt to the challenge of

complexity – “the dynamic state between chaos and order” Kieran Sweeney (2006)

The Healthcare Archipelago

GENERAL MENTAL PRACTICE HEALTH

COMMUNITY HOSPITALSERVICES SERVICES

JURISDICTIONS INSTITUTIONS

PROFESSIONS

REGULATORS AND INSPECTORS

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• Is the service for people with seizures & epilepsy better in Adelaide than the service in Melbourne?

• Who is responsible for the pelvic pain service for people in North Adelaide?• How many liver disease service s are there in South Australia and how

many should there be?• Which service for frail elderly people in Auckland provides the best value?• How many services are there for people with MusculoSkeletal Disease in

South Australia, and which gives best value?• Is the variation in outcome for heart failure in the South Australia services

increasing or decreasing?• Who is responsible for publishing the Annual Report on care for people

with Parkinson’s disease in North Adelaide?• Is the service the people in our population with atrial fibrillation

below the minimal acceptable standard of high quality, ie in the top quartile in the middle of the range (a-b)

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 and equity for those

populations and the individuals within them

Triple Value Agenda

Cancer

Respiratory

Gastro-intestinal

Between ProgrammeMarginal 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 £ from one budget to another

Allocative efficiency

Cancer

Respiratory

Gastro-intestinal

MentalHealth

Between ProgrammeMarginal Analysis and reallocation is a commissioner responsibility with public involvement

Cancers

Respiratory

Gastro-intestinal

MentalHealth

Many people have more than one problem ; GP’s are skilled in managing complexity

MedicallyUnexplainedPhysicalSymptoms

Homelesspeople

Children

Older People With fouror more diagnoses

Cancers

Respiratory

Gastro-instestinal

ObesityGastroIntestinal

Liver

Within Programme,Between SystemMarginal analysis is a clinician responsibility

Cancers

MSK

PorosisOA/Joints

RA

Respiratory

Triple Value Agenda

Technical Value (Efficiency) = Outcomes / Costs

Outcome= Benefit (EBM +Quality) – Harm (Safety )Costs (Money + time + Carbon)

Added value from doing things right (quality improvement)

Higher Value

HigherValue

High Value

Lower Value

Lower Value

THE INSTITUTIONAL APPROACH

After a certain level of investment, health gain

may start to decline Benefits

Investment of resources

Harms

Benefits - harm

Point of optimality

1. Reduce lower or negative value activities

Cancers

Respiratory

Gastro-instestinal

Apnoea

COPD (Chronic

Obstructive Pulmonary

Disease)

Asthma

Triple DrugTherapy

Rehabilitation

O2

Smoking cessation

Within SystemMarginal Analysis is a clinician responsibility with patient involvement

Cancers

MSK

PorosisOA/Joints

RA

MRI

Replacement

Arthro/washout

Respiratory

All people with the condition

People receiving the specialist service

People who would benefit most from the specialist service

3. See the right patients

Hellish Decisions in Healthcare

High Value Innovation +Disinvestment from

Lower Value Interventions

Triple Value Agenda

Evidence,

Derived from

the study of

groups of

patients

The values this patient

places on the problem that

matter most to them, and on

benefits & harms of the options

The clinical and social condition of this

patient; other diagnoses, risk factors

and their genetic profile

Choice Decision

Personalised and Patient Centred Care

“By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.”Source: Straus, S.E., Richardson, W.S., Glasziou, P., Haynes, R.B. Evidence-Based Medicine. (2000) How to practice and teach EBM. (3rd Edition). Elsevier Churchill Livingstone. (p.1).

After a certain level of investment the health gain may start to decline;

the point of optimality

Benefits

Investment of resources

Harms

Benefits - harm

As the rate of intervention in the population increases, the balance of benefit and harm

also changes for the individual patient

Necessary appropriate inappropriate futileHigh value Low value Negative Value

BENEFIT

HARM

LOW VALUE (BUREAUCRACY BASED CARE)

HIGH VALUE (PERSONALISED & POPULATION BASED)

Deliver Care through Integrated, Population-based Systems

Develop clinical focus on populations

Personalise Care & Decision -making

Change the Culture to a collaborative culture

DIGITAL KNOWLEDGE

The Healthcare Archipelago

GENERAL MENTAL PRACTICE HEALTH

COMMUNITY HOSPITALSERVICES SERVICES

Chaos…..….Complexity……...Order Person aged 87, 5 diagnoses8 prescriptions, cared for by Daughter with alcoholic husband

Man aged 23, Potts#Football

woman aged 45 invited for cervical screening

Man aged 67 with Dukes A colorectal ca.

Man aged 57 with Psychosis, drug dependence, and severe epilepsy

woman aged 73, webuser, with T2 Diabetes, STEMI, high blood pressure, homeopathy

woman aged 67 painful hip &mild depression

Complex Adaptive Systems

• “Certain nonlinear systems … are commonly described as being Complex, because their behavior is defined to a large extent by local interactions between their components. When such systems are capable of evolution they are also known as Complex Adaptive Systems.”

• Source: Rihani, S (2002) Complex Systems Theory and Development Practice. Understanding non-linear realities. Zed Books Ltd. (p.7).

SELF CARE

INFORMAL CARE

GENERALIST

SPECIALIST

SUPER SPECIALIST

This is an example of a national service set upas a system

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Hierarchy Network

LOW VALUE (BUREAUCRACY BASED CARE)

HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)

Deliver Care through Population-based Systems

Develop clinical focus on populations

How to achieve high value through Population and Personalised care

Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and providedevidence based, patient centred care, and to improve effectiveness, productivity and safety

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

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 developmentQuality of patient informationProfessional 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

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• Is the service for people with seizures & epilepsy better in Adelaide than the service in Melbourne?

• Who is responsible for the pelvic pain service for people in North Adelaide?• How many liver disease service s are there in South Australia and how

many should there be?• Which service for frail elderly people in Auckland provides the best value?• How many services are there for people with MusculoSkeletal Disease in

South Australia, and which gives best value?• Is the variation in outcome for heart failure in the South Australia services

increasing or decreasing?• Who is responsible for publishing the Annual Report on care for people

with Parkinson’s disease in North Adelaide?• Is the service the people in our population with atrial fibrillation

below the minimal acceptable standard of high quality, ie in the top quartile in the middle of the range (a-b)

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Hierarchy Network

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OBJECTIVES FOR AN ASTHMA SYSTEM

•To prevent asthma•To diagnose asthma quickly and accurately•To slow the process of the disease by effective and safe treatment•To help the individual afflicted adapt to the challenges•To involve patients, both individually and collectively, in their care

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•To prevent asthma•To diagnose asthma quickly and accurately•To slow the process of the disease by effective and safe treatment•To help the individual afflicted adapt to the challenges•To involve patients, both individually and collectively, in their care•To make the best use of resources•To mitigate inequity•To promote and support research•To support the development of staff•To report annually to the population served

LOW VALUE (BUREAUCRACY BASED CARE)

HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)

Deliver Care through Population-based Systems

Develop clinical focus on populations

Personalise care & decision making

How to achieve high value through Population and Personalised care

Evidence,

Derived from

the study of

groups of

patients

The values this patient

places on the problem that

matter most to them, and on

benefits & harms of the options

The clinical and social condition of this

patient; other diagnoses, risk factors

and their genetic profile

Choice Decision

Personalised and Patient Centred Care

LOW VALUE (BUREAUCRACY BASED CARE)

HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)

Deliver Care through Population-based Systems

Develop clinical focus on populations

Personalise care & decision making

Change the Culture to a collaborative culture

How to achieve high value through Population and Personalised care

“The culture of a group can now be defined as a pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.”Source: Schein, E.H. (2004) Organizational Culture and Leadership. John Wiley & Sons Inc. (p.17).

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“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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• Observe the artifacts

• Read the documents

• Speak to informants

ASSESSING THE CULTURE

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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

Ban old language

Introduce new language eg MUDA

LOW VALUE (BUREAUCRACY BASED CARE)

HIGH VALUE (PERSONALISED & POPULATION HEALTHCARE)

Deliver Care through Population-based Systems

Develop clinical focus on populations

Personalise care & decision making

Change the Culture to a collaborative culture

How to achieve high value through Population and Personalised care

DIGITAL KNOWLEDGE

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Map of Medicine - COPD

Work like an ant colony; Neither markets

nor bureaucracies can solve the challenges

of complexity