© Nuffield Trust 17 March 2016

Redesigning care

Nigel Edwards

Chief Executive, The Nuffield Trust

Honorary Visiting Professor

London School of Hygiene & Tropical Medicine

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Starting point

Every system is perfectly designed to achieve the results it gets

So to change the results it is necessary to change the design rules that under pin it

Some of our current design rules are not very good…..

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Odd design rules

• Organise around

• Medical disciplines not patient problems

• Individual events not patient journeys

• The sickest patients see the most junior doctor

• Store patients until you are ready to see them

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Outpatients in the 1920s

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New design principles

Some that already apply:

• Standardise where possible

• Centralise where necessary, decentralise where possible

• Safety as a system property

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New design principles: Purposeful design

Purposefully focus on the design and improvement of the system:

• Remove unnecessary complexity

• Focus on continuous improvement and develop skills and leadership to support this

• Apply improvement science approaches to system design

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Population health management

Understand the population’s health needs and match services to patient/user characteristics based on need and risk. :

• Registries

• Shared assessment processes

• Proactive care to anticipate need

• New ways to target and work with different populations (e.g. different models for highly mobile populations or ethnic groups with different expectations of how to use services)

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Match need to services

Develop the capability to deal with the complexity of patient needs and match these to services:

• Multidisciplinary teams including social care and mental health

• Capture the benefits of generalists and specialists

• Providing specialist advice more widely across the system – for example by the use of technology

• Reduce care coordination challenges and hand-offs by multi-skilling professionals and care workers

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Flow

Focus on flow

• Align the approaches of different parts of the system and the pace at

which they work

• Match capacity to demand

• Separating different types of process flow from each other.

• Focus on the interfaces, the transmission of information and

standardisation of processes, equipment, communication, etc.

• Availability of senior decision maker at the front end of the process

with access to alternative service choices

• Plan for every patient – make & execute decisions

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Hospitals: Specialisation and generalism

Treat the whole patient

Escalate quickly where necessary

Rebalance specialism and generalism

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Networks

Networks as a key organising principle

• Staff working across organisational and sector boundaries

• Shared approaches to patient management

• Tiered services based on need and risk and easy transfer between parts of the network

• Focus on knowledge sharing and QI across the network

• Clear accountability for outcomes

• Focus on relationships more than structures

• Back up with technology

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Measure outcomes that matter

This requires:

Different methods of data capture

Goal based care

Shared decision making

Patient activation

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Shared decision making

1

3

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Fully deploy digital technology

1. More systematic, high quality care

2. More proactive and targeted care

3. Better coordinated care

4. Improved access to specialist

5. Engaged patients

6. Improved resource management

7. System improvement and learning

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Changing the nature of interactions

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Design systems where staff can flourish

Control and mastery

Manageable workload

Human scale organisations

Functioning teams

Feedback on performance

Tools to improve services

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Staff: skills and work

Break down barriers between physical and mental health

Multiskill to reduce hand-offs

Create systems that allow staff to work at the top of their licence (without burning them out)

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Plan for environmental sustainability

Carbon

Water

Communities

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Communities

Work with the resources of the wider community

• Help the wider community to build its strength, inclusivity and resilience

• Community development approaches

• Don’t try and control it

• Don’t use it to do things statutory services should be doing

Be honest about what we can actually deliver

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Technical

• Problem is well defined

• Solution is known can be

found

• Implementation is clear

Adaptive

• Challenge is complex

• To solve requires transforming

long-standing habits and deeply

held assumptions and values

• Involves feelings of loss,

sacrifice, anxiety, betrayal to

values

• Solution requires learning and a

new way of thinking, new

relationships

• Triggers avoidance of

uncomfortable issues

What sort of change

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Three implications

A capability gap

Having the right change model

Creating a the time and space to develop and apply these