“Walk that walk and go forward all the time. Don’t just talk the talk, walk it and go forward. Also, the walk doesn’t have to be long strides; baby steps count too. Go forward”. Chris Gardner, Entrepreneur, author and inspiration for the film "The Pursuit of Happyness."
Are you completely, 100%, satisfied with the outcomes you currently achieve in life and work? If you are, you can stop reading; if not, please read on.
Einstein defined insanity as, “doing the same thing over and over again and expecting a different result”; in effect, if you are not happy with current outcomes you need to change something in the delivery to get a better, improved, or different outcome.
So why is it, then, that providers have numerous ideas for making the shift from in hospital to out of hospital care, but cannot actually effect the required change? Why is it that only a very few individuals in NHS commissioning structures are genuinely prepared to disrupt what happens now and effect long term, sustainable change in the shift from in hospital to out of hospital provision?
The following are basic examples of services that can be delivered through General Practices, preferably working at scale, for 50%, 60% or 70% of Payment by Results (PbR) Tariff, and in effect offering a 50%, 40% or 30% saving on PbR to a CCG. That is a huge saving compared to the targets being set, and of course the savings could be reinvested in creating further changes. Small steps towards large change count just the same.
• Community diagnostics, e.g. continuous (holter) ECG and 24 hour ABPM; both services using cutting edge technology with no up-front set up costs;
• Community DVT, where the wells score, d-dimer and initiation and follow up of treatment are all completed in General Practice, some even deliver the non-obstetric ultrasound meaning no secondary care input
• Community Gynaecology, uro-gynaecology, heavy menstrual bleeding, fitting and removal of ring pessaries, coils and implants, treatment for uterine fibroids and endometrial assessment with pipele biopsy
• Remote monitoring of Warfarin, avoiding numerous appointments in already over worked General Practices and freeing significant capacity, while making a profit for those who provide
• Diabetes insulin initiation and titration
However, if we find excuses (some call them reasons) not to change then nothing happens, other than we spend our time erecting barriers and obstacles, usually in the form of needless bureaucracy, to prevent change and then complain that the overspend is getting worse and the only solution is to throw more money at it.
I already have a very small number of clients who deliver remarkable results, mostly working round the local CCG rather than with them, and in the process making what we are told is a “highly complex system, which we simply don’t understand” look effortless. The key point is why do we have to work round and against the CCG, when all of the Practices are Members of the CCG? Where is the collaboration, the drive to redesign pathways of care, improve patient outcomes and reduce costs? The answer is that it’s all hidden behind needless bureaucracy and cries of conflict of interest, which is non-existent if the CCG implemented the policies contained within its own governance frameworks. However, they choose not to, and so nothing changes.
There are other projects; however, those detailed in the list above are so basic and straightforward they should be the place to start, and yet they are not. They are kicked as quickly as possible in to the long grass by CCGs who simply want to continue as they are without changing anything and yet hope for a different outcome.
I have these projects running now. Yet when the pilot project running within a federation is delivering all the outcomes, and key performance and result measures, for 70% of PbR Tariff, why do we have the CCG announcing it needs to go back through a whole sub-committee process to be considered for commissioning for a start in 2018? Why would you waste 30% of PbR for another 18 months, when the NHS is on the brink and the savings can be realised now?
The above services are what I would describe as “innovation at the edges”: as far from radical as you can get, and yet highly effective. My view remains that the bureaucracy at CCG level is designed simply to block projects such as these from progressing; there is no other logical explanation. These projects are using the latest technology (without set up costs) and drugs to effect sustainable change by implementing one high quality and standardised approach to patient care, without variation, which has improved patient outcomes and reduced costs.
Yes, it is only across a small number of services, and the savings generated will not solve all health economy problems; however, at least there will be savings and a start made towards developing bigger and more complex shifts in care. They are an indication of commitment and intent.
These basic services provide the foundation for the move towards integrated delivery, by developing a phase of interdependence between Primary and Secondary Care. This creates the space for the development of relationships that may start out with a degree of suspicion but then go on to be sustained on a foundation of mutual trust, through integrated delivery.
I don’t believe you can make the leap from independent to integrated in one leap, and have seen little by way of example to challenge that view; however, I do believe you can make the move in two phases, independent/interdependent and then interdependent/integrated, by disrupting current pathways and making the shift from in to out of hospital care, where the providers need to work together to achieve the delivery.
If Simon Stevens genuinely believes CCGs are going to commission £22billion in efficiency by 2020, I’d suggest he is entirely wrong – of course if you have examples, please share them.
Service providers could deliver services in a different way to achieve the level of efficiency required; however, to do that we need to take the needless CCG process out of the equation and let the providers get on with delivering in a different way to achieve what is required, with a gain share approach, which shares 50%/50% the savings between Commissioner and provider, allowing the providers to reinvest in further ideas. Start with small, simple projects, establish the right relationships, avoid creating needless bureaucracy, set realistic timescales for task and finish groups of providers to come up with solutions and get on with it. Find reasons to do rather than excuses no to, and suddenly we will start to see the efficiency challenges being met.
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