Driving innovation: a case study using a simple evaluation tool

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Professor Terry Young, Dr Fay Wilson, Alan MacDonald and Mr Simon Dodds describe for ICJ an evaluation tool that was used to support the development of a rapid access clinic in an existing health centre in Erdington.


Project management is simple: look after people, plan well, monitor effectively and intervene as needed. However, people, planning, monitoring and intervening are complicated, so good project managers mix in experience and tools they pick up over a lifetime.

Figure 1: Map of the project design to extend the capacity of an existing health centre (in blue) with rapid access care
Figure 1: Map of the project design to extend the capacity of an existing health centre (in blue) with rapid access care (click to enlarge).

Case study

The team from Badger (Birmingham and District GP Emergency Room) Group used a 6M Design® approach with three pre-implementation stages (map, measure, model – a prototype based on a simulation), and three phases of implementation (modify, monitor, maintain).

Once a working upgrade of the facility was in place, two reviews were conducted in January 2022, using a simulated set of patients (based on a typical case-mix) and putting this stream of virtual patients through the service to see how it was responding.

Across the two days, the workforce involved in the review included: heath care support workers; receptionists; and clinicians – around 8 people in all. A 4N framework was used for collecting and analysing the feedback.

To understand 4N, figure 2 (used with permission from SaaSoft) shows a creative journey into new territory – leaving behind what is already there and implementing what is desired. Specifically, 4N feedback uses the dimensions of time (present/future) and emotions (positive/negative) to create a chart which is split into quadrants, defined as:

  • Nuggets (relates to the present and the things about which the stakeholders have positive feelings)
  • Niggles (relating to the present but capturing features where the feelings are negative)
  • Nice Ifs (similarly, relating to the future and positive feelings)
  • No Nos (finally, relating to the future and negative feelings)

Niggles identify what hasn’t gone to plan to date. To grasp this feedback, an improvement tool called a Niggle-o-gram® was used, based on the familiar failure modes and effects analysis (FMEA). The list of niggles was graded based on three scores:

  • Incidence: how often does this niggle occur (never, 0 to 9, always)?
  • Impact: what is its effect (no impact, 0 to major impact, 9)
  • Influence: how much can we do (nothing, 0 to 9, change it completely)

Using this scheme, niggles that nobody could do anything about were assigned low priority. In this case, the top 5 niggles came out as shown in table 1.

Figure 2: Bridging the creative gap, while taking what works well with you.
Figure 2: Bridging the creative gap, while taking what works well with you (click to enlarge).
Table 1 (click to enlarge).

A more intuitive way of grasping the feedback is to produce a word cloud, weighting the size of words in each quadrant by their priority in the rankings.

Figure 3: Word cloud of key issues raised in all four quadrants of the 4N feedback process.
Figure 3: Word cloud of key issues raised in all four quadrants of the 4N feedback process (click to enlarge).

Using the findings to address key issues

One tension to emerge was around staffing, since booking patients in at reception takes less time than appointments with the healthcare worker or clinical staff. With everything running absolutely smoothly, a single receptionist might have coped, but interruptions and sporadic other tasks meant that having two receptionists was important for safety.

In turn, this created a tension between having a workload that would utilise two receptionists, and the capacity for healthcare and clinical appointments. In the end, a system designed for 10-minute appointments was fine tuned to 12-minute appointments to get the best combination of reception and other staff usage.

A second issue was Covid safety in a waiting room that could only accommodate 4 patients. Again, from modelling and other analysis, this was too few to manage the overall capacity planned for the centre, so a new process was developed whereby patients arriving in their cars would use their cars as their waiting room (and the receptionist would contact them to walk straight to their appointment), freeing up the waiting room for the exclusive use of those who arrived in other ways.


In the end…

Using a 4N framework as part of the management of an expansion of a health centre, an existing service was quickly upgraded for rapid access Covid patients, and tested robustly for capacity, throughput and safety.

Tools such as this are critical to the success of any agile or pop-up service. The good news is that the 4N approach is easy to understand, straightforward to implement and bridges the worlds of experience and clinical quality.


About the authors

Mr Simon Dodds, MA, MS, FRCS

Mr Simon Dodds is a general surgeon at University Hospitals Birmingham NHS Foundation Trust. He studied medicine and digital systems engineering before following a career in general and then vascular surgery. In 1999, he was appointed as a consultant surgeon at Good Hope Hospital in North Birmingham and applied his skills as an engineer and a clinician in the redesign of the vascular surgery clinic and the leg ulcer service.

In 2004, the project was awarded a national innovation award for service improvement. This experience led to the design, development, and delivery of the Health Care Systems Engineering (HCSE) programme.

Alan MacDonald, BSc

Alan studied at Nottingham Trent University and has a BSc (Hons) in Biomedical Science.

He worked for the Badger Group as an Out-Of-Hours primary care team leader and later became a data analyst. Since the start of the COVID-19 pandemic in March 2020, he became directly involved with the development of a multi-lane drive through Covid Referral Centre at the NEC.

He has been instrumental in the deployment of other temporary drive through clinics across Birmingham. He has also been actively part of the original team who were successful in applying this concept to the first purpose-built drive through clinic in the UK

He is frequently involved in new & novel projects within the out of hours primary care sector and is currently studying Health Care Systems Engineering.

Dr Fay Wilson, MBChB, FRCGP

Fay trained in Birmingham and has practiced there as a GP there since 1985. Her extensive national and local portfolio includes: NHS HA Non Exec, GMC fitness to practise chair, and associate postgraduate dean at Health Education West Midlands. She has served on the council of the BMA and other bodies. Fay brings people together to develop new models of care, a notable success being the Birmingham Multifund co-operative, a pioneering nurse-led walk-in centre and a prototype GP provider-at-scale ahead of its time in the mid-1990s.

Dr Wilson is medical director and co-founder of Badger, a GP social enterprise since 1996 providing out of hours and urgent primary care. COVID-19 introduced her to systems engineering, new people and new ways of thinking. Her ambition for the last decade has been to slow down.

Prof Terry Young, BSc, PhD, FBCS

After 16½ years as a research Engineer, Divisional Manager and Business Development Director, Terry became a professor at Brunel University London for 17 years.

He has a BSc in Electronic Engineering and Physics, a PhD in laser spectroscopy both from the University of Birmingham, UK.

His research has been in health technology, health services, and information systems. He has taught information system management, project management and e-Business.

His awards include the Operational Research Society’s Griffiths Medal, 2021, for analysing the return simulation methods offer when used to improve healthcare services.

Prof Young set up Datchet Consulting in 2018 to support innovation on the borders of academia, health and industry, of which the project reported here is an excellent example.

If there is a Cinderella in health infrastructure, it is primary care

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primary care

Chris Green MP, Chair of the APPG for Healthcare Infrastructure, calls for the government to properly prioritise the primary care estate in its upcoming refresh of the Health Infrastructure Plan.


In recent years, attention has been focused on a national level on the government’s headline hospital building programme. While investment in acute infrastructure is imperative, we have been waiting with bated breath for a year for the refresh of the Health Infrastructure Plan (HIP).

Addressing the NHS England and NHS Improvement National Estates and Facilities Forum in March 2021, Health Minister Ed Argar MP promised it would set out “the direction of travel for the primary care estate”.

Since then, the radio silence from Whitehall has been one of the factors behind cross-party parliamentarians coming together to revive the All-Party Parliamentary Group for Healthcare Infrastructure.

Our mission is simple: to highlight the importance of high-quality healthcare infrastructure to support the NHS in meeting the demands of the future, including post-pandemic care.

The state of the primary care estate and the lack of a long-term strategic framework is holding back everything from modernisation and integration of NHS care, to tackling the maintenance backlog and embedding new roles into primary care. A YouGov survey of healthcare professionals conducted last autumn found 40 per cent saying the premises they worked in constrained the services they could provide to patients.

In a report published in February on integrating additional roles into primary care networks (PCNs), The King’s Fund concluded that a lack of adequate estate was becoming an issue across primary care and would require expertise in the design and use of space to support multidisciplinary teamworking. This is just one area where the refresh of HIP must offer concrete solutions.

The direction of travel for the primary care estate must reflect the lessons we have learned throughout the Covid-19. A survey of professionals working in hospitals, health centres, GP surgeries and mental health sites at the height of the pandemic found that half felt the sites they were using were fit-for-purpose. In addition, 70 per cent called for more flexible space and 49 per cent for external space for patients and staff.

Work is going on to achieve these aims at primary care facilities across the country like Gracefield Gardens in Streatham or Lowe House in St Helens or at Bolton One which serves my constituents. But we need the refresh of HIP to prove NHS infrastructure is about more than just hospitals.

An analysis of PCN clinical directors conducted by the NHS Confederation last year found that more than 90 per cent felt a lack of estates infrastructure was hindering their progress, while more than 98 per cent felt more funding for primary care estates was needed.

One the important questions that the refresh of HIP must address is what the first iteration identified as a “significant unmet demand for capital in the system”. We need clarity how the necessary investment in primary care estates fits with the post-pandemic public finances.

There are steps that the emerging ICSs can take. Karin Smyth MP and I proposed an amendment to the Health and Care Bill to empower the new Integrated Care Boards to reclaim their stake in projects delivered under the NHS Local Improvement Finance Trust programme. We hope ICBs will take back their share in these vital schemes to ensure they are best used to serve the needs of the primary care estate in their local areas.

The APPG will be launching a call for evidence on meeting short, medium, and long-term health infrastructure needs shortly. We want to hear from those at the centre of ICSs responsible for primary care.

A refreshed version of HIP will be the bedrock for the return to normality as we move on from Covid. We want to hear what you need to succeed.

To get in touch, please write to healthinfrastructureappg@connectpa.co.uk or to receive regular udpates from the group, please visit our website.

Built Environment, News

NHSPS generates £53 million in cost efficiencies during pandemic

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cost efficiencies

NHS Property Services (NHSPS)’s annual report, published on 13 December 2021, has revealed that it generated £53 million in cost efficiencies for the health service during the first year of the pandemic.


NHS Property Services (NHSPS)’s annual report, published on 13 December 2021, has revealed that it generated £53 million in cost efficiencies for the health service during the first year of the pandemic.

NHSPS, which owns and manages 10 per cent of the NHS estate, exceeded its initial cost efficiencies target by £20 million. These savings helped to mitigate inflationary pressures on the NHS, enabling NHSPS to prioritise the pandemic response and keep its charges flat.

There was an additional twenty per cent increase on capital investment, which saw improvements to NHS sites, such as GP surgeries and hospitals across England.

To support the NHS Covid-19 response, NHSPS refurbished spaces to create capacity for over 1,500 beds across England between April 2020 and April 2021. NHSPS also worked with customers and local health systems to set up 250 vaccination sites.

In total, NHSPS delivered 110 transformational estate projects, as part of its ‘Healthy Place’ scheme. This will benefit over two million patients and provide 100,000 sqm of upgraded space for the NHS.

A new social prescribing programme was also launched, creating 21 more spaces, and contributes towards the goal established in the NHS Long Term Plan to refer at least 90,000 people to these services by 2023/2024.

Over the twelve-month period, NHSPS has prioritised reducing the carbon footprint of the health estate, in line with the NHS’ goal to become net zero by 2040. Initiatives have included switching the building portfolio to 100 per cent renewable energy, upgrading to LED lighting and installing smart meters. This has saved £10.6 million and 8,600 tonnes of carbon.

Martin Steele, Chief Executive Office for NHSPS, said: “2020 was a challenging year for everyone, both within and outside of our organisation but it has been incredible to lead an organisation that has been so committed to supporting the NHS during this difficult time.

“Through collaborating with Integrated Care Systems and local health authorities we have adapted existing buildings to support the vaccine rollout and explored how community-based health and wellbeing initiatives can be delivered locally. We have learnt important lessons that will help us to improve the health estate and ensure it is fit for patients both now and in the future. I look forward to continuing to work closely with our customers to deliver local solutions and the best value possible for the NHS at both a local and national level.”