Health systems: What should they deliver and why is this so difficult?
What do we want from a health system? Professor Terry Young looks at the advantages of modelling to understand what solutions will be most effective and the difficulties of implementing change in the UK.
What do we want from a health system? Surprisingly, there is a consensus. Our STPs (Sustainability and Transformation Partnerships) are seeking:
- Hospitals with unified points of entry and ways to track all patients’ needs all the time
- Streamlined services elsewhere that are responsive, connect to one another and avoid duplication.
- Smart information to make this new world of care affordable and manageable.
Many also want preventative measures, measures promoting healthier lifestyles, and mental health measures which, if anything, present an even trickier challenge. There are a number of tensions that contribute to our inability to make the health and care service we want.
The first reason health and care services in the UK struggle to deliver change is that we have been inordinately successful in delivering good care in the past.
This creates a sense that the skill-set needed to shape the future is already within our grasp.
The systems that we currently have in place have been shaped by those earlier successes. When there were fewer of us and we didn’t live so long or suffer from more than one condition at a time, systems could be simpler to meet more manageable needs. Even our ideas for measuring performance were shaped by, or are a reaction to, that context.
From the healthcare estate, we have inherited across the country to the way we think about care, the specialised clinical disciplines and the delegation of responsibility and accountability between services are all a result of heritage within the sector. However, things have changed somewhat. People are living longer, developing more long-term lifestyle diseases and multi-morbidity.
Moving care into the community
One cannot simply make like-for-like substitutions when transferring care from the hospital to the community since community services operate completely differently. In 2016, the Whole Systems Partnership built a model to explore a community-based cardio-respiratory service to accept 10 per cent of urgent cases and 50 per cent of GP referrals, replace 15 per cent of inpatient admissions, and manage 80 per cent of follow-up appointments. The model redefined the workforce into four skill levels to deliver a leaner skill-mix, a smaller overall workforce with a clear idea of the structures needed in both hospital and community.
Finding a new language
Our second challenge is to live with our legacy while finding a new language to articulate a wholly different future.
Even without a legacy, healthcare systems would still be almost impossible to design because they are so complicated and different pieces of the puzzle take wildly different amounts of time to develop. People take time to train – more than a decade in many cases – while drugs and technology develop at vastly different rates. At the other end of the spectrum, buildings go up quickly, but approvals and funding slow the process down. How then, do you introduce a new idea and ensure that it can be delivered?
The key to any design is knowing what to keep and what to change. Taking a cancer centre, for example: should it be designed for those heavy linear accelerators? Will the treatments in 25 years be mainly energy beams, chemistry, genomics or nanotechnology? And will oncologists, gerontologists, GPs or nurse practitioners run the service?
This is a fiendishly difficult problem because it involves great uncertainty about the future and requires great confidence that the final system will deliver what we want, without unpleasant, unintended consequences.
Simulation: try before you buy
In other sectors, people simulate or even game to explore such extremes. In the ‘60s, for instance, when nobody knew how to land people on the moon, huge effort went into simulation and simulators. Part of this was cultural; teams that created unfamiliar launch or recovery scenarios competing against teams that would run the missions, adding new pieces of doctrine every time a simulated mission crashed. On the other hand, there were mock-ups of each capsule and piece of equipment and the astronauts learned to work with, or within, it.
Today, one would not plan a new route for an airline or launch a new smartphone without extensive simulation of each operation and the impact of changing demand and other external forces. Even our cars have simple simulators that estimate whether we will reach our destination or run out of fuel.
It doesn’t matter where you start simulating: In a clinic, consulting room, ward, theatre, or at home. Simulations are part of our industrial heritage, so we understand well how to build, test and use models. Good models eventually enmesh the whole system to show where delays will build up, how much an extra nurse on the ward will cost or what benefit a new scanner will bring to all the people who will use it.
The Memorial Health System in Illinois models all patient journeys in detail from the emergency department to CT scanners and on to wards. Its engineering design methods routinely identify savings that can be applied. In one case, an extra elevator implemented to cut delays as patients moved from wards to the operating theatre paid for itself in a few days. In another study to streamline CT scanning, the addition of an extra individual to check the preparation of the patients saved half an hour per patient, which fell within a minute of modelled predictions.
We know an enormous amount about health and have leveraged that knowledge miraculously over the past half-century. What we must now learn is how to design systems to leverage that knowledge more cheaply and consistently than anything anyone has yet achieved. For the real challenge is more difficult still: To design the new while keeping the old system going until it is replaced.
Professor Terry Young worked in industrial R&D before becoming an academic. He has over 30 years’ experience in technology development and strategy, health systems, and value for money. His recent sabbatical was spent gathering evidence of where simulation has been used in healthcare and how much it is worth to design new processes. Three of his downloadable papers are:
Using industrial processes to improve patient care (2004, with Brailsford et al., British Medical Journal)
Performing or not performing: what’s in a target? (2017, with Eatock & Cooke, Future Hospital Journal)
Systems, design and value-for-money in the NHS: mission impossible? (2018, with Morton and Soorapanth, Future Hospital Journal)