Policy Exchange Research Notes

ALL CHANGE PLEASE

Professor James Barlow, Jamie Burn, Gavin Lockhart

EXECUTIVE SUMMARY

The NHS’ performance in taking up and spreading innovations and existing best practice is variable. All Change Please is an inquiry into what can be done to improve this position.

All Change Please has been my summer reading. NHS is taking a deep dive into innovations and how to set them into practice in British healthcare. Mediracer has a role in this project. For more information, please, read this posting.


DEFINING OUR TERMS – WHAT IS ‘INNOVATION’ AND ‘BEST PRACTICE’?

We follow Greenhalgh et al’s description of innovation as ‘a novel set of behaviours, routines, and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or user’s experience, and that are implemented by planned and coordinated actions’.

Within this umbrella definition there are different forms of innovation – some innovations may be technological (such as a new medical device) and others may be changes in care practices or the organisational arrangements for delivering care. The boundaries are often blurred, however, with new technologies commonly requiring new practices or organisational forms for their successful introduction. Different strategies to encourage adoption and manage implementation are therefore necessary, depending on the nature of the innovation.

• Mediracer is a technical device for distributed diagnosis of Carpal Tunnel Syndrome. Professional diagnostic services can be taken closer to customers and patients.
  

‘Best practice’ can be defined as the most efficient and effective way of accomplishing a task, based on repeatable procedures that are proven to work in practice. Examples of best practice can be found in pockets of excellence within the NHS, but often fail to spread.

• Take a look at the Mediracer Medical Futures Award Gallery 2007.
  

Spreading innovation and best practice in the NHS typically involves two forces: a ‘push’ from government and commissioning organisations, as well as manufacturers, and a ‘pull’ from health service delivery organisations.

Local organisations do not have the capacity to identify, collect and assess every new technology coming to market, meaning that efficient central mechanisms are required to ensure all NHS patients benefit from important advances. But to embed best practice in every area, and update it with every new innovation, would be a huge drain on resources and would negate local ‘incremental’ improvement by returning to bureaucratic governance. Therefore, incentives for self-improvement are also required.

Health Care Policy Questions in UK and Mediracer

I got this information through Veijo Lesonen with a more specific reference to this PDF and page 7 that I'll be quoting below the NHS Policy Exchange Information

Health: "The traditional model of the NHS has been characterised by a highly centralised management structure; successive governments have failed to delegate responsibility to a local level. Policy Exchange believe that Healthcare providers need to become embedded in their local communities and that strong public involvement in decisions about health and social care priorities is critical. Our research, whether into improving healthcare innovation or the role of the private sector, is from patients’ perspectives."

The quote on page 7 starts here.

The artificial barrier between health and social care is a further division. Social care is not part of the NHS system; yet caring for those with long-term conditions requires effective communication and collaboration between different professional teams that span this divide. This often proves difficult.

Cultural silos

“There’s no question that one of the barriers to innovative medicine in the UK is the medical profession. And they’re very, very conservative … I would argue, exceptionally so, to the disadvantage and detriment of their patients.”

Managers naturally rely on the advice and ideas of senior clinicians, because they lack clinical
training, and the culture of the NHS old guard is often characterised as conservative, parochial, and territorial. Clinicians are justifiably protective of their autonomy over clinical matters, but in some circumstances this can be used to resist uncomfortable changes, such as innovations that disrupt their professions, or the push for greater transparency through clinical audit. It is very difficult for managers to lead service change in the health service, and thus to respond to pressures from commissioners and the centre to improve quality.

Case Study 1: Mediracer diagnostic device (link to pdf)

Carpal tunnel syndrome (CTS) causes pain and tingling in the hands and is 3-5% prevalent in the
adult population. Currently, diagnosis requires referral to a neurophysiologist, which can add up to six months to the treatment pathway. A new hand held device for diagnosing CTS has now been developed, which can be used in outpatient and primary care settings. The technology has been taken up by a team in Leicester, who created a one-stop clinic for diagnosis and treatment of CTS.

In less than two years they had secured over 90% of referrals from the Strategic Health Authority (SHA) saving the NHS £1.7 million and earning an innovation award from Medical Futures. Since publicising their work, the team has encountered significant opposition from third parties. For example, neurophysiologists argue that the test is not as accurate as the gold standard (the new test is sensitive (94%) and specific (98%) compared to a conventional EMG test performed by a specialist).

Instead of looking for ways to incorporate the greatly improved pathway and make sure problem cases are referred for further tests, there has been a resistance to dialogue.

This technology could greatly reduce waiting times and Medical Futures estimates the potential national savings to be over £72 million.

There are also divisions between different professional groups, who can have diverging interests. Tightly-knit professional networks can operate as channels for new ideas to spread.

But they also serve to create cultural divisions between professions, reducing the spread of innovations that impact on multiple clinical areas and require close inter-professional collaboration.

The simple rule for adoption in the NHS is; the more parties that are involved, the less likely it is to happen.

Helge: It looks like the climate for innovation adoption isn't much different in many other countries. Medical innovations are suffering while the field is limited to very large organisations with deep pockets. Mediracer has stubbornly continued to fight against a likewise stubborn opposition. But what if we would have a more adaptive environment? What could it mean for patients? And how about health care costs?

HealthBlog : UK National Health Service: locked and loaded for the next 60 years

Searching and googling for doctors blogging. Carpal Tunnel Syndrome Diagnostics and mediracing is a narrow specialty. I know that blogging is popular in US. Europe is coming online a little later. We would like to learn more about the health care bloggers in UK and EU.

HealthBlog : UK National Health Service: locked and loaded for the next 60 years: "The NHS is celebrating its 60 birthday. I pointed out to NHS leaders in both Scotland and England, that like their American managed cared counterparts, they are ideally positioned to lead the world in provisioning health information, medical care and services, but for every citizen in their country, not just to members of a particular hospital or health plan.

Essentially, the NHS is a system that looks very much like a Group Health, Kaiser or UPMC, only very much larger.

The NHS is also a system that now has all the tools and technologies needed to provision information, care, and services using exactly the most appropriate modality; whether in a hospital, clinic, physician's office, patient's home, or 'virtually' on the Internet.

The only limiting factors are perhaps organizational inertia and the challenges associated with changing and modernizing well ingrained cultures and behaviors of clinicians and clinical practice.

Helge: Change management!

I believe the NHS is not only locked and loaded for the next 60 years, but it is in excellent position to lead the world by example in the application and use of information technology to improve the health of all citizens."

About the blogger:

HealthBlog

Thoughts, comments, news, and reflections about healthcare IT from Microsoft's worldwide health director Bill Crounse, MD, on how information technology can improve healthcare delivery and services around the world.

Operations cancelled as NHS runs out of money - Health - Times Online

Helge: The Times article about NHS running out of money. Learned about it from a UK healthcare blog. This article was written a year ago. How are things today? Any improvement?

Operations cancelled as NHS runs out of money - Health - Times Online: "No patients will be given a hospital appointment in less than eight weeks, and none admitted for elective surgery unless they have waited a minimum of 12 to 16 weeks. Those treated quicker will not be paid for.

The trust also announced the immediate suspension of treatments for varicose veins, wisdom teeth, X-rays of the back, operations for carpal tunnel syndrome, bunions, arthroscopy of the knee, and grommets for the ear, among others.

“We fully appreciate the difficulties that the introduction of these measures entail,' Dr Soo-Chung's letter says. 'However, the financial position of the PCT is such that there is absolutely no alternative to this programme if we are to avoid even more difficult decisions in the near future.'

Helge: What about early diagnostics and treatment? Mediracer could help to cut costs and to assist occupational health people and employers to react to CTS at an early stage.

UK NHS Health Care Policy and Mediracer

UK Health Care Policy and guidance

The Department of Health is responsible for setting health and social care policy in England. The Department's work sets standards and drives modernisation across all areas of the NHS, social care and public health. As well as policy documents, this section of the site contains guidance on implementation.

I'm reading this to learn more about the UK National Health Care, how it's organized, how Carpal Tunnel Syndrome Diagnostic Methods are integrated, and how Mediracer and Telemedicine could be used in this context.

Human resources and training

The development and implementation of HR policies is crucial to obtaining and retaining a high performing workforce. The policies need to reflect the strategic objectives of organisations together with recognising the impact of wider demographic, sociological and technological trends and consider the medium and longer-term implications of these.

Therefore the workforce requirements need to be considered strategically and help deliver national priorities as set out in local delivery or business plans. It is essential that there is a clear 'line of sight' between HR practices and the delivery of high quality services.

Of central importance is creating the 'right' culture and developing 'customer' focused values. This section outlines the thinking behind these goals, and explains the various strategies that are helping to achieve them.