How to design a centre that closes 4,000 patient journeys a month for £1,000/patient or less, all in. #Health

The 3 Es: employment, ‘ealth and education

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If you’ve been following (starting here), you already know how to identify the cohorts to serve in selecting your 4,000 patients a month, and where that number came from.  You have a basic design process by which a team of experts can shape pathways and to compress them into single-session encounters. You have a knowledge model to map what you need to know about each patient and how to get it.

That’s it! Identify the appropriate cohorts, design the pathways for patients and staff and specify a knowledge infrastructure to manage and inform the entire processes.  It’s a big ask, so the heavy lift of design and IT specification must be done just once and done better than we’ve done before.

We still need to revisit three critical phases: starting, finishing and prioritising in between, and then I’ll sign off with a short message on the organisational tides that you’ll have to master.

Good luck!

Recap

Knowledge workers, informed by digital and human networks, make decisions and implement them using logistics to bring people and equipment together, or to take services to patients.

We now know how to design services with such people, but from my experience, the clinical mindset profoundly shapes care delivery, so I want to stress three things

• starting

• finishing

• the bit in the middle

…but not in that order.

Finishing

Project planning starts at the back! First, you need to be clear about the ideally served patient. You also need a target, so let’s decide that 90% of those who enter should emerge as ideally served patients. With success, we can raise the target, later.  Remember, one-stop shops are not universal providers: they are focused centres that do a few things exceptionally well and very fast.

Ideally served patients walk away having shed their fear of the unknown. They know what was wrong and have already started a course of medication, therapy, rehabilitation or disease management. If the next step is surgery, you need an accelerated system so as not to lose patients’ confidence.  For instance, you might prep them on the day, with a slot for surgery in the next 72 hours.

What about the 10%, for whom unexpected complications appear, who cannot make decisions on the day, or who find the process unmanageable?  You’ll need a protocol for them: a clear and pleasant plan to move them into another part of the system with an assurance that they will be served in a timely manner.

Starting

How well prepped your patients are on arrival will determine how far they can go in a single session. So, will they walk in from the street, arrive from a GP or be referred from elsewhere?  Presumably off-the-street is a step too far, but you’ll need protocols for GP or hospital referrals.  Ideally, all blood tests will have been done and someone will have spoken to the patient and gone through their medical history (a job for AI?).

If you can, avoid the path lab.  Point of care technology is great (and getting better) but you can’t afford to prick fingers too many times without risking your ethics approval, while getting samples to a lab and back even in an hour is tricky and costs 25% of your time budget.  Working from good results at the outset is best.

It’s your choice how you schedule.  With smart ‘phones you can track arrivals and manage queues from when patients leave home, so again, you’ll want to know the best flow options and you’ll need to model them.

And then, you’re off!

Making the middle work

Almost certainly, the biggest shock to the medical mindset lies in trading clinical priorities for a system based on first come, first served. The urge to put the neediest first, and the resultant proliferation of queues for different levels of need, is deeply embedded in healthcare.  It’s dangerous, in my view.

It makes sense when choosing between a patient with toothache and a car crash victim. It makes no sense if both patients are likely to see next Christmas with or without your help.  For cases in between, remember that queues are voracious consumers of effort and most of the waste they generate is invisible. You think you are managing them, but they are eating away at your organisation soul.

Queues have a beguiling way of drawing us in with sweet promises that there is so much to do that it would be better to shelve this patient for a little while and press on with something more urgent.  Worse still, these promises are self-fulfilling, so that soon you are drowning in the deferred need you have accidentally created!

The only way I know around this is to be reflectively alert, always on the lookout for ways to eliminate delay. It’s a whole new world that will take a while to get your head around.  Worse still, once you’ve mastered it, you’ll become an evangelistic bore on the benefits of wait-free care.

Organisational implications.

Getting these centres up and running will involve huge organisational effort and the silkiest of organisational skills. Whereas big has been rewarding, small is suddenly beautiful and so those at the top who want to support you will have all their instincts confounded.  You’ll need a narrative that captures the purity of the vision and also the complexity of getting it off the ground or keeping it on the road (maybe best to keep those metaphors apart).

Somehow lockdown seems to have programmed the NHS into believing that almost anything can be managed through 30- or 60-minute videoconferences, so that people’s days are now packaged liked sliced bread. It will take patience and skill to get the right people’s attention for long enough.

I’m assuming that a central drive will address the issues of procurement, because deciding how to cost-up and justify something like this will be tricky, as will selecting partners to work with.

However, let’s assume that we succeed, and that we are chomping through the backlogs across the Country at 400,000 patients a month.  What will happen next?

What happens next is that you discover you are part of a much bigger system. You’re a virus in a host that may have its own antibodies. To begin with, you’re a helpful little virus, alleviating pressures, almost from day 1 and offering the hope of less stress in future.  In time, crushing and unofficial overtime can be dispensed with, and staff can go home on time.  Before that, some of the eyewatering budgets for locums and temporary staff will have been redirected.

But in a system that now has a track record and considerable resource invested in managing waiting, you may also hit some existential barriers.  What if you push through the 18-week barrier or it suddenly becomes possible to get people through A&E in 4-hours without much fuss?

Like Rear Admiral Moffett (see post 3) or Taiichi Ohno (see post 4), you’ll need someone to push on through with almost religious zeal, not just to preserve the centres and tame the waiting, but to ensure that the learning seeps into the rest of the service. And that might just save the NHS.

I think that’s it.  Have fun!

Professor Young: researching for 40+ years; in healthcare for 25; and using NHS limbs for 50+.

The series

Fixing the NHS: hurdling todays barriers for a fitter future (25 July 2024)

Fixing the NHS: the digital arts and a simple knowledge model (1 August 2024)

Fixing the NHS: the digital arts and service design (8 August 2024)

Fixing the NHS: the digital arts and getting the right numbers (15 August 2024)

Fixing the NHS: making the virtuous vortex work (22 August 2024)

How to design a centre that closes 4,000 patient journeys a month for £1,000/patient or less, all in (29 August 2024)

Fixing the NHS: the bite-sized story in 6 charts (5 September 2024)