Meeting the challenge of Health Care Reform
by Philip Boxer
Health Care Reform presents governments everywhere with a challenge. Richard Veryard raises the question here of whether the latest round of changes in the UK will be any different. Between 2002 and 2004 I was involved with colleagues in pathfinder projects, aiming to address these issues in the UK, the report on which can be found here. What follows is a summary of the nature of this challenge as we came to understand it.
The pathfinder projects were aiming to generate three kinds of benefit in order to deliver step-change improvements in the orthotics service across the UK’s NHS as a whole:
- Type I - defining current demand and realigning product/service protocols to it.
- Type II - re-organising referral protocols and configuration of clinics to improve delivered health care within existing catchments.
- Type III - extending the organisation of the clinical service to include re-organisation of the catchments within the Primary Care Trusts.
The pathfinders established that the scale of Type II benefits were significantly greater than Type I benefits because of the role of the clinic within the larger Primary, Acute and Long Term Care contexts. It was expected that this would even more true for Type III benefits.
But how could these different levels of benefit be achieved across the NHS as a whole? To answer this question we need to understand the role of Architecture.
We discussed here a way of thinking about ‘Architecture’. When applied to the context of Health Care, we want to understand the way the different kinds of Trust determine the way that care is provided in response to patients’ demands.
The traditional approach to improving patient care is to focus on the patient journey through a succession of care pathways relating to the patient’s need for treatment. For well-defined patient conditions, this means optimising and aligning the process steps along the care pathway. These improvements affect the care pathway architecture within which treatments can be offered. Type I benefits were achieved by changing the care pathway architecture of the Orthotics Clinics, through such things as implementing clinical delegation and treatment protocols.
The pathfinder projects made a fundamental separation between care pathways and referral pathways. Care pathways define the way treatments are provided, while referral pathways define the way patients are enabled to find the treatments that they need for their particular condition. The referral pathway architecture is affected both by the way care is funded – affecting the way the funding of clinics relates to the way patients need to be treated, and also by the way clinicians themselves are able to make use of each others’ specialisms in how they diagnose a patient’s treatment needs. Type II benefits were achieved by changing the referral pathway architecture governing the way patients reached the Orthotics Clinics, including such things as direct referral and universal review processes.
Finally, some of the conditions experienced by patients can be reduced in their effects if their emergence is anticipated. Thus (for example) the screening of diabetic patients or of children with special needs can reduce the risk of later conditions arising. The health risk governance architecture created by the different Trusts collaborating in the provision of care governs the way these risks can be anticipated.
Each of these architectures depends on the excellence of the architecture at the level below it. Thus without improvements in care pathways, improvements in referral pathways cannot be supported. Equally, without greater precision in the way referral pathways respond to patients, they cannot support more proactive approaches to managing health risk. In other words, the levels of benefit progressively build on each other as the architectures are progressively developed. In these terms we can distinguish three different kinds of approach to the provision of services to patients, each one of which delivers a different type of benefit:
- being treatment-centric requires excellence in the care pathways
- being episode-centric requires clinical teaming built on mutual respect for treatment excellence; and
- being care-centric requires innovation in the way care is delivered through time within the context of patients’ lives that must be supported by a patient-centric approach to treatment.
So how is architecture to be intervened on in such a way as to achieve these benefits?
The conclusion we reached was that a proactive, demand-driven East-West dominant approach was needed to achieving step-change; and that a North-South dominant approach, based on encouraging Trusts to make step-changes through implementing published best practice guidelines, would not work. Understood in terms of the following diagram, moving ‘across’ to the right involves responding increasingly to the particular needs of the individual patient, while moving ‘up’ involves changing the organisation of the architectures within which this responsiveness can be made affordable and practicable on a sustainable basis.
- In a North-South dominant approach, new architectures are designed by top management, and then ‘implemented’ through imposing step-changes on the way clinicians can use them to respond to patients. This is the ‘command-and-control’ approach to change, which, to be successful has to be successful at anticipating the full complexity of behaviours involved in responding to patients. This is never possible in practice.
- In contrast, an East-West dominant approach rests on the clinicians developing greater responsiveness in the way they meet their patients’ needs, and provides them with the means of altering the architectures within which these changes can be made sustainable. This is approach to change can be successful because it is able to work with the full complexity of the situation ‘at the edge’.
So what makes this East-West dominant approach to change difficult for National Governments to implement?
There has of course to be sponsorship for the changes needed, both at the Trust level and at the National level, in order to create a context within which change can take place. But even given this, the demand-led focus on the need for change then has to be driven from the ‘edge’ by the specific needs of the patients. This in turn requires forms of support and transparency that can enable such change to happen, by providing funding for the transition, by providing support for this way of working out how to effect change, and by ensuring that the changes made can be sustained in a way that is accountable.
This means being able to sustain power at the edge, and this is a 21st Century Challenge that Governments have not yet learnt how to meet.