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NHS England and NHS Improvement Professor Matthew Cripps Director of Sustainable Healthcare 4 November 2019 Unwarranted variation - Sustainable Healthcare improvement @matthew_cripps1
NHS England and NHS Improvement
Professor Matthew Cripps
Director of Sustainable Healthcare
4 November 2019
Unwarranted variation - Sustainable Healthcare improvement
@matthew_cripps1
2 |2 |
• Does anyone set out to be an improvement leader?
I ended up here out of frustration…
• “Why do I always have to be the one to say No?”
• “What would we be doing differently if I lived in a world where I got to say Yes?”
• Accidentally invented the RightCare approach…
How do people end up in improvement?
2
3 |3 |
• Is the primary purpose of improvement –
1. To improve the health system, or;
2. To keep the system financially viable so you can continue to improve the health system?
• If it’s both, then the focus of improvement leaders should be -
Where are we letting our population down the most in terms of their healthcare? And;
Where are we wasting the most money doing the letting down?
= The algorithm for the 1st step to healthcare improvement – Where to Look
What’s the point?
3
4 |4 |
Start at the End: What are we trying to deliver? Donabedian’s Point of Optimality
5 |5 |
So, where is the Point of Optimal Value?
Necessary Appropriate Inappropriate Futile
High Low Zero Negative
CLINICAL
ECONOMICVALUE
Resources
BENEFIT
HARM
6 |6 |
• Improving population healthcare in a way that drives financial sustainability
• Triple Value
Triple Value
Allocative
Technical
Personal
Value For Money – The 3 E’s
Economy
Efficiency
Effectiveness
Sustainable Healthcare
7 |7 |
CONSENSUSUNDERLYING CAUSES – Unwarranted variation (Overuse and Underuse)
IMPROVEMENT
• Processing
• Prototyping
• Persuasion
• Persistence
LEADERSHIP
• Evidence-based
• Awareness
• Simplicity
• Enabling
PROCESS PRINCIPLES
• Talk about the same stuff
• Focus on the fix and future
• Demonstrate viability
• Isolate reasons for non-delivery
PROCESS
• Where to Look
• What to Change
• How to Change
KEY INGREDIENTS
• Indicative Data and Evidence
• Clinical Leadership and Engagement
• Improvement Process
BEHAVIOURAL SCIENCE and KNOWLEDGE TRANSFER
TRIPLE VALUE / VFM
• Allocative / Economic
• Technical / Efficient
• Personal / EffectiveSU
STA
INA
BLE
HE
ALT
HC
AR
EKey components of sustainable healthcare improvement
8 |8 |
There is a statistically significant correlation between higher quality, outcomes and patient satisfaction and more clinicians on the boards of NHS organisations
Clinical Leadership and the Changing Governance of Public Hospitals, Public Administration 2015. Veronesi, G., I. Kirkpatrick and F. Vallascas
Clinicians on the Board: What Difference Does It Make?’, Social Science & Medicine, 77, 147–55. (2013) Veronesi, G., I. Kirkpatrick and F. Vallascas
The same researchers also found that, in the absence of extensive financial involvement, more clinical leadership leads to less efficiency
• Add in extensive financial engagement and this goes away
• Leaders in improvement need to make sure everyone is involved
“I never achieved any significant improvement without a manager and an accountant standing next to me” – Professor Sir Bruce Keogh
Key ingredient – Clinical leadership
9 |9 |
The foundations of improvement
• Identify where to focus improvement and follow effective improvement processes
• Lead, ensure and progress via EASE –
Evidence-based positioning, choices and decision-making
Awareness – the first step to improvement
Simplicity – embrace reductionism
Enablers – inputs, processes, outputs & outcomes
• Enabling your team - Push vs Pull
“It is said of a good leader that when the work is done, the aim fulfilled, the people will say “we did this ourselves”” – Lao Tzu
10 |10 |
Evidence-based positioning
• Make sure you know you’re right…
• If we ensure we take evidence-based positions, then we know we’re doing the right thing.
• How many of us do this now (whether instigating, engaging in or resisting change)? For most of us – not as much as we could…
11 |11 |
A bat and ball cost £1.10
The bat costs one pound more than the ball
How much does the ball cost?
Quick and Easy Maths
12 |12 |
Intuitive and considered thinking:‘Thinking Fast and Slow’
• Daniel Kahneman, Nobel science prize winner, psychoanalyst and
behavioural economist - “we all think fast and slow”
• Where are you on the scale?
• His research shows beyond statistical doubt that
If we give a predominance to either fast (intuitive) or slow
(considered) thinking (which most of us do)…
This makes us are more often wrong than if we use both
consistently and when most appropriate
Intuitive Considered
13 |13 |
How do you become more balanced?
“All I know is that I know nothing” - Socrates
• Step 1 - Assume you might be wrong
• Step 2 - Seek further evidence
Ante/ Pre-mortem planning* - Imagine failure – assume you follow your first thought and it goes horribly wrong – what might have happened? Why? Does this mean you should change your first thought?
• Step 3 - Argue with yourself…
*Really effective in getting the most out of your team
14 |14 |
Awareness – What causes variation in healthcare?
The first Atlas of Variation (2009) – destabilised complacency by
highlighting huge and unwarranted variation in:
• Access
• Quality
• Outcome
• Value
Also revealed two other problems:
Overuse – leading to
• Waste
• Patient harm (even when the quality of care is high)- “First do no harm”
Underuse – leading to
• Failure to prevent disease
• Inequity
15 |15 |
Awareness is the 1st step to population healthcare improvement
If the existence of clinical and
financial variation is unknown, the
debate about whether it is
unwarranted cannot take place
16 |16 |
• We have to know where we aren’t very good in order to know where we can get better
“What good is running if you’re on the wrong road?” – German proverb
• This leads to a key concept of leading improvement -
Embrace negatives to create positives
• Where aren’t we very good? Leads to “how do we become good?”
• (In pre-mortem planning) What could go wrong? Leads to “how do we mitigate?”
Awareness – the first step
17 |17 |
Simplicity…
• System Vs Pathway - do people design complexity or simplicity best?
• Thales’ principle of reductionism and Ockham’s Razor
Components (steps in pathways) are simpler to understand than whole systems (FE, UC)
Break down to simple components, design optimal and build back up into complex systems
• Mild heart conditions treatment – change lifestyle first, before prescribed drugs. Learnt this via reductionist research on body chemistry and physiology.
What can the ancient Greeks and the medieval English teach NHS improvement?
18 |18 |
• Leaders of improvement need to, e.g:
• Simplify the problem
Overuse and Underuse
• Simplify how to identify the solution
Focus everyone on “what would we look like if we were as good as we could be?”
• Simplify the process –
Where to Look
What to Change
How to Change
Simplifying Improvement
18
19 |19 | • 19
20 |20 |
• Examined causes of non-elective admissions, A&E attends and costs.
• Identified unique cohorts of patients as highest risk of emergency admission:
CHF & CRF
CHF & COPD
Diabetes, CHF & CRF
Diabetes, IHD & CRF
• Commissioned additional regular primary care contacts for at risk population
and, via system-wide MDTs, developed care plans with the patient
• 24% reduction in targeted non-elective admissions
• 17% reduction in targeted A&E attends
• Now being spread across East Berkshire CCGs and wider STP footprint
Slough CCG – Complex Case Management
21 |21 | NHS Bradford City CCG
Heart disease pathway of a page –
Why Bradford chose CVD
= 95% confidence intervals
Initial contact to end of treatment
22 |22 |
Enablers - Inputs, processes& outputs
• Which are most important to get right? Two minutes in pairs…
• You can have the best inputs in the world but if there’s no (consistent) process, what are you going to do with them?
• Your process can be optimal but if the “way in” isn’t you’ll use it on the wrong things
Dangerous as means you’re good at delivering the wrong stuff
• If you don’t have well articulated outputs, how will you deliver what is needed and know you’ve done the job? And how will you enthuse stakeholders to join in at the beginning?
23 |23 |
Where to Look – The Way In
We believe the most important parts of any process are the ‘way in’ and ‘way out’
24 |24 |
An unambiguous statement
Ann approaches the bank
25 |25 |
Ambiguity
With balaclava on head and gun in hand,
Ann approaches the bank
26 |26 |
Ambiguity
Seeing the ducks on the river,
With balaclava on head and gun in hand,
Ann approaches the bank
27 |27 |
Algorithms & decision-making
• Over 200 studies into decision-making via algorithms vs decision-making
without them
• 60% found that algorithms led to significantly better decision-making
• 40% found that there was no difference
• This is essentially a 100% victory for decision-making via algorithms –
they never lead to lower value decisions and most often lead to higher
value ones.
• How does this manifest in healthcare? E.g. without algorithms,
experienced radiologists contradict themselves 20% of the time when
they see the same image on different occasions.
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Use decision trees for The Way In
• The use of clearly defined decision criteria: Reduces ambiguity
Makes engagement easier
Increases the quality of projects selected
Increases likelihood and impact of delivery
• Do you have these in place? Are you using them?
• Leaders can ensure that they exist and are used…
29 |29 |
Do not
proceedNo
Are there
any health
benefits?
Ideas &
Cases
Is it a
must do?
Can it be
delivered
?
Does it
save
money?
Can it be
made
deliverable?
Prioritise
Yes
Yes
Yes
Yes
Yes
No
Do not
proceedNo
Does it
increase
value*?
Yes
Rate of
Return <12
months
Rate of
Return >12
months
High Priority
RoI* >£250k
Medium Priority
RoI* >£100k
Low Priority
RoI* <£100k
Medium Priority
RoI* >£250k
Low Priority
RoI* <£250k
Set
Tim
eta
ble
fo
r co
mp
leti
on
of
case o
utl
ine*
Blackpool CCG Decision
Tree for prioritising reform
proposals
No
No No
High Priority
RoI* >£500k
30 |30 |
High Intensity Users – Rhian’s story
2BCI (Before Continuous Improvement) – Rhian has an idea
0ADC (After Decision Criteria) – Rhian’s idea adopted, mobilised within 1 month, impact immediate (50 HIUs helped, £2M saved)
1ADC – Rhian taken around the country as living case study, CCGs begin to adopt
3ADC – NHS RightCare industrialised, Rhian’s innovation promoted
5ADC – c.90 CCGs now running HIU programme
6ADC – Long-term Plan announces that all CCGs must adopt in 2019/20
31 |31 |
Why won’t everyone just do what I think?
“What we wish, we readily believe, and what we think,
we imagine others think also” – Julius Caesar
• It might be that what you think is wrong. But, often its
because how we convey what we’re thinking doesn’t
tick other people’s boxes
• So, do we seek to change the boxes they want ticked
(huge cultural and behavioural shift) or is it simpler just
to tick their boxes?
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Enabling - The decision-making table
Consensus
Medic
General
Manager
PH
officer
AHPNurse
LA CEO
CFO
Provider
33 |33 |
Is that all? No….
• Meeting the needs of differing perspectives/objectives/ mandates are part of the equation
• But that alone won’t tackle everything….
• …behaviours and how our minds work matter at least as much…
• An understanding of behavioural science can help all leaders and their teams
34 |34 |
Meet Linda
• Linda is in her mid-30s
• At university she studied political science and her dissertation was
on women’s rights in the post-industrial political landscape
• In her teens and early 20’s she was politically active regularly
attended feminist events and political marches
• Which of the following do you think most likely describes Linda now?
1. Linda is a healthcare manager in a CCG
2. Linda is a healthcare manager in a CCG and member of the
CCG’s equality and diversity working group
3. Linda is a healthcare manager in a CCG, member of the E&D
group and a politically active feminist
35 |35 |
Linda’s probabilities
Healthcare
manager /
member of
E&D
group
Healthcare
manager
Healthcare
Manager /
E&D
Group /
active feminist
36 |36 |
• The 1st rule of probability – “every additional variable makes a thing less likely”
• Ambiguity and Representativeness – scant information lets our fast-thinking grab the available evidence, add in made-up stuff, over-ride statistical fact, and latch on to the person we’d like Linda to be
All without us realising
• Halo effect – we like that Linda is a feminist and that she works in healthcare. This makes it difficult for us to acknowledge the possibility of negatives – such as that the burdens of life have led her to drop her political activation
Broken rules and flawed intuition
37 |37 |
• A poorly chosen font makes us pay less attention to the message in a document, and to be more inclined to disagree with it.
• If you nod whilst seeking to persuade someone, they’re more likely to be persuaded
• People in good moods relax, their considered thinking switches off and they are more likely to make errors of logic.
• If you frown while you think, you’re less likely to be tricked by your intuition
Behavioural science – influencing us all
38 |38 |
Welcome to your practice level data pack on
cardiovascular disease (CVD). This pack helps to identify
variation and opportunities between demographically similar
general practices on key indicators along CVD pathways.
The focus on practice-level variation is to help CCGs to
target their improvement support to the member GP
practices that will most benefit. To this end, GP practices
have been compared with their own demographic cluster
group and not with the CCG’s.
Pick out the most important words in this NHS RightCare narrative…
CCGs and practices can use this pack to target population healthcare improvement and work together to bring quality and value up to that achieved by similar practices, working closely with NHS RightCare and its Delivery Partners.
39 |39 |
Information framing
• Three ways of conveying information –Numbers
Pictures
Narratives
• Don’t assume everyone likes it the way you do - if you want everyone engaged, engage everyone!
40 |40 |
Shaping your case
• Remember you are talking to people not organisations (even when
they represent organisations)
• Avoid ambiguity – you are fighting resistance and cognitive ease! They* are stretched, pressured and looking for justification not to do things
– make your case unequivocal or they will fill gaps with “why its ok not to
do this”
*They = everyone you need to help you
• Think about framing – prime philanthropy and rational egoismMake it something they want to do – “This is the right thing to do for
others. It will also make your life easier and you will feel good about
yourself for doing it”
41 |41 |
Shaping your case
Stay evidence-based but use emotive framing and avoid the fear of
loss (or use it as a lever). The fear of loss….
• Golfers are far more likely to putt successfully when seeking to avoid a
bogey than when seeking to gain a birdie (why? Fear of loss makes them
concentrate more – costs even the great Tiger Woods a shot per
tournament and an average of $1m prize money every year of his career)
• Attempts at large-scale transformation very often fail (why? Because
people focus on what they are losing more than on what they are gaining)
“NHS invests in brand new specialist stroke centres to save lives”
vs
“Local stroke centres closing, ambulance journey times to increase”
42 |42 |
‘Fear of loss’ framing
• Lung cancer survival rates – surgery is significantly better than
radiation in the long term, but surgery has a short-term survival
risk
There is a 90% survival rate at 1 month
There is a 10% risk of mortality within 1 month
• 80+% of lung cancer surgeons recommend surgery when
confronted with the first statistic, less than 50% do when
confronted with the second. But they are the same statistic, framed
differently
• Clinical knowledge is no counter to emotive framing or fear of loss
43 |43 |
• Discharge decisions for psychiatric patients:
Denominator 1 - Patients similar to Mr Jones are estimated to have a 10% probability of committing an act of violence within the first few months of discharge
Denominator 2 – Of every 100 patients similar to Mr Jones, 10 are estimated to commit an act of violence within the first few months of discharge
• Psychologists/ psychiatrists are twice as likely to deny Mr Jones’ discharge when faced with denominator 2 (c.40% vs c.20%)
Denominator Neglect - Impact on healthcare
44 |44 |
Visualisation - a high intensity user
Day
A&E
attends
Admissions Other Treatment
1 2 1 Admission None
2 3 Referred to GP (not followed up) None
4 1 None
6 2 IV Infusion None
7 1 Referred to Haematology None
Total 9 1
45 |45 |
Data visualisation
46 |46 |
Closing the perception gap – The Holy Grail
• The perception gap pervades the system
• 70% of breast surgeons believe a primary concern of women with
breast cancer is to keep their breast
The real number is 7% of informed women
• 95% of people with elective stents think they reduce risk of heart
attack
They don’t (most informed people don’t want one)
• 5x more doctors think patients are the biggest barrier to Shared
Decision Making (SDM) than think medics are
Cochrane found effective SDM is “physician, not patient, dependent”
47 |47 |
Closing the perception gap
“It is far more important to understand the person who has
the disease than it is to know what disease the person has”
48 |48 |
• Often difficult and can be uncomfortable –
“To avoid criticism, say nothing, do nothing, be nothing”
- Aristotle
• Everyone gets to be a Homer, but which one do you want to be?
“Trying is the first step to failure”
– Homer Simpson
“Give me a place to stand and I will move the Earth”
– Homer (The Iliad)
None of this is easy!
Presentation title
49 |49 | Presentation title
@matthew_cripps1
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Knowledge transfer – your internal encyclopaedia
• “Describe something you are passionate about from your personal life, that has nothing to do with healthcare, and tell us what it can teach us about improving the NHS”
• In pairs -
One of you to describe something you are passionate about from your personal life, that has nothing to do with healthcare (2 mins)
Then work together to identify something it can teach us about improving the population’s healthcare (3 mins)
51 |51 |
Knowledge Transfer – what happens when you miss opportunities for prevention?
A lesson from history…
52 |52 |
The fate of the Carthaginians
Positive lessons
• Improvement agenda – Imagine, Design, Build
• Creative optimal design – let’s defeat the enemy with
elephants!
• Innovative problem solving – e.g. how do we get the
elephants across rivers to the battleground?
Answer = elephant rafts!
Negative lessons
• What happens if you have unwarranted variation in
detection and primary and secondary prevention?
53 |53 |
The Second Punic War (218 – 201BCE)
The Carthaginians (modern day Tunisia) were the power in the
Mediterranean basin
IDENTIFICATION OF RISK-FACTOR AND SECONDARY PREVENTION
• Young upstart building a power base
• Needed putting in their place – Rome…
• Pretence for war
Carthage accused Rome of unwarranted variation in their trading
Gave an impossible ultimatum
Declared war when Rome refused to comply
• General Hannibal was given whatever he wanted to attack Rome -
Carthage were willing to pump prime secondary prevention to avoid
future acute exacerbation….
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He wanted elephants…
55 |55 |
Primary prevention
• But before Hannibal, let’s do a lessons learned review to see if Carthage missed any detection and primary prevention opportunities…
• By about 800BCE, Carthage had been founded by Queen Dido
• Meanwhile, over in modern day Turkey – Trojan War ending: Prince Aeneas was leading an escape from Troy These Trojan refugees landed in Carthage and were taken in by Dido
• Then ensued Purcell’s opera –Dido and Aeneas
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Lessons learned review - Detection and Primary Prevention
RISK FACTOR & DETECTION OPPORTUNITY
• Whilst he was there, the gods warned Dido that Aeneas’s descendants would found Rome and Rome would destroy Carthage
PRIMARY PREVENTION FAILURE
• Blinded by love, she let Aeneas and his refugees go and killed herself from sorrow at his departure
• Had she paid attention to the gods, she could have prevented Rome ever happening
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Back to Hannibal & Secondary Prevention
• The war is going well for Carthage – until immediately after…THE BATTLE OF CANNAE (2 August 216BCE)
• Still studied at Sandhurst as an example of missing the perfect opportunity, and the consequences that can follow.
• It also shows that the only thing we learn from history is that we don’t learn from history - the Allied forces repeated the exact same mistake on D-Day
• At Cannae –
All available Roman soldiers had been sent
The Carthaginians annihilated the Roman army
This meant no soldiers in Rome and none between the Carthiginians and the city.
• There wouldn’t be another opportunity to march on a defenceless Rome and destroy it for another 636 years when the Visigoths managed it.
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So, what did Hannibal do?
He just sat still and did nothing.
• Why?
• Fear? Disbelief that it could be this easy? Crisis of confidence?
• Lack of a robust programme plan? Inflexible strategy? Had to
propose it through three committees and then the Board before
he could act?
• No one knows for sure.
• But we do know what happened next….
59 |59 |
Secondary prevention failure – acute exacerbation
• Hannibal finally marched on Rome but
The Roman armies stationed elsewhere had rushed home and the city
was defended again.
• What was the long-tem consequence that occurred due to this lack of
secondary prevention?
ACUTE EXACERBATION – negative population health impact
• Carthage eventually lost the war
• Rome invaded Carthage, destroyed the city and enslaved the population.
• It was the end of Carthage and Rome dominated for 600 years.
Moral of the story
• If we miss our detection, primary and secondary prevention
opportunities then far more acute and costly things happen that might
have been avoided… and that might be the end of us….
@matthew_cripps1
60 |60 | Presentation title
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Remember – you can’t switch it off!
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Switch it off!
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Thank you
Presentation title
@matthew_cripps1
