A living system: Health and care


What would a Health & Care system say if it could talk?

Hello my name is H.A.C and I am a system. 

I am complex in nature, difficult to understand and challenging to change. I am made from multiple inter-connected horizontal parts but expected to deliver services along vertical cross cutting pathways. My interconnected parts don’t always get on and some never talk at all, but each and every one of them will do all they can to survive. 

If you do not know me and then try to change a part of me, another part of me may no longer work as it should and unintended consequences can occur, which are not my fault. 

To know me is to understand the whole of me. 

To understand the whole of me is to know where my inter-connected parts are aligned and where there is a space between. They tell me that in order to eat an elephant, it is necessary to eat it a piece at a time. So to understand me, is to de-construct me, a piece at a time, pathway by pathway/patient user cohort by patient user cohort, microsystem by microsystem, organisation by organisation. To understand me is to know where I meet and where I fail the needs of those whom I serve, where I am productive and safe and where I am not and where I get it right first time and where I fail time and time again. 

To understand me, gives you the power to change me. 

Design my change properly and I give you the power to control me. Design me poorly and you risk consequences occurring which you never imagined. Consequences which are not my fault. 

To change me; is to change physically how I operate but more importantly how I think and behave. 

To keep that control, you must maintain me, nurture me and continually improve me. To leave my individual components to go their own way, out of context of the whole of me, risks infecting me with ambiguity, inconsistency and variation. Ambiguity, inconsistency and variation are the fuel for failure demand, failure demand at best is re-work, at worst a clinical incident. 

You will have lost control of me. 

To know me is to understand me, to understand me enables to you to change me, to change me gives you the power to control me. 

I am not alone; I am one of 44.

This is an extract from ‘Health & Care; How to connect, integrate and operationalise your local system. 

Download the free white paper to understand how the NHS can tackle this challenge using systems thinking and the Toyota way. 

Building GP Capacity and Resilience: The Productive GP Programme from NHS England



Guest blog, Healthcare - Ross Maynard

Productive General Practice Coach


As one of the coaches on the Productive GP Programme run by NHS England, I work with GP practices to improve their processes, strengthen their resilience and expand their capacity in a number of ways. One of these is to look at frequently attending patients.

The process is fairly simple:

1) Identify those patients who consume the most appointments in the practice

2) Review their patient records to determine if other clinical or support services could be used to ease pressure on appointments and improve patient care.

The systems that GP practices run make it easy to identify those patients that attend frequently. Doctors and practice nurses then get together to review patient information to see if other approaches might help to reduce the demands that these patients place on the practice to release space for other patients. These alternative pathways might include interventions from mental health specialists and other clinical professionals; alternative therapies; as well as voluntary and community groups and services.

In my experience, many of the patients who consume the most GP appointments have mental health or addiction issues. The extent to which other services can help reduce dependency on the GP practice will depend on the provision in the local area. Nevertheless it may be possible to reduce the burden on the GPs alone by taking a more proactive approach to scheduling appointments – sharing appointments between a nurse and GP for example – and being clearer about how often the patient needs to be seen.

Some practices are lucky enough to have the space to arrange clinics specifically for mental health issues; for counselling; and even for advisers to come in to try and address the social issues that lie behind stress and anxiety.

Let me give some examples:

In many surgeries, it is the time of the practice nurses that is under most pressure. In one small practice, with only 2 part-time nurses, training Health Care Assistants to change dressings freed up approximately 150 nurse appointments per year.

In another small practice, frequently attending patients were not much of a problem – there were only 22 patients who had had more than 10 GP appointments each in the past year. However, even there alternative interventions for six of the patients helped reduce the pressure, and gave the patients a more comprehensive care plan.

By contrast, a large urban practice had nearly 800 patients who had 20 or more appointments (GP and nurse) each in the previous year. This equated to 7,900 consulting hours. Nearly 300 of those patients had over 30 appointments in the previous year (nearly 2,000 consulting hours). Here the ongoing work to reduce the impact on resources of patients who, medically, don’t need to be seen so frequently has the potential to release considerable capacity, so that patients trying to get an appointment can be seen more quickly.

With another mid-sized suburban practice, only 15 patients had had 30 or more appointments in the previous year. A review by the GPs identified that 7 of them could be referred to recently enhanced mental health provision in the area.

Of course many patients who attend surgery frequently do need to be there. But taking the time to review records, particularly in a multi-disciplinary meeting, can help identify new approaches and ease some of the pressures. Even a reduction of 10% or 15% in the number of appointments generated by frequent attenders can make an important difference.

And it is not all just about frequently attending patients. “Zero attenders” also represent a golden opportunity for practices to focus on preventative work. Among the patients on the list who have not requested an appointment at all in the last year (the “zero attenders”) many will have conditions where some proactive preventative work will reduce costs for the health service should those conditions worsen. Such groups include those with diabetes, asthma, hypertension, and so on.

For example, one small practice identified 150 patients in the eligible group who had not attended a smear test in the last five years. These patients had had all the usual reminder letters but, rather than let it lie at that, the practice took a proactive approach to telephoning the patients to explain the importance of the test. A reasonable proportion of that group (about 20% at the time of writing) subsequently attended for the test.

Another practice targeted patients in the eligible group who had not undertaken the available bowel cancer screening, as well as those missing their smear tests.

Another small practice focused on high blood pressure, asthma and patients with a BMI over 35+ and, with a coordinated approach, successfully got many of them to attend for health advice and a review of their prescription drugs.

This is the sort of work that GP practices should be doing. It is good for patients and it saves the NHS money in the longer term. Often, however, practices do not get to do as much of this work as they would like because they are dealing with other workload pressures. The Productive GP Programme can help focus on some of these issues to improve processes and develop better plans. Of course this requires a time investment to review processes and activities, but the benefits far outweigh this input.

Addressing the medical needs of patients who request and attend many appointments enables a practice to improve the care it provides and, at the same time, free some capacity to undertake more preventative work with patients who would rather not attend their GP clinic. The data is relatively easy to extract. Time is then needed to review records and develop appropriate plans. The time spent on this valuable work will reap benefits for the practice and help improve the care it provides to its whole community.

Those working in GP practices might like to find out more from their CCG, or visit http://www.gpip.co.uk/ 

Why standards are the first building blocks to change your business


Healthcare - Simon Bricknell

KM&T Senior Managing Consultant

We’re Lean experts at KM&T – but what does that mean? Most of us have either spent time working for Toyota or other manufacturers directly. Those that haven’t, they’ve probably worked in the NHS or have joined us from the start of their careers. What that means is, we’re all really familiar with setting and maintaining ‘Standards’. 

I’ve recently been working on a complex project in General Practices within NHS England. For those that don’t know, a General Practice effectively operates like a small business. That means few decision makers, an informal way of working and a culture that has been developed over years and sometimes in an unplanned way. 

Our work is about helping the Practice to improve its efficiency. That’s not always easy to do with the pressure the NHS is currently under. So what do we do?  

We start small

The term ‘Standardisation’ can turn people off. Instead we use real language terms to softly introduce and maintain Standards. So we always start with a workplace organisation (5S) exercise. Once a workspace is well organised, with everything in its correct place, it’s easy to maintain a well-functioning environment. 

As people start to see the benefit, any barriers come down quickly. 

We get to the root cause

When you’re dealing with something as complicated as medicine, there’s really no way to tell a doctor you’re going to standardise their procedure. But often clinical variation within a practice can cause some real capacity issues. Where one doctor might see a patient once, others may see the very same patient 3, 4 or 5 times. 

So we bring clinical teams together to look at a driver diagram, a simple root cause exercise and then come to a common (clinically led) standard to which the practice is expected to work. It’s a challenging task, but done well, it reduces variation for clinical staff and frees significant practice capacity.

We work with not against

Getting anyone to do something they don’t want to do is never going to end well. Imposing it on them is likely to end in all out revolt. So it’s imperative to work with teams to help make the standards their own. Rarely do we implement standards that haven’t been suggested by the staff we’re working with. 

Communicate relentlessly

I’ve saved the most important for last. If you don’t communicate why you’re doing this, what it means for the organisation, and that you’re fully committed to it, would you expect your staff to buy in? Communicate relentlessly from start to finish to ensure that your standards are met. 

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