Healthy Innovation Conference Brochure

8/12/2019 Healthy Innovation Conference Brochure

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Healthy innovation

Bank of America Merrill Lynch5 Canada SquareLondonE14 5AQ

Tuesday 26 February 201308.30 16.15

#healthyinnovation@reformthinktank

Professor Lord Darzi KBE, Earl Howe, Jane Cummings, Ciarn Devane,Dr Victor Dzau, Wayne Felton, Dr Nicolaus Henke, Jamie Heywood, SirThomas Hughes-Hallett, Anant Kumar, Steve Melton, Tim Murphy, Javier

Okhuysen, Sir John Oldham, Cally Palmer CBE, Amy Pott, Viren Shetty,Stephen Thornton, Adrian Wooldridge, Pedro Yrigoyen

Innovative delivery in healthcare

What makes a disruptive innovator?

Innovative delivery models: Accessible primary

care, better hospitals and coordinated careDelivering innovation in the NHS


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Healthy innovation

1www.reform.co.uk @reformthinktank#healthyinnovation

Contents

Programme 2

TheReformteam setting the agenda 5

Innovative delivery in healthcare 6

Innovative delivery models: Accessible primary care 8

Innovative delivery models: Better hospitals 10

Innovative delivery models: Coordinated care 12

Delivering innovation in the NHS 16

Reform More for less 18

Reform Join us in 2013 19

Register your support 20

Kindly supported by:

Reform

45 Great Peter Street

London

SW1P 3LT

T 020 7799 6699

[email protected]

www.reform.co.uk

TheReformResearch Trust is also grateful for a grant towardsthe costs of the event from the Health Foundation


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Healthy innovation

2 www.reform.co.uk @reformthinktank#healthyinnovation

08.30 09.00 Registration and

breakfast

09.00 09.15 Welcome andintroduction

Nick Seddon, Deputy Director,Reform

09.15 09.45 Innovative delivery inhealthcare

Professor Lord Darzi KBE, Chair, Institute of Global Health Innovation, will deliver a keynote speechdescribing the work of the Global Health Policy Forum and the progress made since the Global Health PolicySummit in August 2012 towards the challenge to deliver high quality, affordable and accessible healthcare.

Chair Nick Seddon, Deputy Director,Reform

09.45 10.45 What makes adisruptive innovator?

Innovators are already transforming how healthcare is delivered and organised. These pioneers have challengedestablished models of care and professional assumptions to develop radically different services that arecheaper, more accessible and safer. There are common factors in that make disruptive innovators in healthcaresuccessful. This session explores what it takes to be a disruptive innovator in health.

Dr Victor Dzau, Chair, International Partnership for Innovative Healthcare DeliveryJamie Heywood, Chair, PatientsLikeMe

Viren Shetty, Senior Vice President, Strategy and Planning, Narayana Hrudayalaya

Adrian Wooldridge, Schumpeter Columnist, The Economist

Chair Tom Kibasi, Partner, McKinsey & Company

10.45 11.15 Coffee

11.15 12.00 Innovative deliverymodels: Accessibleprimary care

Effective primary care can produce healthier populations at lower cost. However in both the developed anddeveloping world access to primary care can be limited and quality can be variable. Modern technology has thepotential to transform traditional primary care services based on family physicians, bringing safe and high qualitycare closer to the patient and using a wider range of clinical practitioners.

Pedro Yrigoyen, Co-Founder, MedicallHome

Sir John Oldham, GP and National Clinical Lead, Quality and Productivity, Department of Health

Wayne Felton, Strategic Director of Healthcare, MITIE

Chair Will Tanner, Senior Researcher,Reform

12.00 12.45 Innovative deliverymodels: Betterhospitals

General hospitals are at the core of many health systems, where an increasing variety of medical services andspecialities have been consolidated into single campuses. However this business model has proved highlyinefficient and does not always ensure quality and safety. Specialisation of services and hospital franchises offerways to maximise productivity and improve services for patients.

Javier Okhuysen, Co-Founder, SalaUno

Anant Kumar, Chief Executive Officer, LifeSpring Hospitals

Steve Melton, Chief Executive Officer, Circle

Chair Thomas Cawston, Research Director,Reform

12.45 13.30 Lunch

13.30 14.00 Innovative delivery inthe NHS

Earl Howe, Parliamentary Under-Secretary of State, Department of Healthwill deliver a keynote speechthat setting out how the NHS will achieve faster innovation in healthcare services to improve productivity andquality for patients.


14.00 15.00 Innovative deliverymodels: Coordinatedcare

The fragmentation of traditional health systems has been a driver of costs and waste, and prevented patientsreceiving high quality care. However with patients often needing to obtain services from different providers andspecialties, old professional boundaries have become obsolete. High performing systems are now able tocoordinate care around the needs of patients and encourage population health.

Tim Murphy, President, Beacon Health Strategies

Ciarn Devane, Chief Executive, Macmillan Cancer Support

Jane Cummings, Chief Nurse, NHS Commissioning Board

Amy Pott, Director of Market Access, UK and Ireland, Baxter Healthcare

Chair Pam Garside, Co-Chair, Cambridge Health Network

Programme


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Life. Health. Care.

At Baxter Healthcare, we focus on saving and improving the quality of patients lives.

Building on our 80 year history of medical rsts, we innovate every day to bring the next generation of therapies, technologies and

service to patients and healthcare professionals in the UK.

Working through partnership and consultation with the NHS, we are delivering QIPP through our Evolving Health programme. Visit

our website to nd out more www.baxterhealthcare.co.uk

Healthy innovation

15.00 16.00 Delivering innovation in

the NHS

While the lessons of innovative healthcare are known, diffusion and adoption of best practice remains slow. In

particular, the rate of innovation is faster in the developing world compared to the more developed healthcaresystems such as the NHS. Legacy infrastructure, entrenched professional cultures and perverse incentives havemade the radical innovation that is needed harder. Overcoming these barriers to innovation is a key challenge forpolicy makers.

Sir Thomas Hughes-Hallett, Executive Chair, Institute of Global Health Innovation

Stephen Thornton, Chief Executive, Health Foundation

Dr Nicolaus Henke, Director, McKinsey & Company

Cally Palmer CBE, Chief Executive, The Royal Marsden NHS Foundation Trust


16.00 16.15 Closing remarks Nick Seddon, Deputy Director,Reform,andSir Thomas Hughes-Hallett, Executive Chair, Institute ofGlobal Health Innovationwill sum up and close the event.


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circlepartnership.co.uk

We believe hospitalscan be better


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TheReformteam setting the agenda

Nick Seddon ,

Deputy Director,

Reform

Cathy Corrie,

Researcher,Reform

Andrew Haldenby,

Director,Reform

Tara Majumdar,

Researcher,Reform

Will Tanner,

Senior Researcher,

Reform

Thomas Cawston,

Research Director,

Reform

Healthy innovation



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Professor Lord Darzi KBEThree strands of innovationin the healthcare sector

Health services need to change. The

creeping epidemic of chronic conditions,

and an ageing population, present new

health needs for which our episode focused

health service is poorly suited. As the recent

Francis report emphasised, citizens rightly

expect high quality services that are also

compassionate and patient-centred. Put

these factors together with long term

nancial pressures and it is hard to see

how the NHS can remain sustainablewithout innovation. More of the same

simply wont do.

Innovation can of course mean different

things. I might mean new technology or

drugs. I could be talking about new clinical

practices or business processes. But whats

needed most is scalable service innovation:

in other words, fundamental improvements

in how healthcare is delivered that can be

disseminated throughout the health system.

I think there are three particularly

important types of service innovation on

which the NHS should focus in the coming

years, drawing on what works elsewhere inthe world.

The rst is workforce innovation. Chronic

conditions require a different skill and

workforce mix, orbiting around primary

care. This means fewer specialists in

hospitals, but more nurses, allied health

professionals and paraprofessionals (e.g.

tness and nutritional experts) out in the

community. Interestingly, workforce

innovation is most advanced in countries

like India or Brazil where the key challenge

is a shortage of skilled professionals. We

have much to learn from their experience.

The second type of innovation is

self-care. In industries like air travel and

banking, consumers now assume many

tasks that were previously the responsibility

of providers. Similar opportunities to shift

the boundary between provider and patient

abound in healthcare, mediated by

technology and enabled by patient up-

skilling. Not only could self-care offer the

potential of more cost-effective services,

there is also evidence that it improves

outcomes for those that suffer from asthma,

chronic obstructive pulmonary disease,

diabetes and other common conditions.

Patients involved in their own care are often

more satised too.

A nal area is around personalisedmedicine. It is hard to overstate the changes

this paradigm shift could entail for health

systems. New preventative, diagnostic and

therapeutic services will need to be designed

that are tailored to individuals specic

genomic and specic biomarkers. Patients

will need to understand their particular risk

prole and what they can do to prevent

disease. For other members of the health

ecosystem, such as pharmaceutical rms, a

whole new way of doing business will need

to be found.

Unlocking the benets of these service

innovations will mean radical change at each

level of the system. Policy and regulation

needs to be modernised to take advantage of

more effective workforce models, to allow

patients to maximise the care they can

deliver themselves and to enable the

research and therapies that will make a

reality of personalised medicine. The

professions need to embrace rather than

resist workforce innovation, empower their

patients and translate the immense power of

genomic, proteomic and metabolomic data

into clinical practice. But it is perhaps the

patient who will have to change the most.Future health services will not revolve

around consultants in hospitals; instead,

they will facilitate the active involvement of

users themselves in providing their own

care, drawing on a detailed understanding of

a personalised risk prole, working with

nurses, pharmacists, nutritionists, tness

experts and other advisors more often than

with the specialist doctors of today.

So whilst we desperately need service

innovation, there is no guarantee it will

happen. Stagnation is as likely as progress.

This is one reason why conferences like this

one which aim not only to showcase some

of the best innovations from around the

world, but also to catalyse their uptake in the

NHS are important. This is also the

mission of the Institute of Global Health

Innovation at Imperial College London,

which I direct. The sources of the next phase

of progress in healthcare are becoming

apparent. Now all we have to do is have the

courage to tap them.

Professor Lord Darzi KBE, Chair, Institute

of Global Health Innovation

Earl Howe

Innovative delivery in theNHS

The NHS is full of brilliant people with

brilliant ideas. It has a long and proudrecord of innovation and creativity

stretching back across its 64-year history.

Innovation embraces both the great

discoveries like penicillin and new

techniques such as keyhole surgery, but also

smaller changes in ways of working to

improve patient care, for example the

development of community matrons.

The NHS has an impressive history of

inventions and new ideas but the adoption

and spread of these ideas is too slow, and

sometimes even the best of them fail to

achieve widespread use. Patients have the

right to expect better health, better care andbetter value from their NHS.

Like many other health economies, the

NHS faces a tougher nancial climate. This

means that simply doing more of the same is

no longer an option. We need to do things

differently. Innovation is an essential tool in

helping address the challenges of an ageing

population, chronic disease, health

inequalities and rising public expectations

especially when resources are constrained.

The NHS Chief Executives Review of

Innovation,Innovation, Health and Wealth

led by Sir Ian Carruthers, Chief Executive of

NHS South of England, was designed to seek

views on how the NHS could help accelerate

the spread and uptake of new ideas and

innovations on the ground. Although

responses came from many different

Healthy innovation


Innovative delivery in healthcare


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organisations and individuals, with very

different interests and backgrounds, the

feedback received was very consistent. Our

approach has been to focus on a limited

number of actions:

We should reduce variation in the NHS,

and drive greater compliance with NICE

guidance

Working with industry, we should develop

and publish better innovation uptake

metrics, and more accessible evidence and

information about new ideas

We should establish a more systematic

delivery mechanism for diffusion and

collaboration within the NHS by building

strong cross-boundary networks

We should align organisational, nancial

and personal incentives and investment to

reward and encourage innovation

We should improve arrangements for

procurement in the NHS to drive upquality and value, and to make the NHS a

better place to do business

We should bring about a major shift in

culture within the NHS, and develop our

people by hard wiring innovation into

training and education for managers and

clinicians

We should strengthen leadership in

innovation at all levels of the NHS, set

clearer priorities for innovation, and

sharpen local accountability; and

We should identify and mandate the

adoption of high impact innovations in the

NHS, and make compliance a pre-

qualication requirement for access to

CQUIN payments

On 10th December 2012, Sir David

Nicholson published Creating Change

Innovation, health and wealth: One Year

On. This demonstrated that of the 31

recommendations made inInnovation,

Heath and Wealth, 25 have already been

delivered and the remainder are on track.

We recognise that whilst much has been

achieved, there is more to be done to

develop a culture of innovation that is

spread right across the NHS.Innovation is not just about the future of

the NHS and health and social care, it is

about the future of our countrys economy.

The aim is to make the UK a strategic

partner of choice for global stakeholders

because of its unique health service,

supportive scal environment and world-

class talent and facilities. This will generate

wealth for the economy whilst maintaining

and enhancing the health of the nation.

The NHS remains a major investor and

wealth creator in the UK, and in science and

engineering in particular. NHS success in

adopting innovation helps support growth

in the life sciences industries. That in turn

enables these industries to invest in

developing the technology and services the

NHS needs for its own further development.

It is clear the NHS must raise its game in

developing more effective and more

cost-effective interventions if it is to stay one

step ahead of pressures rather than running

to catch up. In doing so, cost-effective

innovation will not only help to provide the

very best quality of care but will also

invigorate the economy.

Earl Howe, Parliamentary Under-

Secretary of State, Department of Health

Dr Victor DzauWhat makes a disruptiveinnovator?

As we look at the challenges facing health

systems around the world, it becomes

increasingly clear that relying on the same

approaches, methods and ways of thinking

from the last century is not going to drive the

change that this world so desperately needs

in healthcare. When I look at my own

country, the USA, which spends 17 per cent

of GDP on healthcare, I know thatsomething needs to be done very differently

to avoid what will be an unmanageable

situation for many in a matter of years.

Naturally, change has been happening.

For example, the passage of the Affordable

Care Act led to the creation of the Center for

Medicare and Medicaid Innovation, set up

with the remit of testing innovative care and

payment models, and encouraging the broad

adoption of models that provide improved

healthcare at decreased costs.

For a challenge as great as the one were

facing around the world, I believe that we

need to think and act boldly. The termdisruptive innovator may make some of us

feel uncomfortable, and may make some

entrenched organisations feel threatened,

but ultimately, nobody has ever achieved

radical change without creating this sense of

unease. Such is the importance of this topic

that two years ago, Duke Medicine,

McKinsey & Company and the World

Economic Forum co-founded and launched

the International Partnership for Innovative

Healthcare Delivery (IPIHD), designed to

identify these types of innovators and create

a platform for accelerating the growth and

adoption of disruptive innovations in

healthcare delivery.

We have found and learned from some

remarkable models of care from around the

world. Examples include LifeSpring

Hospitals, which delivers babies for a

fraction of the cost of other hospitals in

India by driving process standardisation and

right-skilling of the clinical workforce, and

MedicallHome, a Mexican healthcare

company working in partnership with a

telecommunications company to create

access to advice and triage from doctors as amonthly service accessible via mobile

phone. We can learn a great deal from these

and other models that can help us

understand what epitomises a disruptive

innovator. For me, there are three

underlying facets to this.

Vision, drive and commitment are

pre-requisites to impact to be a true

trailblazer in healthcare you must be able to

clearly envision the change you want to drive

and have a steadfast commitment to forge a

new path in this direction. Secondly, you

must be able to apply game-changingprinciples and lessons centred on tangible

value creation for the health system.

Examples include re-purposing existing

technology and networks to drive efciency,

smart use of human capital in the value

chain and building care around the patient.

Finally, disruptive innovators must be able

to navigate the turbulence of the health

system effectively to ensure widespread

adoption and avoid becoming an island of

innovation in a sea of stagnation.

These unique individuals and

organisations cannot work in isolation. They

need to be connected to each other throughpeer networks that can support and nurture

their work, as well as to partners and

collaborators that can accelerate the

potential impact of their breakthrough

ideas. Only through taking an ecosystem

approach to addressing the challenges in

health systems with different stakeholders

can the need in health systems around the

world be met by the radical new thinking

that disruptive innovators are bringing to

the pitch.

Dr Victor Dzau, Chair, InternationalPartnership for Innovative Healthcare

Delivery

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Pedro YrigoyenMedicallHome and over-the-phone healthcare

MedicallHome was launched in Mexico in

1999 to bring 24/7 access to medical advice

by phone for paying subscribers. Through a

partnership with telecommunications

provider Telmex, MedicallHome offers

over-the-phone triage to 1.2 million families

(over 4 million individuals). For a xed cost

of USD $5 per month, subscribers have

immediate access by phone to qualied

doctors who use Cleveland Clinic protocols

to diagnose and make treatmentrecommendations. Subscribers can access

the MedicallHome network of 6,000 doctors

and 3,200 healthcare delivery sites or

request an in-home doctor visit, all at

reduced prices.

MedicallHomes founders have also created

two mobile applications for smartphones and

are also launching a Medicall portal market,

through which non-members can buy

discounted medical services.

The MedicallHome model is currently

being launched in Colombia and Peru with

local telecommunications companies and

the founders are working toward replicatingit in Ecuador as well. They are also working

with large employers in Mexico to

implement the model as an employee

benet, which could reduce absenteeism f

or employers.

MedicallHome addresses three primary

challenges in the healthcare system in

Mexico. First, access to medical care is a

problem, especially in rural areas. There are

too few doctors and nurses and rural

patients must often travel long distances to

access care. Second, the cost of seeing a

doctor (typically about USD $30) places aburden on low-income individuals, who may

avoid seeking care because of the cost. Third,

there is high variation in quality among care

providers and it is difcult for patients to

identify the best physicians.

The MedicallHome system uses an

existing resource (telephone network) in

order to increase patients access to medical

advice and to eliminate unnecessary travel

to, and payment, for doctor visits.

Nearly two-thirds of the calls are resolved

over the phone, increasing the efciency of

the care delivery system and saving patients

both travel and money. For the calls that

merit referral, patients can choose a doctor

or clinic based on location, price or specialty,

and receive a discounted rate for the visit.The system provides consistent quality of

care, verifying clinicians in the referral

network and using triage protocols from the

Cleveland Clinic for the phone service.

MedicallHome is currently in discussion

with both Federal and State governments in

Mexico over ways to create more widespread

healthcare cost savings. Medicall believes

that pre-screening primary care contacts by

phone could signicantly reduce the costs of

the national health system. Navigating the

political realm of the established

stakeholders in the public health delivery

system has been challenging and they have

encountered resistance to innovation in this

area. Because the social security program for

health has a very high political and popular

prole, Medicall believes that change will

require the support of federal leaders.

Pedro Yrigoyen, Co-Founder,

MedicallHome

Sir John OldhamTechnologically drivenprimary care

The passionate champion of primary care,

the late Barbara Stareld, dened primary

care by enumerating its key functions:

Serving as the rst point of contact for

all new health needs and problems;

delivering long term, person-focused

care; comprehensively meeting all

health needs except those whose rarity

renders it impossible for a generalist to

maintain competence in them; and

coordinating care that must be receivedelsewhere.

Primary care is a highly effective means of

healthcare delivery in terms of cost and

quality, and will never be more necessary

than in the next few decades. The digital

revolution can transform the means by

which the point of contact can be made,

yet healthcare is the industry where

technology is still usually an add-on to

the existing means of service delivery,

as opposed to fundamentally changing

the operating mechanism.

Healthcare lags behind societal changes

in the way that service industry interactswith its users. Healthcare demand will rise.

In Western industrialised countries this

coincides with a lower long term economic

trend that will constrain the response to that

rising demand. In addition, it will shortly be

the Facebook generation that will have long

term conditions; they will wish to interact in

a different way; much more involved in

managing their own care and pulling in

knowledge remotely when they want it. In

emerging economies the penetration of

mobile technology far exceeds the

infrastructure for traditional healthcaredelivery, yet demand for healthcare is rising

in these countries also not least from an

increase in the diseases of greater afuence.

These pressures, in my view, mean it is

inevitable that access to, and utilisation of,

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Healthy innovation


healthcare will have to be more

technologically driven.

The seven challenges that must be

addressed for primary care globally to

realise its potential are:

1. Poor patient access and perceptions

2. Insufcient coordination and integration

3. Low professional prestige and limitedavailability of the workforce

4. Lack of infrastructure investment

5. Misaligned incentives

6. Under-utilisation of information and

technology

7. Variable quality standards and regulation

All of these challenges can be, and have

been, overcome. Around the world,

innovative models of primary care exist that

offer lessons on how to improve things.

Some of the best examples are from

emerging countries who have been much

more innovative in the means of healthcaredelivery because they have had to be.

Disruptive innovation in the West and for

the NHS will require reverse learning and a

willingness and humility to do so.

There are case studies, from different

continents, which show how change can

come about. For example:

Allow patients to access clinicians by

email, phone or Skype, to increase

convenience and reach;

Use whole primary care teams (including

nurses and assistants) to deliver lower

skill healthcare tasks;

Use lay community outreach workers toraise awareness and support change in

behaviour;

Scale-up access to primary care where it is

required in under-served areas.

Policymakers can use these lessons to

improve primary care. Three aspects in

particular will be considered: action on

incentives, information and technology, and

quality standards and regulation. These are

the areas that governments across the world

can most consistently inuence.

Governments cant innovate but can affect

the climate for innovation to occur. Thisapplies equally to the NHS.

Sir John Oldham, GP and National Clinical

Lead, Quality and Productivity,

Department of Health

Wayne FeltonImproving the carepathway

In October 2012 MITIE Group entered the

health and care landscape for the rst time

with the acquisition of the fourth largest

provider of homecare in England and Wales.

It is clear that the system is facing a

considerable challenge: 4 per cent annual

savings against an ageing population that

will see the number of people over the age of85 double within the next 20 years.

The scale of this challenge demands a

transformation in how services are

delivered. This has been possible in other

sectors of the economy such as the insurance

industry. When faced with escalating costs,

reduced income and greater demand,

insurance companies brought all of the

stakeholders together into one single

process with the common aim of delivering

improved customer satisfaction at a

signicantly reduced cost. Implementing

changes to the industry was only possiblebecause it had control over all the key

elements of the provision of insurance. This

is not always the case in health and care,

where the separation of budgets is the

principal hurdle to allowing services to be

reengineered, and can sometimes mean that

the full potential of some services is not used

to reduce costs and improve quality.

Certainly this is the case for homecare

providers. There is an excess of one billion

home visits a year. That is an incredible

number of regular contacts with the types of

individual that drive a huge proportion of

our annual health expenditure. These homevisits provide a signicant opportunity to

conduct the basic checks that could provide

early warning of an event that would result

in a greater cost to the health budget overall.

Yet contracts are let that drive homecare

away from delivering greater value; no scope

for innovation is allowed, the focus is purely

on the cheapest hourly rate.

One major opportunity would be for

homecarers to support the management of

patients with chronic conditions. By way of

example, 2,800,000 people in the UK are

currently diagnosed with diabetes, 90 per

cent with Type II Diabetes. These patients

require regular and frequent monitoring of

blood sugar, insulin levels, weight and blood

pressure, and other clinic visits for diabetic

retinopathy, renal function and podiatry, in

addition to those health problems associated

with poor circulation. This is a signicant

burden in time and travel to patients visiting

multiple clinics, and also to the health

service. The cost of diabetes to the NHS is

over 1.5 million an hour or 10 per cent of

the NHS budget for England and Wales.

This equates to over 25,000 being spent ondiabetes every minute.

In total, an estimated 14 billion pounds

is spent a year on treating diabetes and its

complications, with the cost of treating

complications representing the much higher

cost. The prevalence of diabetes is estimated

to rise to 4 million by 2025. Many of these

patients have problems with mobility, so

even the most basic checks require the use of

the ambulance service. This cost ranges

from a taxi fare to a more signicant amount

for a two man ambulance. How many of

these visits could be covered by a trainedhealthcare assistant supported by the

appropriate telehealth? They could provide

a number of these checks at home in

addition to their existing duties, at little

marginal cost, directly submitting the

results into the GP/hospital database.

Currently decisions are made that impact

on elements of the care pathway to the

potential detriment of other parts. A decision

not to provide a home visit to an individual

could certainly impact the likelihood of that

person being admitted to A&E.

We look forward to the national

introduction of personal health budgets, asthey have produced positive results for

patients in the trial sites. It is encouraging to

see that the budget gure will be produced

as a result of a multi-disciplinary assessment

of the individuals needs. However, it is less

clear how community services paid for by

these budgets will be commissioned. If

brokers are to support decision making with

recipients, how do the brokers keep up to

date with available services? Will there be

the same quality checks on providers? A

multi-disciplinary approach to the sourcing

of social and community care would surelyhelp in the quality and choice of services

available. This may enable some of the

benets above to be realised.

Private providers are part of the care

pathway, eager to provide a high quality

service and work collaboratively with the

NHS and social services to improve patient

lives. We hope that private companies are

seen as partners facing the ongoing

challenges and nding joint solutions for the

benet of patients and carers.

Wayne Felton, Strategic Director of

Healthcare, MITIE


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Anant KumarThere has to be a betterway

Like many social businesses, the genesis for

LifeSpring began with a simple belief:

There has to be a better way. At the time, I

was working in the contraceptive social

marketing program of HLL Lifecare Limited,

an Indian state-owned company that

manufactures and markets contraceptive

products. Whilst working in the family

planning clinics of both private and

government hospitals in Hyderabad to

promote family planning services, I wascontinually disturbed by the conditions in

which low income women were delivering

their babies. The government hospitals I saw

were under-resourced and overcrowded,

leading to difcult conditions for both

patients and medical professionals. There

were not enough beds, doctors, or space to

cope with the number of people needing

care. Pregnant women would wait in long

lines outside the hospital, often having to

pay bribes for minimal services.

Then there were the private hospitals

offering services that were of high quality

but priced out of reach for lower-incomefamilies. However, low income women

would often sell assets or borrow money at

high interest rates to nance a delivery in

private hospitals, as they preferred to receive

a higher standard of care. LifeSpring was

thus born to ll the gap between the existing

options: a hospital that could serve poor

women with affordable, dignied healthcare.

I knew, however, that nancial sustainability

was crucial for a scalable model.

In 2005, we launched our rst hospital as

a pilot. Women would pay a low, all-

inclusive price for a complete delivery

package, and would receive high quality

healthcare services. We would also focus on

customer care, recognising the women as

empowered customers as opposed to

recipients of charity. LifeSpring offers

services that cover the whole range of a

womans pregnancy, as proper antenatal

care is essential to minimising complications

during delivery.

Our low cost model is based on the

following main characteristics: service

specialisation, a no-frills set up, high asset

utilisation, and para-skilling (breaking down

a complex process into simpler tasks that less

skilled professionals can perform repeatedly).

Our prices are one-third to one-half of the

prices charged at other hospitals offering asimilar quality of services.

An additional innovation of our model is

the way we apply frameworks from the

private sector to our work. Extensive data is

collected at LifeSpring, for example from our

customers and operations. We use this data

to streamline operations, keeping costs as

low as possible, and we analyse our customer

socio-economic data and feedback to better

understand their healthcare needs.

Our rst hospital reached operational

protability in 18 months, ahead of our business

plan forecasts. In 2008, LifeSpring received

joint equity funding to scale up our model. Our

investors are Acumen Fund (an American social

venture fund) and HLL Lifecare Limited. With

their $3.8 million in equity, we were able to

grow from one to six hospitals in our rst year

as a private limited company.

LifeSpring has also benetted very

signicantly from a partnership with the

Boston-based Institute for Healthcare

Improvement (IHI). IHIs expertise in

clinical quality improvement has helped

LifeSpring decrease our rates of maternal

and neonatal morbidity, improve clinical

protocol adherence and strengthen a cultureof safety in all of our hospitals. In addition to

these clinical outcomes, our quality

improvement initiatives have

simultaneously increased operational

efciency, leading to a reduction in our

operating costs.

In addition to helping women to deliver

their babies in a safe and affordable way,

LifeSprings operations have indirect effects

as well. We are reducing the burden on

resource-constrained government hospitals

by attracting patients to our hospitals and, by

inuencing the quality of other providers, we

are catalysing an improvement in the quality

of care being offered by the wider market.

Anant Kumar, Chief Executive Ofcer,

LifeSpring Hospitals

Steve MeltonClinically led hospital care

Its now been over a year since Circle began

our ground-breaking contract to run

Hinchingbrooke hospital. Circle is an

employee co-owned partnership, with a

strong belief in clinical leadership, frontline

decision-making and at management

structures. Simply put, we think the people

who know patients best should have the

biggest say in how hospitals are run.

Hospitals are curious entities so bring

unique management challenges. Many

businesses are either solution shops,

diagnosing and consulting like managementconsultancies, legal or architectural rms, or

value adding processors like factories,

manufacturers or farmers. Hospitals never

separated these two functions, and are

therefore a complex hybrid. Whilst on the

one hand the professional services ethos is

vital to free those who know patients best to

make the best decisions for their patients, on

the other hand, hospitals need production

style processes to deliver efciency and total

quality control.

Our solution is the Circle Operating

System. This operating system splits

hospitals into separate clinical units:

clinician-led teams that are handed power to

act as small businesses in their own right,

with control over budgets, staff and rotas.

Each of these clinician leaders is given a seat

on the main hospital board, meaning that

whole tiers of management can be removed

between the board and the ward. Each unit

takes ownership of their own data, including

patient feedback, clinical results and

nancial sustainability, and the clinical

leaders are accountable to their peers on the

board for their teams performance. In this

way, we create a professional servicesenvironment that gives every member of the

team responsibility, and aligns them to a

common purpose. This fosters a culture of

engagement where staff own and solve

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Innovative delivery models:Better hospitals


13/24

problems, and learn to continuously

improve their service.

This system has already produced great

results in Hinchingbrooke. This year

Hinchingbrooke has consistently ranked top

full-service hospital and top A&E out of 46

in the East and Midlands region league.

Clinical mistakes have dropped by 60 percent. The hip and knee unit have reduced

their patients length of stay after an

operation from 5.6 to 3.5 days by learning

best practice from Circle partners in other

hospitals. Every ward and department has

started collecting feedback about patients

hospital experience, and in response weve

scrapped unfair parking nes, over-hauled

menus, and installed bedside TVs and

entertainment systems.

None of this has been easy. It has meant

changes to some peoples roles and rotas.

Others have had to learn new skills, andsome have had to change their shifts and

working patterns. But by giving power and

responsibility to the clinicians and staff who

know patients best, and slashing the

bureaucracy that blocked their ideas from

being implemented before, were seeing

real progress.

For us, the task at Hinchingbrooke is a

marathon not a sprint. We chose to focus

rst on xing quality issues, and were on

our way to balancing the books next year. Its

now time for us to plan the next lap on our

journey, which is making Hinchingbrooke

nancially sustainable for the long term. Weknow this will require an innovative

approach and some radical thinking to

provide comprehensive, joined-up health

services across the area. Thats why were

starting to think about how we can work

with our GP and community service partners

to deliver the regions healthcare in an

integrated way through a networked

approach between different services.

Fundamentally, Circle is about the power

of a partnership model to bring out the best

in healthcare professionals for the benet of

patients. Were committed to doing so acrossthe country for many years to come.

Steve Melton, Chief Executive Ofcer, Circle

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Tim MurphySeizing the valueopportunity

Whether a resident of the United States or the

United Kingdom, we have all personally

experienced the disjointed nature of our

respective healthcare delivery sectors. From

the mind-numbing and repetitive obligation

to repeat the same details every time you

access a healthcare service, to the feeling of

confusion and anxiety when being instructed

only once on how a loved one should

transition their care from an institutional

setting back to the community. We eachexperience healthcare as a set of discrete and

non-coordinated services rather than an

organised system of care. We tolerate this

suboptimal value chain for reasons ranging

from psychological (doctors have special

powers, who am I to question their care

instructions) to bureaucratic (impossible to

change the ways of the NHS, Medicare, you

ll in the blank). Unfortunately, this

tolerance comes with a massive price tag:

poor health outcomes, wasted time, effort,

money and most importantly people living

less well and productive lives.

Given this sad state of affairs, over thepast 20 years numerous efforts have been

initiated to combat poorly coordinated care.

There are many examples of better

coordinated care to achieve improved health

outcomes and cost efciencies.

Improvements in care planning through the

life cycle of complicated procedures (e.g.

UCLAs innovative kidney transplantation

programme), disease management health

coaching for chronic conditions (such as

diabetes and chronic obstructive pulmonary

disease), and the increase in home and

community-based services to avoid

unnecessary institutional lengths of stay are

some examples. In isolation, each of these

attempts does lead to improvements, but the

lack of an established toolkit of best

practices, dissemination mechanisms,

training in coordinated care, and an

accountability ethos for value improvements

limits systematic improvement.

There are many areas in the delivery of

healthcare services that could benet from

integrated and coordinated care approaches.

End-of-life planning and the management of

major non-chronic disease conditions are

examples of very costly episodes of care that

are rife with opportunities to improve value

through better coordination and

communication of care, and should bepursued with vigor. In addition, a massive

value opportunity exists in care coordination

for individuals challenged by multiple

chronic physical conditions, especially those

individuals also suffering concomitantly

with a mental health diagnosis. Individuals

with poorly coordinated care plans for

multiple chronic physical conditions,

combined with a mental health diagnosis,

will continue to spend a signicant sum of

money year after year with limited

improvement in health status.

The following statistics put the care

coordination opportunity for individuals

with multiple chronic physical conditions

and a mental health diagnosis in context:

In the United States, 1 per cent, 5 per cent

and 10 per cent of the total population

consumes 20 per cent, 48 per cent, and 67

per cent of annual healthcare

expenditures, respectively;

Individuals in the 1 per cent higher

spender cohort, 5 per cent higher

spender cohort, and 10 per cent high

spender cohort, expend on average

$76,000, $36,000 and $24,000 per

individual annually, respectively; Almost 50 per cent of the individuals in

the top 10 per cent high spender cohort

in one year will be in the top 10 per cent

higher spender cohort the next year;

Individuals with at least one chronic

physical condition and a functional

impairment (highly correlated with a

mental health diagnosis) account for 14

per cent of the total population;

These individuals consume approximately

46 per cent of annual total healthcare

expenditures;

Approximately 67 per cent of their service

costs are provided in an A&E or inpatient

setting.

The above statistics reveal that individuals

with multiple chronic physical conditions

and a mental health diagnosis are amongst

the highest consumers of healthcare dollars,

that they continue to be high consumers of

healthcare dollars year on year and that

their preferred setting to consume these

services is A&E or inpatient. Finally, the

usage and cost patterns suggest that they are

not improving their health status.

Effective coordinated care planning of

physical, mental and social support for these

individuals on an integrated basis is the key for

lowering annual expenditures and improving

their health status. The means to achieve theseobjectives are more readily available to us

today than in the past. Specically,

Signicant improvements in data

collection and relational databases have

spurred the creation of sophisticated data

warehouses that enable the development

of algorithms to identify individuals with

multiple chronic physical conditions and a

mental health diagnosis;

Once identied, effective engagement

strategies are now more mature and

enable better involvement of these

individuals in a discussion of their health

and welfare needs;

These discussions typically yield into an

agreement for in-person health risk

assessment which will then inform a

person-centred plan, a roadmap to deliver

improvements in health status; and

Experienced care coordinators put in place

supports, services and communication

modalities to ensure that individuals,

families and caregivers are organised in

their efforts to meet the care plans

objectives.

Evidence has shown that the above

approaches can yield savings and healthimprovements. In the United States, Beacon

Health Strategies, a company that provides

care coordination services for individuals

with serious mental illness (who are usually

co-morbid with one or more chronic

physical health conditions), has employed

these strategies to lower total healthcare

costs by 10 20 per cent. A particular case

study in the western area of New York State

of individuals served by Beacons care

coordination services showed:

59 per cent reduction in A&E attendance

62 per cent decrease in the average length

of stay in a mental health inpatient facility

34 per cent decrease in reported self-harm

incidents

44 per cent increase in reported gainful

employment

Innovative delivery models:Coordinated care

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15/24

The appeal of effective care coordination is

that it is not dependent on a breakthrough

drug or technology for savings. All it requires

is timely and reliable information that is

analysed to identify high-using individuals

who could benet from committed team

support. When individuals trained in person-

centered planning coordinate the delivery ofhealthcare and social support, then we have a

truly integrated system of care.

Tim Murphy, President, Beacon Health

Strategies

Ciarn DevaneTime for transformationalchange

Macmillan Cancer Support has spent its rst

century raising awareness of cancer care

needs and nding innovative models to

leverage the delivery of that care. To deal with

todays challenges of an ageing population, an

increase in co-morbidities and a NHS that

needs to signicantly reduce its cost base, we

need to identify and promote more innovative

means of delivering care. Here are some of

our solutions.

First, we need to understand the

population. We now know that there are

over two million people in the UK living with

and beyond a cancer diagnosis; by 2030

this number will double. We also know what

this population looks like at a local level.

We are sharing this data with commissioners

and providers in order to help them

understand and cost the services that are

needed. Commissioning better evidence

on the population needs is essential to keepgoing forward.

Secondly, we need to build awareness and

ensure the generalist community is

supported in its provision of cancer care.

Macmillan has worked in partnership with

GP Update to develop a one-day cancer

course for GPs. To date this has been

delivered in four locations in the UK to

approximately 300 GPs.

One of the biggest lessons from the

course is that GPs have a hugely important

role, not only in cancer prevention and

diagnosis but also in helping patients living

with the disease. To quote one participant:

As a GP you tend to feel that once a

diagnosis is made you dont have that much

involvement after that, but I think the thing

that struck me most from this course was

how practically I could improve care to

patients who already have cancer maybe

not immediately but further down the line.

We surveyed over 250 practice nurses and

found that 86 per cent felt that they could take

on a greater role for cancer with the right

training and skills. We are now running a

number of pilot courses to help increase theircondence and skills to take on a greater role

for cancer. Evaluation is showing that practice

nurses who have undertaken the course feel

more condent about communicating

effectively with people with cancer. They see

themselves as a catalyst in the practice to

provide better support and have an increased

understanding of the benets of exercise and a

healthy lifestyle, supporting people to know

what they can do for themselves.

Thirdly, we need to engage the corporate

sector community in order to create new

relationships and integrate information andsupport. During 2012 we launched a Boots

Macmillan Information Pharmacist role. In

the space of less than nine months over

1,000 pharmacists signed up and completed

cancer awareness training. As a result of

which, they can better support cancer

patients and their families in high street

locations across the UK.

Completing this package has given me

the self-condence to tackle a

conversation with someone with cancer.

Not an easy task, but at least I now have

the knowledge to answer any queries/

concerns that they may have. If I dont

have the answer, I know where to

signpost themSo its not a question

of- to be or not to be a Boots Macmillan

Information Pharmacist, but, why

wouldnt you want to be part of a cancer

care network that can genuinely make a

difference to customers lives?

A Boots Macmillan Information

Pharmacist.

Fourth, we must encourage a shift to

supported self-management at the end of

treatment. A key priority for 2013 will be

implementing the survivorship recoverypackage in every cancer care pathway:

assessment and care planning, treatment

summary and patient education event

(health and wellbeing clinic). From testing,

we believe this will make a signicant

difference to peoples outcomes. We have

successfully worked in London to get this

included within their commissioning

intentions, which we will use as a model to

spread across England.

We know that 80 per cent of people living

with cancer arent physically active enough

to benet their health. During 2012 we took

over the stewardship of Walking for Health,

the largest network of health walk schemes

across England, offering regular short walks

over easy terrain with trained walk leaders.

With more than 600 local schemes, Walking

for Health contributes to improving the

health of over 75,000 regular walkers

nationwide. Weve built up a body of evidence

to show that health walks are a cost-effective

way to improve the nations health. We will be

working to encourage health and social care

professionals to actively signpost to this local

and free service.Fifth, we need to spread innovative

models of end of life care in order to enable

choice and reduce costs. The majority of

people in this country die on a hospital ward,

often against their wishes. Our research

shows that with the right support, 73 per

cent of people with cancer would prefer to

die in their own home while only 27 per cent

wouldnt. In Midhurst Surrey, we have

supported a community based model of care

that facilitates the use of integrated care

packages. Our evaluation of the service

showed that this model extends choice forpatients, clinicians, families and carers,

facilitating 71 per cent of patients to die at

home as part of an integrated specialist

palliative care service. Referral to the

specialist palliative care service was

associated with patients spending fewer

nights in a hospital setting and having fewer

A&E attendances. It is also associated with

fewer deaths occurring in a hospital setting,

which would save the NHS money on

hospital costs in the patients last years of

life. We are now pushing for this model to be

adopted widely across the UK.

Finally, we will need to begin poolingthird sector resources and expertise if there

is to be a push for change within the NHS.

We are a founding member of the Richmond

Group, a coalition of ten cross condition

charities, who are working together as a

collective voice to better inuence health

and social care policy. The Richmond Group

has the aim of improving the care and

support for the 17 million patients we

collectively represent.

The increasing prevalence of long term

conditions will place an unsupportable

burden on the tax payer if we do not redesign

how we deliver health and social care. For

the NHS this means a shift in thinking to

preventing illness and not simply curing

sickness. If this is to be achieved it will

require transformational change and system

re-design, rather than salami-slicing existing

services or incremental improvement. We

want ministers and commissioners to

therefore support our ve-point agenda for

the reformed NHS upon which huge

productivity gains are possible. We ourselves

want to be part of the solution. Involving

patients in decision-making improves

quality and saves money. Ultimately, higherquality care is cheaper care.

Ciarn Devane, Chief Executive, Macmillan

Cancer Support

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16/24

Jane CummingsWhat good looks like

Now, more than ever, innovation has a vital

role to play in delivering higher quality care

and value for money while at the same time

driving economic growth. Patients often

need services from different providers and

specialities, meaning old professional

boundaries have become obsolete. The

publication of the Global burden of diseaseillustrates that it is not limited to the NHS,

but is a worldwide phenomenon. People are

living longer, often developing long term

conditions. The treatments and services we

have at our disposal to reduce the impact of

these conditions on the quality of peoples

lives are expanding year on year.

To provide the care required for the 21st

century, there needs to be a radical shift in

thinking, assumptions, systems and

processes. This means care where the

hospital works with community services,

mental health services, general practice and

social care to provide for people with complexneeds by a team built around those needs.

Firstly, we need to make the individual

and their carers central to the purpose of

every organisation, profession and the

system. The strengthened NHS Constitution

now includes a patients right to receive care

that is coordinated and joined-up around his

or her needs.

The NHS Commissioning Boards role is

not to direct innovative models but to create

a framework within which they can emerge,

be enabled and be supported.

Patient stories repeatedly tell us aboutmany examples of fragmented care. Not only

does this offer patients and service users a

very poor experience of care, but it also puts

them at greater risk of harm due to poor

communication and information sharing,

both between patient and professional and

between different members of a

multidisciplinary team.

With the support of national partners

(Department of Health, Monitor, the Local

Government Association and the

Association of Directors of Adult Social

Services), the NHS Commissioning Board

has commissioned National Voices (anumbrella organisation for a large number of

national health and social care charities) to

develop a single description and denition

of what good integrated care looks like

for an individual. It incorporates a headline

denition: My care is planned with

people who work together to understand

me and my carer(s) put me in control,

co-ordinate and deliver services to achieve

my best outcomes.

The ultimate aim is for all organisations

involved in the delivery and organisation ofhealth, care and support services to adopt

the narrative as a mark of what good looks

like and consider what steps they need to

do to make it a reality for people.

The new Clinical Commissioning Groups

(CCGs) have responsibility for driving

clinically-led commissioning to deliver

better outcomes and have a duty to promote

the integration of care.

Inevitably, there are local barriers to this

which we will all need to address, including

those of organisational culture. The

commissioning and delivery of integratedcare needs to become the practice norm and

not the exception, with the NHS

Commissioning Board and other national

partners, including in local government,

providing the tools, guidance and support to

enable this to happen. Each local system will

need to develop a model of coordinated care

that is appropriate to the local context.

There is no single right model.

At the same time, the new Health and

Wellbeing Boards offer an opportunity for

commissioners to collaborate in ways that

were not previously possible,

commissioning for their populations basedon an agreed Health and Wellbeing strategy

and shared priorities. Equally, both NHS

and local authority commissioners should

develop synergies to help avoid duplication,

maximise the quality of care and be

cost-effective.

The NHS Commissioning Boards

recently published planning framework

for 2013-14,Everyone Counts, sets out

important key steps for local planning. This

includes considering explicitly where and

how commissioning budgets can be

integrated whenever this will advanceshared priorities, and secondly taking the

practical steps to ensure that the people who

will benet, including in particular

vulnerable groups and those with long term

conditions, receive an integrated experience

of care.

At national level, the NHS

Commissioning Board and its key partners,

including the Local Government

Association, Monitor, the Department of

Health, the Association of Directors of Adult

Social Services, Public Health England and

latterly the Association of Directors of

Childrens Services, are collaborating topromote, encourage and enable coordinated

care and support. An early product will be

the publication in May 2013 of a Common

Purpose Framework for integrated care

addressing four key areas: what do we mean

by integrated care; what is the case for

change for integrated care, what are the

national barriers and enablers; and what

tools and support are required to help

deliver integrated care locally.

Our ambition is for an NHS dened by its

commitment to innovation, demonstrated inboth its support for research and its success

in the rapid adoption and diffusion of the

best, transformative and most innovative

ideas, products, services and clinical practice.

Jane Cummings, Chief Nurse, NHS

Commissioning Board

Amy PottCreating a continuum ofcare

As one of the largest suppliers of products

and services to the NHS, with a unique

diversied portfolio, Baxter helps support

the treatment and care of thousands and

thousands of patients at almost every stageof the pathway of care from hospital, to

local community, to home.

With that in mind, we have a

responsibility to support the NHS in its

challenge to deliver excellent, outcome led,

patient centred care, which delivers value

for money for the NHS and for UK

taxpayers. Alongside this we are committed

to investing in the UK and contributing to

the wealth generation agenda.

Healthy innovation requires all

stakeholders to work together in an open

and transparent way to deliver newsolutions. The needs of the NHS are

changing, and we, Baxter (and our Life

Sciences Industry counterparts) need to

change what we do for the NHS to meet

these new demands. The Baxter Evolving

Health Programme has been developed to

partner with the NHS to help meet the

ongoing challenge of delivering quality,

innovation, productivity and prevention

(QIPP). We have worked with the NHS to

look at total care pathways in order to see

where cost savings can be made across the

whole service. We do, and will, challenge

ourselves to bring new perspectives, skillsand resources to the NHS to unlock cost at

the same time as improving patient care.

We have some great examples of

innovative solutions to existing treatment

Healthy innovation



17/24

pathways that have yielded cost savings to the

NHS, at the same time as improving patient

care and experience. These examples are not

limited to single patient types or clinical

settings, and are not about just introducing a

new product to an existing service. They are

about doing things differently managing

services and inventories differently, bringingtelehealth and homecare treatments together

for patients with long term conditions in a

meaningful way and adopting new ways

of treating patients that will reduce hospital

length of stay. All of these solutions require

thinking about the integrated continuum of

care, not simply a single treatment episode.

The next phase of the challenge is

working with the NHS to facilitate

innovations to be spread at scale and pace

throughout the entire organisation, so the

NHS as a whole can realise the benets that

are possible. This will rely on the ongoingstrengthening of the partnership between

the Life Sciences Industry and the NHS and

making sure those partnerships are built on

trust not simply transaction.

Epistaxis:

Epistaxis, or nosebleed, is the most common

ear, nose or throat (ENT) emergency, and in

England over 27,000 patients presented to

secondary care in 2008-9. The mean length

of stay for epistaxis in the UK is over two

days. The aim was to reduce length of stay

without compromising the quality of care. In

2009-10, Aintree University Hospital NHSFoundation Trust had 250 admissions for

epistaxis. Patients stayed a mean of two days

at a minimum cost of 400 per day.

Reducing this by just one day could yield

savings of around 100,000 for the Trust.

There is limited ENT experience in many

emergency departments. Frequently, nasal

packing is used as rst line treatment for

even small volume bleeding when a more

conservative or targeted approach would be

safe and effective.

Floseal is a paste-like haemostatic

matrix designed to stop bleeding quickly.The median time to haemostasis is 120

seconds. The product consists of expansile

bovine gelatine granules coated in human

thrombin. The use of Floseal in persistent

epistaxis through studies has shown shown

statistically signicant improvements in

both patient and physician experience

compared to nasal packing.

Baxter and Aintree jointly agreed that to

truly address the challenges within the

current treatment regimen the service

needed to be redesigned. This service

redesign was primarily intended to address

the training requirements within both A&Eand with the junior doctors who often found

it easier to use nasal packing and habitually

admit patients, rather than identify the

bleeding point and decide on a further

course of treatment. A new treatment

pathway was designed and implemented in

December 2010.

Baxter and Aintree worked in partnership

to implement training, materials and a

multidisciplinary approach to implement

the pathway and the introduction of

Floseal. Implementing the new pathwayhad a direct impact on patients with some

requiring no additional treatment. The

emergency staff were also motivated by the

results to not use nasal packing immediately

as they saw the positive effects on reduction

in length of stay.

An audit conducted after one year of

implementation showed that compared to

the preceding three years, in 2010-11 the

total number of bed days due to epistaxis

was reduced by 30 per cent, and mean

length of stay was reduced by 21 per cent.

Dialysis Access Academy:

Peritoneal Dialysis (PD) is an underutilised

therapy in the UK despite the economic,

clinical and lifestyle benets. NICE guidance

published in 2011 states that peritoneal

dialysis should be considered as the rst

choice treatment modality for people with

established kidney disease and that people

on long-term dialysis receive the best

possible therapy, incorporating regular and

frequent application of dialysis and ideally

home-based or self-care dialysis. Despite

all the legislation and guidelines, there has

been a continuous decline in the number ofpeople having their dialysis at home. Part of

the key to enabling growth of PD is to

provide the easy access to insertion of the

catheter required to perform the treatment.

A positive effect on PD uptake has been

reported where nephrologists insert

catheters under local anaesthesia (LA)

rather than surgeons using general

anaesthetic.

Baxter worked in partnership with

leading nephrologists to develop a robust

clinical training programme and pathway

redesign for the medical insertion of PDcatheters. This team agreed the structure

and content of an accredited four step

training programme for the medical

insertion of PD catheters using the

Percutaneous Seldinger technique. To date,

over 20 teams from UK renal units have

attended the course with excellent success

rates, and positive patient feedback.

Amy Pott, Director of Market Access,

UK and Ireland, Baxter Healthcare

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18/24

Stephen ThorntonDelivering continuousimprovement

Healthcare is of profound importance to us

all, and ensuring high quality healthcare for

everyone is one of the greatest challenges we

face. To meet this challenge, health services

must be continuously seeking to understand

how they can improve.

At the Health Foundation we help people

to take a step back, innovate, and plan the

practicalities of change. We encourage

innovation from across the healthcare

system; a good idea is a good idea, no matterhow small it is or where

it comes from.

Our interest is primarily in the

innovation of how health services are

delivered. We understand that new

technologies are reliant upon innovative

behavioural change if they are to full

their potential to improve care. A paperless

NHS, for example, will not only require a

digital infrastructure that allows sharing of

data across the service and with patients;

it will also demand changes in ways of

working and innovation in the delivery

of new approaches.Approximately 60 per cent of GP

practices already have the technology in

place to allow patients 24-hour online access

to their own patient records, but despite the

Governments decision that all NHS patients

should have this access by 2015, few

practices have seized the opportunity. The

Health Foundations MyRecord project is

exploring how to support general practice in

making records accessible to their patients.

Having the technology in place is only the

starting point. Our project is tackling the

cultural, organisational and psychological

barriers to turning on patient access, as well

as exploring the factors that support

adoption of the technology.

But innovation is not only about brand

new developments. The challenge is as much

about embedding existing innovation in

routine care. The Health Foundation led the

rst major programme to improve patient

safety in the UK: the Safer Patients

Initiative. It was complex and large scale in

its approach to improvement, recognising

that change needed to take place across

whole organisations and systems, rather

than focusing on individual incidents.

This programme had a signicant

inuence on participating hospitals and

their staff, on patient care, and on thewider NHS system. However, achieving

organisation-wide change was extremely

challenging. We learnt that if something

is new to a team in a particular setting

they will see it as innovation even if it is

routine elsewhere. To implement ideas

across the whole of a trust that are in use

in a ward or a unit is innovative in itself

and requires local testing and adaptation

as well as an organisation that is ready to

implement change.

The experience of the National Patient

Safety Agencys Matching Michigan

programme, which sought to replicate the

Michigan Keystone programme led by

Professor Pronovost, also emphasises the

challenge of spreading innovation. The

Health Foundations Lining Up project sent

researchers into intensive care units to

observe the implementation of this nationally

organised infection control programme as it

was happening. The project has found that

the cultural context for an improvement

initiative is profoundly inuential and it is

seeking to learn how an innovation that

works in one setting can be successfully

implemented somewhere else. We will bepublishing this research in spring 2013.

When considering how to deliver

innovation in the NHS its important not to

forget the role of patients. We are working

with the renal team in Yorkshire and the

Humber to provide patients with the option

to undertake self-dialysis on a medical unit

and support them to do so. The project has

helped patients rebuild independence and

control, and introduced exibility into a

previously rigid regimen. Changing practice

in this way demands new behaviours and

skills from both patients and health

professionals. Implementation of this

innovative way of undertaking dialysis has

to be sensitive to each individual patient,

taking account of their whole life their

condence, motivation and well-being.

To learn more about the Health

Foundation and our work to improve the

quality of healthcare visit www.health.org.uk.

Stephen Thornton, Chief Executive, Health

Foundation

Dr Nicolaus Henke, TomKibasi and Stephen MoranWhats holding the NHS

back

The challenges facing the NHS are well

known: how can the service improve access

and raise the quality of care it provides

within an increasingly tight budget?

Innovations in healthcare delivery may

provide some new answers to long-

established problems. Working with the

World Economic Forum and Duke

University, we have created the

International Partnership for Innovations in

Healthcare Delivery. Its role is to support

innovators to scale up their businesses and

promote the spread of innovation around

the world.

Broadly, we observe three models of

innovation emerging. Franchise based

delivery models are businesses that replicate

proven operating models, can rapidly scale

into new delivery channels and deliver

consistent quality through standardisedoperating procedures. Production

specialisation models deliver services at

dramatically lower cost by achieving

economies of scale, very high asset

utilisation and more efcient skill mixes.

Technology enabled delivery models include

the use of digital devices (e.g., voice, text,

data, video over cell phones) to deliver

healthcare services at a distance.

The impact can be dramatic. Aravind

Eye Care System delivers at scale (some 60

per cent of the cataract surgery volumes)

and does so at one-sixth of the unit cost of

the NHS, after allowing for the different

cost bases in England and India. It also

delivers higher quality outcomes with

fewer complication rates. Over a million

households subscribe to MedicallHome

Delivering innovation in the NHS

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19/24

in Mexico, paying $5 on their phone bill,

and the telephone based advice service

solves two-thirds of the cases over the

phone. Hundreds of other innovations

can be found.

So what holds the NHS back from

embracing innovation? What would make

the difference? Here are ve things:

1. Dont let evidence be an excuse.

A proper evaluation of the evidence for

impact is always necessary and must be

part of any plans for new delivery models.

However, true innovation by denition is

unlikely to have signicant codied,

peer-reviewed evidence of impact. The

private sector does not expect good

business ideas to undergo a randomised

control trial. Good management requires

good judgement, and the combination of

courage and common sense.

2. When you commit to change, do it atscale.

Once the business case has been built and

is considered sound, leaders need the

courage to act at scale. Too many pilots

and small scale changes dont gain

traction or get picked up elsewhere in the

service because the prole is too small

and the impact not measurable. Indeed,

many changes can only have impact if

they are executed at scale.

3. Let people who think they can do it

better try.

The NHS needs to let new providers who

want to innovate at least try. Currently,

there are too many barriers preventing

new players entering the market. The

biggest single thing that could be done

would be to open up access to payments

for innovative players.

4. Reward risk taking and dont penalise

failure.

Quality of care must never be

compromised for innovation. Yet at the

same time, the NHS needs to incentivise a

culture where nding innovative ways to

deliver that quality is both respected and

rewarded. Too often incentives are gearedtoward maintaining the status quo.

Innovators should be celebrated and

rewarded. And opening up to innovation

means accepting some things will fail too.

5. Let patients judge success

Patients should be the ultimate judge of

what works and what doesnt. This means

giving them easy to understand

information on the quality and the

efciency of their providers. Patients

need to be able to give rapid feedback on

the care they receive and other patients

need be able to see this. Clinicians need tobe prepared to be visibly accountable for

their performance to patients. With the

right information, patients will have the

freedom to choose great care and

will demand the levels of innovation

they see in their wider lives from their

health service.

There is much to be done if the NHS is to

capture the innovation opportunity.

Dr Nicolaus Henke, Director, Tom Kibasi,

Partner, and Stephen Moran, EngagementManager, McKinsey & Company

Cally Palmer CBEThe NHS: Too big to fail ortoo big to work?

The acceleration of technological advance,

especially in the world of cancer, an ageing

population and economic constraint all

mean that we must do things differently,

and fast, to deliver high quality healthcare.

At The Royal Marsden we have an additional

imperative, to contribute to better ways of

diagnosing and treating cancer globally and

to operate as a test bed of innovation and

good practice for the NHS. These things are

obvious and simple in concept. So why isinnovation so difcult to achieve?

The rst problem is cultural. The NHS is

rightly prized for its ambition to deliver the

highest standards of care to everyone who

needs it, when they need it, in a

technologically advanced and sensitive and

caring manner. However, equity of access

and cultural adherence to a national system

of healthcare often translates as a need to

standardise everything: standardisation of

kit and infrastructure, standardisation of

terms and conditions of service,

standardisation of clinical practice.

However, standardisation andinnovation are not easy bedfellows. The

resistance to an organisation like mine

trialling new technology, new drugs and new

service models is considerable. We address

this locally by asking clinicians to operate as

marketeers, by taking nancial risk, and by

using evidence to demonstrate that

innovation can improve productivity. Why

bring a patient back to hospital 20 times if

Cyberknife technology can produce a better

result in 3 visits? Why treat a patient with a

drug that wont work if a PET/CT scan and

individual tumour proling can ensure more

targeted and effective treatment?

The scale of the NHS can and should be a

wonderful advantage in the diffusion of

research and innovation. It is good to see

that organisations are connecting to spread

good practice and innovation through the

introduction of Academic Health Science

Networks, but it is vital that these acquire a

focus, a sense of purpose, and are subject to

rigorous evaluation of their performance

and output. They must secure the right

balance between engaging their partners

and delivering results for their communities.In my own environment in West and

South London we have recently established

the London Cancer Alliance, covering a

population of 4.8 million, and including two

Academic Health Science Centres, The

Institute of Cancer Research and 17 provider

organisations. Its purpose is to develop

integrated care pathways across a much

larger catchment than ever before,

eradicating duplication and ensuring

patients have seamless and high quality

care, informed by the latest research.

It isnt the simplest organisation. Itcannot supersede the sovereign authority of

individual partners. However, it can, and

does, provide a platform for common data

and information to evaluate and improve

performance, and it is an excellent way of

extending and systematising collaboration

in research and innovation. The excitement

for clinicians is that they are able to set the

agenda rather than receiving direction on

service priorities and service models. The

excitement for scientists is that they have

ready access to a blend of clinical and

academic expertise across a wide clinical

and research network.The NHS works best when it encourages

local innovation, exibility and leadership.

Of course it must set parameters, universal

principles and context, but it does not work

well when it invents, reinvents and applies

systems and processes which are resource

intensive but ineffective in improving care

or encouraging innovation. The best

developments at The Royal Marsden are

those where we have had the freedom as

an NHS Foundation Trust to work to our

strengths, and with our local communities,

to make a difference. This covers everythingfrom developing the latest drug for advanced

prostate cancer for patients worldwide to

trialling real time feedback from patients on

their personal experience of care. We are

frequently asked why we are doing things

differently. A better question is what is

the evidence base and how fast can you roll

this out?

Cally Palmer CBE, Chief Executive, The

Royal Marsden NHS Foundation Trust

Healthy innovation



20/24

ReformMore for less: Case studies

of successful reform

More for less is Reformsnew website

showcasing 35 case studies of successful

public service reform from the UK and

around the world. The website aims to

improve th

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