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Guest editorial Monday 1 November 2010: A 20-20 vision of a wrap-around health service

Professor Terry Young, Chair of Healthcare Systems of the School of Information Systems, Computing and Mathematics, Brunel University, outlines the new approach from the Cumberland Initiative to using modeling techniques to deliver massive improvement in healthcare.

What is the best possible outcome for the NHS in its struggles? Twenty per cent savings? Twenty per cent more care?

At £20,000 per QALY (QALYs are quality-adjusted life years; the way NICE measures health gain, for the time being), that would mean an extra million QALYs a year. Put crudely, it would average out at an extra week of perfect health for each of us every year.

Just now, the landscape is morphing. Maybe the changes will mean that we can have both: a 20:20 vision.

A dozen years ago, I worked for an international group making medical scanners and communications equipment for sectors where customers wanted a combination of kit, software and management services.

Quantifying the value of knowledge
In healthcare, we recognised that we could harness information in new and powerful ways.  But how would we know what it was worth? I am not sure anyone yet knows the answer to this exquisitely tricky problem.

Coming from research, and photonic systems, I picked up my business thinking the hard way. But I knew you only make sales once you convince customers that what is on offer will leave them much better off – either through gains or savings.

The rationale over value at the time was that you bought an application and shed staff (I came to think of this as the ‘buy-and-fire’ proposition).

The redundancies were often at the periphery – record clerks, perhaps – while the benefits to patients, doctors, nurses or anyone else, were intangible and eluded the dialogue around value.

So it seemed that process information, at any rate, offered little to healthcare.

The deferred future of healthcare IT
Nonetheless, and coming to the end of the twentieth century, we could look back on fifty years of IT-backed process development.  Giant companies – EDS, Oracle, SAP and many others – had sprung from a landscape where the wreckage of old manufacture was still evident.  They powered the processes and planning of reinvigorated and new industries with information, to previously unimaginable levels of quality and productivity.

As the Institute for Health Improvement in the US and the Modernisation Agency in the UK rose to the challenge, it looked like healthcare was set for an information-powered era – through the National Programme for IT – of unparalleled productivity and quality.

Well, it didn’t work out then.

But here are four reasons for optimism now:

Firstly, change is inexorably afoot.  It may not be possible to influence it for long, but the impact will be hard to escape.  The last such opportunity was a decade ago, but once again the challenge of delivery is being considered in basic terms and whatever emerges will be different.

Secondly, there is a new focus on patients and integrating services around them.  When Lean Thinking told manufacturers they need to focus on the product and not the production line, the message took a long time to sink in.  It appeared that focusing on millions of components, and their journeys to assembly and on to the customer, represented a fiendishly difficult view.  It drew attention away from the business of grinding out marginally higher efficiencies from the factories, year-on-year.

The emergence last Thursday (October 28th, 2010) of a new College of Medicine (www.collegeofmedicine.org.uk), committed to wrapping the service around the patient – the whole patient – rather than the other way around, is evidence that the tectonic plates are shifting.

Plans for an NHS Staff College (1) to provide a base for strategic planning and leadership development, is another reason to believe that change is not just inevitable, but will be for good – in all senses of the word.

Thirdly, doctors are increasingly seeking or driving the change.  And it won’t work without the doctors.

And finally, as academics, we too are stirring in a new way. This summer, nineteen academics from a dozen universities gathered in Cumberland Lodge at Windsor Great Park, where we hit on the 20:20 vision: 120% of the care delivery – those extra million QALYs – at 80% of current costs.

A model solution
Such a challenge demands a radical approach. Both the military and modern industry rely heavily on models and simulation.  Simple models drive monthly predictions, productivity or inventory – while incredibly complex simulations protect soldiers, sailors and airmen long before the equipment upon which they must rely – and the logistics required to deliver it effectively – reaches the battlescape.

On September 30 and October 1, 2010, we held a second meeting at Trinity Hall, Cambridge.  We recognised that risk-managed process is an achievable policy goal, commissioning goal, and operational goal for healthcare.

And we are identifying the training, metric development, and research, needed to offer credible tools and methods for operations, commissioning and policy.

We identify ourselves as the Cumberland Initiative: there are now around 25 academics from 15 universities or so.  Our next meeting is planned for Lancaster, at the start of December.

If we are right, we might just catch a wave of patient-focused process, and so offer (if the metaphor is not too mixed) a palette of risk-management and process planning tools for NHS staff at all levels.  And that is cause for great optimism.

(1) A Halligan (2010)  The need for an NHS Staff College J R Soc Med  103: 387–391

I would like to thank the many who looked over this manuscript and offered helpful comments, including Sally Brailsford and Jonathan Klein.

Why don’t information industries make a greater impact on care delivery?  IBM Almaden Institute 2010, http://www.youtube.com/watch?v=lyic_yo8Fas

Professor Terry Young: http://www.brunel.ac.uk/~cssttpy/home.htm