Category: Awareness

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Value-for-Money?

We all say we want good value for money from the NHS but what does that mean?

Q1: What do patients value?

Q2: How much public money is consumed by the NHS providing what patients value?

The first question is easier to answer because we are all patients at some time or other. What I value, as a patient, is accurate and complete information that I can use to understand my condition, what the management options are, and what the expected outcomes should be. I need to know this so I can make an informed decision.

What I need and value is a diagnosis, a plan, and a prognosis.

How much money is consumed by the NHS in providing that value is a tricker question to answer. So, to illustrate that I will use a clinical service that I am very familiar with: A hernia service.

A hernia is a condition where an internal part of the body pushes through a weak spot or opening in a surrounding tissue that is meant to hold it in place.

A common type of hernia is one that pushes through the muscles of the abdominal wall, and this sort of hernia can cause severe pain and sometimes even life-threatening complications. So, diagnosing and treating these common hernias is a valued service that the NHS provides.

The commonest hernias are usually quite easy to diagnose. They are lumps that appear in the groin or near the tummy button on standing and coughing or straining, and that go away when lying down and relaxing.

Treating a hernia usually requires an operation, so referral to a surgeon who is experienced in doing these operations is a required step in the care pathway. What the surgeon does first is to confirm the diagnosis, outline the options for treatment together with benefits and risks, and then perform the operation. These are all value-adding steps from the patients perspective.

The time taken for a consultant surgeon to provide this value is easy to estimate. For example, an outpatient consultation to confirm the diagnosis and agree a treatment plan takes about 15 minutes. The operation itself takes about 45 minutes, so that is one hour in total of value-adding work.

So, what does 15 minutes of consultant general surgeon time cost the NHS?

Here’s where an AI-bot can help (p.s. AI = Assisted Investigation). When I asked that question it returned an estimate of about £20 together with a detailed explaination of how that cost was derived. As a tax-payer that sounds like pretty good value for money.

The next question I asked my AI-bot was “How much money does the Treasury (i.e. the UK taxpayer) pay to an NHS service provider to deliver a consultant-led new outpatient appointment?” The answer was £173.

So, if it costs the NHS provider £20 for the consultant surgeon’s time to deliver the diagnosis-and-plan that a patient needs and wants, and the NHS provider is paid £173 for that service, then what is the other £153 needed for?

Finance experts will say “overheads”.

Lean experts will say “non value-adding work”.

So, what is “non value-adding work?”

It turns out there are two sorts: Required and Not required.

Required non value-adding work is necessary to deliver the value-adding work, such as booking a patient into clinic, providing the space for the clinic, employing the reception staff, outpatient nursing staff, and so on.

Not required non value-adding work is not necessary but it happens because things do not always happen right first time. Errors, mistakes and slips generate failures and extra work to avoid, detect and fix. This failure work is expensive, and often very expensive. And that extra work incurs extra cost which gets boiled into the total price.

So, now we know what else contributes to the cost … we are left with a question.

How much of the £153 for every new consultant-led hernia clinic outpatient appointment is spent on non-value-adding-not-required work?

That is a £64,000,000 question. Literally, because that is about the cost to the NHS every year to provide appointments just for patients referred with suspected hernias.

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See-Do-Teach

Improvement implies change, and change implies learningl; so we need to understand how learning works to facilitate change and improvement.

When we learn, we acquire new knowledge, understanding and wisdom. Our ability increases.

Before we can do that we must see the gap between where we are and where we want to be, so that we can focus our attention on filling the gap with the required knowledge, understanding and wisdom. Our awareness must increase before our ability can.

We can sketch a diagram to illustrate the interaction between awareness and ability. The path of learning is shown by the green arrow which starts at the bottom left corner where we are unaware of our inability. Our goal is to master the new knowledge, understanding and wisdom to the point where it becomes second nature. When we can do it without thinking about it.

The first challenge is to see the gap, and to overcome that challenge we need to nurture three traits – willingness, humility and curiosity. We must be willing enough to test our knowledge; we must be humble enough to accept the feedback; and we must be curious enough to ask questions that challenge our assumptions.

Becoming aware of the gap creates an uncomfortable feeling because our awareness increases faster than our ability. But with respect for the ability of others, and with perseverance, discipline and practice we can gradually climb the ability slope to the point where we know how. From that position we can teach how. And over time time our new ability becomes intituive and we become less aware of how we are doing it. That is called “mastery”.

As our ability increases and our awareness decreases (the right hand side of the diagram) we feel a growing sense of confidence and excited anticipation for future learning, change and improvement.

For example, in health care systems it is common to experience what is described as “chronic chaos”. A typical example is a multidisciplinary outpatient clinic that requires the services of a range of specialists to provide specific elements of a patient’s care. The usual experience is a queue of patients waiting (often for hours) and busy staff running around trying to ensure that patients get what they need before the clinic finishes!

The know-how to diagnose and treat the causes of chronic chaos is available, but it is not intuitively obvious (because if it were, we would not have the problematic situation). It starts by making the complex flows within the clinic visible in a way that enables a diagnosis to be established and a plan to be formulated. That visual technique is called a diagnostic Gantt chart and it is over 100 years since it was invented by Henry L Gantt.

One of the most rewarding experiences in health care improvement is to see the surprise and delight on the faces of the staff when they see the behaviour of their clinic as a picture on the wall, and then clearly see a path ahead to a calmer and more productive service.

This is not achieved by someone doing it for them. It is achieved by someone with know-how gently raising a bit of awareness then supporting the clinic team to develop their own ability. This is called the study-plan-do cycle of learning which is the engine of the see-do-teach framework.