1 00:00:10,990 --> 00:00:20,860 So good morning, everyone, and welcome to the surgical Kinahan's. As I said last week, we're very privileged today to have a surgeon giving us a talk. 2 00:00:20,860 --> 00:00:25,120 Hamish is a senior management consultant. 3 00:00:25,120 --> 00:00:34,930 He really has dedicated his time in delivering better service outcomes and cost reductions across NHS and adult social care. 4 00:00:34,930 --> 00:00:45,940 So music to the ears of management to, as you see, are abandoned in the audience this morning. 5 00:00:45,940 --> 00:00:56,320 Hamish has pioneered a new way to better understand and improve services and systems from the perspective of the patient, 6 00:00:56,320 --> 00:01:05,950 which is really very novel and interesting. So he fuses operational research on patient improvement to achieve better health care. 7 00:01:05,950 --> 00:01:12,220 In a nutshell, and who are you looking forward to you telling us about it? 8 00:01:12,220 --> 00:01:16,030 Hamish, and thank you for coming all the way. Good morning, all. 9 00:01:16,030 --> 00:01:24,190 Thank you, Fadi. As fully outlined, I'm not a clinician and you hear me. 10 00:01:24,190 --> 00:01:29,710 My background is management consulting. Sorry, that's right. 11 00:01:29,710 --> 00:01:38,320 But it's okay because I mean, you no harm because I know you guys have had quite a few experiences with a variety of management consultants, 12 00:01:38,320 --> 00:01:47,170 past president and present, no doubt future. I have actually worked in the NHS in a management capacity and impact services. 13 00:01:47,170 --> 00:01:54,130 And before that, I spent slightly longer university, so I wanted to be an academic and hopefully you'll see this through this work. 14 00:01:54,130 --> 00:02:01,030 It was five years ago through a combination of personal experience. My father died of vascular dementia and professional experience. 15 00:02:01,030 --> 00:02:09,010 I saw the the dysfunctional ization of what we've done in health care, and it's no clinicians fault. 16 00:02:09,010 --> 00:02:15,700 It's just the way we have badly designed, managed and thought about how we try to improve health care. 17 00:02:15,700 --> 00:02:21,400 I passionately believe in the last 40 years. We've done a number of things very badly. 18 00:02:21,400 --> 00:02:28,160 We've tried to commercialise health care. We've tried to over medicalised, over specialise and then we fragment lies. 19 00:02:28,160 --> 00:02:33,910 If that's even a word health care, when actually, I think what we need to do is we humanise it, 20 00:02:33,910 --> 00:02:37,690 bring it back to the reason why we have health care and I mean health care. 21 00:02:37,690 --> 00:02:45,520 And in the general sense, I, for one, for example, don't see these arbitrary distinctions between adult social care and community services. 22 00:02:45,520 --> 00:02:51,700 I've never met anyone who can tell me the difference between the two, and I've worked in both primary care too. 23 00:02:51,700 --> 00:03:01,270 I'm a firm believer in designing services against patient demand, of which you're about to hear a lot of there's a lot of slides. 24 00:03:01,270 --> 00:03:09,700 So bear with me. Hopefully they're all value adding in an hour or so, you can tell me whether that's true or not. 25 00:03:09,700 --> 00:03:14,560 I'm going to give you two quotes, one to start with and one to finish with. 26 00:03:14,560 --> 00:03:21,550 The first one is a management guru who I have a lot of time for and a lot respect for. 27 00:03:21,550 --> 00:03:29,570 It's a short, pithy quote, but I just want you to capture that and remember this as we talk. 28 00:03:29,570 --> 00:03:42,420 And then the quote at the end will be a medical quote. Do three things we introduce what I call humanising health care, what it is. 29 00:03:42,420 --> 00:03:47,590 Contrast it with current conventional approaches and then outline what it isn't. 30 00:03:47,590 --> 00:03:57,870 I'm going to give you a rare example of a large District General Hospital, and I've covered teaching hospitals such as this one. 31 00:03:57,870 --> 00:04:03,210 I've covered specialist hospitals such as Moorfields and I've covered district panels. 32 00:04:03,210 --> 00:04:09,690 I've covered community mental health, have covered primary care. I've even done this in adult social care and children's services. 33 00:04:09,690 --> 00:04:14,910 And the amazing thing is the pattern is the same everywhere. 34 00:04:14,910 --> 00:04:17,790 But it will change convention and equally, 35 00:04:17,790 --> 00:04:28,800 how we go about driving and delivering improvement in service organisations and health care is a complex service organisation has to change too. 36 00:04:28,800 --> 00:04:37,560 On the start with the red herrings, as I call them a commonly held health care beliefs, I don't think anyone would disagree. 37 00:04:37,560 --> 00:04:43,200 Well, I'm going to ask, does anyone disagree with those three beliefs? 38 00:04:43,200 --> 00:04:49,950 Because we hear about these all the time. One is that we've got an ageing, growing elderly population. 39 00:04:49,950 --> 00:04:54,570 Statistically, numerically, that is true. People are getting older. 40 00:04:54,570 --> 00:05:03,000 Second, that people want more and more. You and I demand more and more of expectations on health care services. 41 00:05:03,000 --> 00:05:07,170 And the third one is because of the first two. 42 00:05:07,170 --> 00:05:17,590 There's more demand on the system. Well, I'm going to challenge that third one, because empirically, that's not true. 43 00:05:17,590 --> 00:05:23,020 OK, I will challenge the second one because we don't collect the data in any such sophisticated, 44 00:05:23,020 --> 00:05:29,530 intelligent way to be able to tell us actually whether that's empirically true. That's an anecdote I have experience of. 45 00:05:29,530 --> 00:05:35,260 I believe therefore you're demanding something I can't give you. That's not the same thing. 46 00:05:35,260 --> 00:05:40,370 By the way, the friends and family test is not an intelligent gauge of expectation. 47 00:05:40,370 --> 00:05:50,350 The net promoter schools and all of that good stuff doesn't work, and it is possible that you can get old and die gracefully. 48 00:05:50,350 --> 00:05:59,290 Maybe with one two three four co-morbidities with complex conditions and not cause much problems to the health care system, OK? 49 00:05:59,290 --> 00:06:08,590 It's equally apparent, and you're going to see an actual case of this that you can be in your teens, 20s, 30s, 40s and your life. 50 00:06:08,590 --> 00:06:15,610 Be off the rails and cause an awful lot of demand on health care services. 51 00:06:15,610 --> 00:06:19,390 I think this is a universal truism. I think it applies to all health care systems. 52 00:06:19,390 --> 00:06:26,710 I've given talks in a number of other countries and because they see the UK now and it just as world leaders, 53 00:06:26,710 --> 00:06:35,470 they tend to copy, but they tend to copy all bad ideas and concepts as well. 54 00:06:35,470 --> 00:06:46,900 Conventional analysis on the left hand side is what I referred to, and I mentioned it to him just a few moments ago is activity obsession disorder. 55 00:06:46,900 --> 00:06:48,640 It's the belief that you can design, 56 00:06:48,640 --> 00:06:56,710 manage and improve complex service systems such as health care on an understanding only of activity work activity. 57 00:06:56,710 --> 00:07:02,350 And off the back of that, you can drive down costs. And that will improve services. 58 00:07:02,350 --> 00:07:11,470 We do this year in year out in cost improvement schemes, in patient flow programmes and in commissioning well, 59 00:07:11,470 --> 00:07:16,900 they spend an awful lot of time doing exactly the same in their equip programme, equip schemes. 60 00:07:16,900 --> 00:07:25,120 And then we think we we then have to drive things harder and we make more assumptions. 61 00:07:25,120 --> 00:07:28,840 I think this is fundamentally the wrong thing to do. 62 00:07:28,840 --> 00:07:35,740 I call this back to front thinking, or it's like trying to drive your motor vehicle via the rear-view mirror. 63 00:07:35,740 --> 00:07:40,780 There's two guaranteed outcomes of this and this is convention how we do it. 64 00:07:40,780 --> 00:07:47,050 You're going to go really, really slowly. And at some point in time, you're going to crash and it's going to be expensive. 65 00:07:47,050 --> 00:07:52,690 I think the outcomes are that we save up to my services. Dreadful phrase. 66 00:07:52,690 --> 00:08:00,400 We give poor patients experience. It results in higher costs and it reduces staff morale. 67 00:08:00,400 --> 00:08:08,950 It demoralises people. Humanising health care, on the other hand, is actually, why don't we just stop and ask, 68 00:08:08,950 --> 00:08:13,930 who are the people we're doing work activity two and how much is that costing? 69 00:08:13,930 --> 00:08:25,030 And asked these questions around why. I think it's it's it's elegant, it's simple, it gets to the nub of the problem, 70 00:08:25,030 --> 00:08:33,220 and then improvement is not about spending an eternity in management meetings, 71 00:08:33,220 --> 00:08:42,610 devising more paperwork and then trying to project manage that paperwork and never seeing anything happen in the real world. 72 00:08:42,610 --> 00:08:54,480 It's about management, people working with clinicians and medical staff and frontline redesigning services around cohorts of patients. 73 00:08:54,480 --> 00:08:58,410 Not making big assumptions around arbitrary pathways. 74 00:08:58,410 --> 00:09:08,760 OK, such as the world's greatest diabetes pathway, and I ask a simple question how linear diabetes patients do you ever see in a year? 75 00:09:08,760 --> 00:09:16,140 And the answer is none. OK, because everyone that has diabetes will have two, three, four or five other conditions as well. 76 00:09:16,140 --> 00:09:23,310 And so even if you have a world class diabetes service, if everything else doesn't work, they will still fall through the gaps. 77 00:09:23,310 --> 00:09:27,330 And that's what you see points of principle. 78 00:09:27,330 --> 00:09:31,650 I'm not going to go through each of these, but effectively this work is about understanding. 79 00:09:31,650 --> 00:09:40,140 Patient demand is the first point. How many people cause us to do, how much work activity leads to how much costs? 80 00:09:40,140 --> 00:09:50,550 Humanising the analysis is important. As a consequence of that, I use a really simple framework, which is what I call pack people activity costs. 81 00:09:50,550 --> 00:09:55,620 OK? Understand the former to understand the latter. 82 00:09:55,620 --> 00:10:07,140 And you do exactly the same in improvement. OK. And the last one, I think, is really important that systems inform patient behaviour. 83 00:10:07,140 --> 00:10:11,580 I think it is the case that for the majority of people, the way they behave, 84 00:10:11,580 --> 00:10:17,600 whether they be professionals or patients, is a consequence of how they're treated. 85 00:10:17,600 --> 00:10:21,110 Others may disagree, but I think we have to show that empirically, 86 00:10:21,110 --> 00:10:29,360 I hope this work relies on the preto principle of which I'm sure you're all very well aware of. 87 00:10:29,360 --> 00:10:36,080 It's funny that we don't use it, though, in systems and understanding and designing them because it's a natural law. 88 00:10:36,080 --> 00:10:44,930 Not my word phrase, but Joseph Duran, who is now departed American management guru. 89 00:10:44,930 --> 00:10:52,430 Bear in mind those that phrase, the vital few and the useful many, because I will use that quite a bit in what you're about to hear. 90 00:10:52,430 --> 00:11:00,620 It is the case that demand patient demand is on the even small numbers drive all the activity and all the costs. 91 00:11:00,620 --> 00:11:09,560 But yet we don't design and manage and improve our health care systems based on that knowledge in any sensible, systematic way. 92 00:11:09,560 --> 00:11:16,370 How humanising health care works and I hope you like to the dumbbell diagram is. 93 00:11:16,370 --> 00:11:23,810 A heavy focus on research, and that research is not about crunching numbers, so you'll see a lot of numbers in a few moments, 94 00:11:23,810 --> 00:11:32,960 but it's about combining quantitative analysis with qualitative analysis, understanding what and why things work the way they do. 95 00:11:32,960 --> 00:11:43,130 Once you do that and fuse what cooperation research techniques actually gives you everything you need to know in order to improve your service. 96 00:11:43,130 --> 00:11:52,950 The second stage is iteratively redesigning systems and services around cohorts of patients, not pathways. 97 00:11:52,950 --> 00:11:58,140 To improve outcomes, reduce costs and create greater sustainability. 98 00:11:58,140 --> 00:12:02,940 And then the third phase is effectively sustaining and scaling that. 99 00:12:02,940 --> 00:12:09,510 So can we increase the volumes of the cohorts of the patients and take into areas where we hitherto haven't done so far? 100 00:12:09,510 --> 00:12:17,550 That is distinct from how we conventionally do analysis and do improvement. 101 00:12:17,550 --> 00:12:26,010 Another way of describing it is if you understand the what in the why, that will inform you as to how and where you do improvement. 102 00:12:26,010 --> 00:12:30,090 And I will come back to technology at the end of this presentation. 103 00:12:30,090 --> 00:12:34,530 But for me, technology is the last thing you think about. Not the first thing. 104 00:12:34,530 --> 00:12:42,730 OK, technology works on simple, routine processes and procedures often. 105 00:12:42,730 --> 00:12:52,390 What we do is we make some mistake of taking a complex process and thinking we can digitalise it with disastrous consequences. 106 00:12:52,390 --> 00:12:56,850 I'll come back to that later. So far, so good. 107 00:12:56,850 --> 00:12:59,220 That's the theory and the approach out the way. 108 00:12:59,220 --> 00:13:07,530 Now I'm going to talk about how you analyse health care and when you analyse health care from this point, what you find. 109 00:13:07,530 --> 00:13:13,930 As I said, I'm going to use a real life example. This is a large district general in the south of England. 110 00:13:13,930 --> 00:13:18,540 But I'll let you into a little secret. I have done this work in Oxford and just in not too distant past, 111 00:13:18,540 --> 00:13:24,570 and the patterns are exactly the same, whether they're a teaching hospital or a district hospital. 112 00:13:24,570 --> 00:13:26,190 What do I mean by demand? 113 00:13:26,190 --> 00:13:37,170 Demands for me is person shaped how many interactions a human being has with a service in any minute, hour, week, month, year? 114 00:13:37,170 --> 00:13:45,300 And here's the trick. Multiple years. So this work looks at time series data, something I find in management. 115 00:13:45,300 --> 00:13:54,120 At least we never do. We try and benchmark performance over the last financial call to last year's quarter, and then we make assumptions. 116 00:13:54,120 --> 00:13:59,940 It also turns on its head the idea of population health management. What do I mean by that? 117 00:13:59,940 --> 00:14:06,840 Well, in this constituency, this hospital thought it catered for half a million. 118 00:14:06,840 --> 00:14:13,710 Now, where it got that figure from was the combined populations of half a million people, 119 00:14:13,710 --> 00:14:18,270 but it didn't actually see anything like half a million people coming through its doors. 120 00:14:18,270 --> 00:14:23,940 Every year, it saw less than one hundred sixty three thousand. 121 00:14:23,940 --> 00:14:30,750 I've got five years worth of time series data, and that's my rule of thumb to go back five years on the top. 122 00:14:30,750 --> 00:14:36,480 The absolute demand is absolute human beings who enter this hospital in any shape or 123 00:14:36,480 --> 00:14:42,810 form that might be for several outpatient appointments or 180 visits in any one year. 124 00:14:42,810 --> 00:14:49,600 You'll see the mess that we've got. Rising demand is not truth. 125 00:14:49,600 --> 00:14:56,050 Because that population growth is actually less than the locality population growth that the hospital served. 126 00:14:56,050 --> 00:15:06,310 And this is a truism that I found in urban areas or rural areas, whether it's small district hospitals or it's large teaching hospitals, 127 00:15:06,310 --> 00:15:16,420 that will get some people cognitive dissonance for sure, because the media beliefs are and what we are told all the time is that demand is rising. 128 00:15:16,420 --> 00:15:23,530 Well, we capture demand incorrectly. It's activity that we record, monitor and measure. 129 00:15:23,530 --> 00:15:32,350 Why? Because our health care system, certainly in England, is based on tariffs work activity, meaning more activity, more money. 130 00:15:32,350 --> 00:15:42,790 That's not true, either expressed in percentage terms. It's just it's a steady state in every health care economy, including this one. 131 00:15:42,790 --> 00:15:48,010 About a third of the population will use the acute in any shape or form. 132 00:15:48,010 --> 00:15:54,350 Two thirds were in primary care, the balance is different, and if you're interested in that, I'd encourage you to watch my TED. 133 00:15:54,350 --> 00:16:00,080 I did a couple of years ago where I talk about primary care and I was here. 134 00:16:00,080 --> 00:16:06,380 Thoughts on that. Before I move on. 135 00:16:06,380 --> 00:16:17,380 Because that does challenge convention. You can't improve healthcare services, looking activity and cost. 136 00:16:17,380 --> 00:16:20,470 They are lagging indicators of what you've done. 137 00:16:20,470 --> 00:16:31,140 You need to look at a leading indicator and the best leading indicator is the people aspect is that'll determine what the activity needs to be. 138 00:16:31,140 --> 00:16:36,630 This is the same hospital, this is a decomposition chart for one year using my pack framework. 139 00:16:36,630 --> 00:16:46,140 So that is showing you every body that came in in a financial period 12 months into this hospital and how they filtered through. 140 00:16:46,140 --> 00:16:51,500 We do not do this in health care analysis, and I think we need to. 141 00:16:51,500 --> 00:16:58,700 That's the framework explained, that's how the hundred and sixty three thousand get filtered down if I just for this moment in time, 142 00:16:58,700 --> 00:17:10,580 focus on what we now refer to as E.D. You'll see that actually this hospital doesn't cater for half a million in an urgent, urgent and emergency care. 143 00:17:10,580 --> 00:17:19,400 It doesn't even cater for one hundred sixty three thousand. Predictably, it will see sixty three thousand people in any shape or form every year. 144 00:17:19,400 --> 00:17:21,470 That's about 13 percent. And the rule of thumb, 145 00:17:21,470 --> 00:17:32,010 I found doing this in eight or nine areas now is that that tiny percentage varies between twelve to about 14 percent everywhere. 146 00:17:32,010 --> 00:17:39,060 And then when it comes to how many do we admit the challenge isn't even 60 odd thousand people, 147 00:17:39,060 --> 00:17:48,050 it gets lower to 20000 people, which equates to about four percent. 148 00:17:48,050 --> 00:17:55,340 OK. Because you can't actually improve health care systems on a hundred and sixty three thousand people, 149 00:17:55,340 --> 00:18:01,140 but that's fine because you don't have to in urgent and emergency care. 150 00:18:01,140 --> 00:18:06,270 The other interesting thing in health care is that it is complex. 151 00:18:06,270 --> 00:18:13,410 It is more complicated than, say, retail, because you're dealing with different customer bases in elected plan care. 152 00:18:13,410 --> 00:18:21,810 By and large, you're dealing with different people. They are not the same as those that you will see in urgent and emergency care. 153 00:18:21,810 --> 00:18:27,300 When you see both of them appearing in the system, that's actually telling you something. 154 00:18:27,300 --> 00:18:31,530 And that's A. I'm going to talk about later in this presentation. 155 00:18:31,530 --> 00:18:39,660 It's called plank care tipping. It's when you see loads of elective care patients who have tipped from planned care into emergency care. 156 00:18:39,660 --> 00:18:43,890 That's the signal that the design of the elective services isn't working. 157 00:18:43,890 --> 00:18:52,110 So a number of those patients. However, when you fuse the data together and what do I mean by that? 158 00:18:52,110 --> 00:18:57,990 Well, in the acute world, it's how many times do we see you in the urgent care system versus the plan care system? 159 00:18:57,990 --> 00:19:03,930 You come at the pyramid of consumption, which is what I call the vital few. 160 00:19:03,930 --> 00:19:11,220 It's the same here as well. This hospital actually rested on eight thousand five hundred unique human beings. 161 00:19:11,220 --> 00:19:17,370 They were behind a third of all the work that was done year in, year out. 162 00:19:17,370 --> 00:19:25,890 At the top of that tree, there was less than 4500 people, and you're going to see an example of what we did with just one of them. 163 00:19:25,890 --> 00:19:32,250 In the top one percent, this work actually challenges the Kaiser Permanente logic as well. 164 00:19:32,250 --> 00:19:41,250 Kaiser Permanente now is about 30 40 years old. The thinking at the top of the apex of hospitals and health care systems are increasingly far away. 165 00:19:41,250 --> 00:19:46,860 Elderly people whose job is you've got to manage them, who run their complex co-morbidities. 166 00:19:46,860 --> 00:19:53,460 In other words, they're old. They've got loads of things going wrong with them, and therefore you have to case management. 167 00:19:53,460 --> 00:20:04,220 Thus, statistically and empirically not true, of which we'll explain in a few moments time. 168 00:20:04,220 --> 00:20:12,620 What you're seeing here are two protocols applied using the pack framework over 12 months looking at A&E attendances and admissions. 169 00:20:12,620 --> 00:20:22,520 On the left hand side is attendances. You see that figure of 60000 people at the bottom row and admissions on the right hand side looking at 20000. 170 00:20:22,520 --> 00:20:27,590 Now, if we're wanting to do something to improve our performance on the four hour target, 171 00:20:27,590 --> 00:20:36,110 for example, and achieve perhaps the the triple aim of the NHS, 172 00:20:36,110 --> 00:20:44,120 we don't even have to think about it as a sixty thousand people challenge or 20000 people challenge because as you see in attendances, 173 00:20:44,120 --> 00:20:54,670 and it will be the same here as well. Every year, five percent of the work is actually just over 3000 people. 174 00:20:54,670 --> 00:21:02,980 Sorry, I correct myself. Five percent of people, three thousand of the high, nearly 20 percent of all the activity in the world in attendances. 175 00:21:02,980 --> 00:21:09,580 OK, so if we want to do something sensibly in a separate for a world or a vanguard well or care integration world, 176 00:21:09,580 --> 00:21:13,900 let's go find out about these 3000 people. What's happening in their world. 177 00:21:13,900 --> 00:21:20,100 And how do we need to redesign that? Flipped over to admissions. 178 00:21:20,100 --> 00:21:27,810 You see, the numbers get even smaller. Keep your mind's eye on the one percent, the three percent, the five percent. 179 00:21:27,810 --> 00:21:32,520 Again, even when it comes to admissions activity in emergency care, 180 00:21:32,520 --> 00:21:37,140 we're dealing with just over a thousand people, nearly behind 20 percent of everything we do. 181 00:21:37,140 --> 00:21:43,590 Why are those numbers 218, six, five two and one thousand eighty four important? 182 00:21:43,590 --> 00:21:51,420 Because that's the big problem. This is emergency bed capacity in this hospital. 183 00:21:51,420 --> 00:21:58,350 Now I will challenge it because this is also a true truism I found in every hospital again 184 00:21:58,350 --> 00:22:02,940 that we don't have a bed capacity problem as much as we've got a service capability problem. 185 00:22:02,940 --> 00:22:08,770 We never asked the question how many of the same people are in our beds year in, year out? 186 00:22:08,770 --> 00:22:17,810 What I found is when you get to the five percent figure, they're typically behind 40 percent of all the capacity. 187 00:22:17,810 --> 00:22:24,110 Now, I can be candid when I showed this to the chief operating officer at this hospital. 188 00:22:24,110 --> 00:22:32,340 I got a reaction and that reaction was that she left the room for five minutes. 189 00:22:32,340 --> 00:22:39,780 I thought that was a good sign. I thought she'd come back and say, Hey, miss clear your desk on Monday morning. 190 00:22:39,780 --> 00:22:46,920 We need to find out everything we need to know about 218 people because this is going to solve my winter blood pressure problem. 191 00:22:46,920 --> 00:22:56,550 She came back, I can finish the talk, and the only comments she made was that she criticised a typo in my concluding slide, 192 00:22:56,550 --> 00:23:02,370 which says something 218 people behind 15 percent. 193 00:23:02,370 --> 00:23:06,330 Now, conventionally, including in this hospital, we will look at their capacities. 194 00:23:06,330 --> 00:23:10,200 We won't look at numbers of patients, we won't look at the percentage. 195 00:23:10,200 --> 00:23:17,550 Better breakdown of those human beings will just focus on activity numbers, and those activity numbers go up and up and up. 196 00:23:17,550 --> 00:23:22,690 And then we'll sit in meetings and we'll have some guesstimates and ideas and brainstorming or brain 197 00:23:22,690 --> 00:23:28,560 showering or brain thoughts about what we can do when actually we don't need to do any of that. 198 00:23:28,560 --> 00:23:36,990 Just go find out how we need to redesign services that are going to improve human beings lives the case. 199 00:23:36,990 --> 00:23:44,570 I'm going to show you in a minute who's one of these two hundred and eighty? 200 00:23:44,570 --> 00:23:49,880 That reference cost at the bottom is what's called soft reference costs. 201 00:23:49,880 --> 00:23:54,440 It grossly underestimates the true cost of providing a service. 202 00:23:54,440 --> 00:24:02,120 So as clinicians have told me, including here, you can multiply that three, four or five times to get the real cost. 203 00:24:02,120 --> 00:24:11,270 That's the other problem in health care. We need to work out true system costs, not use estimated reference costs. 204 00:24:11,270 --> 00:24:15,570 We can't do that, but it requires some effort. 205 00:24:15,570 --> 00:24:25,220 I said this work challenges Kaiser Permanente, and it does because empirically, when you ask, Okay, who are these vital few? 206 00:24:25,220 --> 00:24:32,060 How old are they? You find that two thirds of them typically are under 65 70 years of age. 207 00:24:32,060 --> 00:24:41,950 The third of them are over are the frail elderly cohort, and they'll will be the ones causing the problems with the transfers of care. 208 00:24:41,950 --> 00:24:46,660 I did some work in Oxford some years ago on the transfers of care, 209 00:24:46,660 --> 00:24:57,580 and it was a problem of one thousand nine hundred people, and this hospital sees nearly 230000 people in any one year. 210 00:24:57,580 --> 00:25:05,110 OK. On the other side, the other thinking is all these people have got common chronic conditions and that's 211 00:25:05,110 --> 00:25:09,760 why they're coming into law or assistance stands for ambulatory care conditions. 212 00:25:09,760 --> 00:25:17,050 They're the common chronic things, the 18 or 19 conditions that we know people have a lot angina, diabetes, dementia. 213 00:25:17,050 --> 00:25:24,110 What's interesting is when these people come in and get admitted, it's not so common chronic conditions. 214 00:25:24,110 --> 00:25:31,050 Well, explain what it is for in a moment. Patient flow, we're all familiar with the term. 215 00:25:31,050 --> 00:25:36,630 We need to improve patient flow. Every hospital has a patient flow programme. 216 00:25:36,630 --> 00:25:40,500 The big problem is because we think that more activity means more money. 217 00:25:40,500 --> 00:25:44,610 Therefore, we just need to flow more patients more quickly. We never take the time to work. 218 00:25:44,610 --> 00:25:49,830 How are we making a profit or a loss in every single human being that comes through? 219 00:25:49,830 --> 00:25:55,470 And the nifty trick here is when you link financial data via activity data sets. 220 00:25:55,470 --> 00:26:01,500 It's all there. We just don't do it all our NHS number unique identifier. 221 00:26:01,500 --> 00:26:06,600 You begin to find out the real cost and whether we're making a profit or a loss on 222 00:26:06,600 --> 00:26:14,310 you and the real staggering feature and these are those cohorts in all their glory. 223 00:26:14,310 --> 00:26:15,950 Depending on whether they've used a lot of urging, 224 00:26:15,950 --> 00:26:22,200 a lot planned care is actually the one I've ringed in red are the vital few cohort groups, the eight thousand five hundred. 225 00:26:22,200 --> 00:26:31,650 In this case, they're the ones behind the operating deficits and every single hospital, and the range is particularly significant. 226 00:26:31,650 --> 00:26:37,350 The top five out of few will always be behind between 70 to 100 percent of the net 227 00:26:37,350 --> 00:26:42,960 operating deficit of the hospital and by definition of the health care economy as well. 228 00:26:42,960 --> 00:26:51,150 When you follow these people out into primary and community mental health, the read over in community mental health is 75 to 85 percent. 229 00:26:51,150 --> 00:26:56,370 In other words, they are the same people and they're the same people in primary care as well. 230 00:26:56,370 --> 00:27:07,470 As I say, if you want to know more about primary care. Have a chat with me or watch my TED talks or talk about that and a little bit more data. 231 00:27:07,470 --> 00:27:13,650 I'm going to be quiet for 30 seconds. This is a real life example, this vulnerable. 232 00:27:13,650 --> 00:27:19,110 I have what I call a Pindell patient who you see a lot of in urgent and emergency care. 233 00:27:19,110 --> 00:27:27,360 For sure they have medical problems, but we need to deal with them holistically and not in a very siloed fashion. 234 00:27:27,360 --> 00:27:38,130 The only thing I'll say, I'm not going to go into too much detail. That was the true system cost for one of those top one percent for one year. 235 00:27:38,130 --> 00:27:43,950 What do I mean by activity obsession disorder and where the system creates its own wasteful work? 236 00:27:43,950 --> 00:27:50,910 Well, the example in her case, as you read through, she did have chronic conditions. 237 00:27:50,910 --> 00:27:56,250 You'll note she was a large lady. So she did have diabetes. 238 00:27:56,250 --> 00:27:59,460 But when she needed to have her repeat medications, 239 00:27:59,460 --> 00:28:08,670 given it simply wasn't a case of going to a local GP because I'm not being flippant that she couldn't get to her local GP. 240 00:28:08,670 --> 00:28:15,570 She equally couldn't find her local pharmacy. So what the protocol was that she would phone 999. 241 00:28:15,570 --> 00:28:24,180 This is no lie. This is genuine. This is what happens because we just don't think she did phone 999 ambulance would come out. 242 00:28:24,180 --> 00:28:28,410 You see this in the case notes. So this work is qualitative and quantitative. 243 00:28:28,410 --> 00:28:36,360 You have to go through case notes, and I've spent many hours in basements going through this. 244 00:28:36,360 --> 00:28:44,730 It's a fantastic mindful of data and resource tells you everything, but we never use it. 245 00:28:44,730 --> 00:28:50,250 The ambulance would come out quickly discovered it wasn't fit for purpose. 246 00:28:50,250 --> 00:28:57,120 So a bariatric ambulance would then be called. The bariatric ambulance could actually take this woman back to the hospital, 247 00:28:57,120 --> 00:29:01,530 but it couldn't physically get her out of her downstairs social housing flat. 248 00:29:01,530 --> 00:29:10,710 So then the fire brigade would be called. You laugh and it is comical, but this happened really, really often. 249 00:29:10,710 --> 00:29:19,170 And then you began to realise that's why the ground, the downstairs kitchen window is boarded up, because that's how they got her out. 250 00:29:19,170 --> 00:29:25,980 And the council never bothered to repair it. Because, hey, what's the point? Then the fire brigade who gets her out should be put on the bariatric. 251 00:29:25,980 --> 00:29:32,940 Ambulance should be taken into and they should be met by junior consultant who may not have known her or her case history. 252 00:29:32,940 --> 00:29:38,270 And what do you think then happened? Remember, she only went in to get repeat medications. 253 00:29:38,270 --> 00:29:44,660 She was disproportionately admitted, and when she got admitted, she wasn't taking up one bed. 254 00:29:44,660 --> 00:29:52,820 She was taken to. She was given to us because both the hospital and the CCG is effectively given up. 255 00:29:52,820 --> 00:30:01,160 They didn't know what to do. That last point about not meeting eligibility criteria is around continuing health care funding. 256 00:30:01,160 --> 00:30:05,900 She was assessed as not being suitable for this on seven separate occasions. 257 00:30:05,900 --> 00:30:14,500 I'll come back to that later. Improvement. 258 00:30:14,500 --> 00:30:21,880 Convention is analyse activity, activity, obsession, disorder and then off the back of that, 259 00:30:21,880 --> 00:30:29,140 we do a lot of conventional project management, are people familiar with the term PPMO project management office? 260 00:30:29,140 --> 00:30:32,710 It's what I call reporting to talk and talking to report, 261 00:30:32,710 --> 00:30:39,430 often in board level meetings that results in no change in the real world, as I'm sure you're all familiar with. 262 00:30:39,430 --> 00:30:44,980 And then off the back of that, we say, Well, what do we do? Well, we'll standardise everything with an each of our life. 263 00:30:44,980 --> 00:30:51,280 Standardisation is fine when the problem to solve is that you've got loads of standard patients. 264 00:30:51,280 --> 00:30:59,380 But if you haven't got standard patients, a standard pathway is going to create a mismatch in both activity and costs. 265 00:30:59,380 --> 00:31:10,510 There is a great cybernetic genius HP Ashby in Oxford in the 1930s that devised the law of requisite variety, 266 00:31:10,510 --> 00:31:17,140 and I think we should heed his advice today. In other words, what he was saying is where you've got a variety of need. 267 00:31:17,140 --> 00:31:23,950 Demand, as I call it, the best way to meet that variety of demand and need is by a variety of response. 268 00:31:23,950 --> 00:31:30,130 And if the variety of need is predictable and this is predictable, demand in health care is really predictable. 269 00:31:30,130 --> 00:31:35,950 Then the responses can be equally as predictable. OK. 270 00:31:35,950 --> 00:31:44,380 But trying to fix, you know, the non-standard patient into a standard pathway never works. 271 00:31:44,380 --> 00:31:49,720 So what I think we need to do is understand patient demand, then understand the nature of the activity, 272 00:31:49,720 --> 00:31:57,280 what it is we're doing that works what doesn't work and then get to work on fixing that and designing it for those predictable cohorts. 273 00:31:57,280 --> 00:32:07,090 That's the prototyping less talk, more action, less boundaries between management and clinicians who work together. 274 00:32:07,090 --> 00:32:12,850 You have skills I do not have, and I may have some skills that you may not have. 275 00:32:12,850 --> 00:32:18,490 And then the name of the game starts with a vital few is to customise their care. 276 00:32:18,490 --> 00:32:27,400 In other words, give them what they need to solve or manage their problems better for some will be to solve them completely. 277 00:32:27,400 --> 00:32:34,650 OK. For others, it's about managing them in a more intelligent way. 278 00:32:34,650 --> 00:32:41,130 Improvement, therefore, looks like this. Asked the question for every single human being, what matters? 279 00:32:41,130 --> 00:32:47,460 Because we did this with Mr. Obama, who is the first time she's ever been asked the question What does it look like for you? 280 00:32:47,460 --> 00:32:56,530 What do you need from us? How do we help you as opposed to telling you we can't help you pushing you away? 281 00:32:56,530 --> 00:33:06,430 And that's why they pinball. Performance metrics, we use a lot of averages in the NHS, the average length of stay, 282 00:33:06,430 --> 00:33:11,410 but an average of an average when you're dealing with these numbers of people is a very, very dodgy number. 283 00:33:11,410 --> 00:33:15,910 So we need to compliment those average metrics with more intelligent means. 284 00:33:15,910 --> 00:33:20,140 How often do we get it right? First time or second time? The third time, a fourth time? 285 00:33:20,140 --> 00:33:29,660 Not that we're going to name and shame and blame the person trying to do better work, but it's going to help us learn how to do more intelligent work. 286 00:33:29,660 --> 00:33:36,860 Representing demand, what do I mean by that? What's the probability that if we've seen you in any one year, you're coming back the next? 287 00:33:36,860 --> 00:33:46,820 For reasons that we don't know about will in this area, it's 60 percent and the other hospital in this place, it was 55 percent. 288 00:33:46,820 --> 00:33:49,770 That's extortion. The high numbers. 289 00:33:49,770 --> 00:34:01,650 Given the health care demand is predictable and then profiling don't benchmark with someone 200 miles away whose demand profile will be different. 290 00:34:01,650 --> 00:34:10,650 The use of data and materials you've got in your own system and this is what we did with the most vulnerable and others like her. 291 00:34:10,650 --> 00:34:15,060 How much are we doing and how much are we doing better than what we did last year? 292 00:34:15,060 --> 00:34:19,320 And who are we seeing a tangible difference on the bottom line? 293 00:34:19,320 --> 00:34:26,010 Think about costs as the last thing. Not the first thing. Paper prototyping were what prototyping is. 294 00:34:26,010 --> 00:34:32,600 Actually, what you find is all these people are clustered in geographical entities. 295 00:34:32,600 --> 00:34:37,020 They're not spread over localities, they won't be in Oxfordshire, either. 296 00:34:37,020 --> 00:34:45,530 And so I know they're not OK in this hospital, 20 percent of the ambulance demand was coming from 1500 people. 297 00:34:45,530 --> 00:34:52,280 These top five lived within a seven, six or seven mile radius of the hospital. 298 00:34:52,280 --> 00:35:02,780 We know where they are. That should then tell us about how we design our services to respond more intelligently where we put our staff. 299 00:35:02,780 --> 00:35:11,120 I think we could still use, you know, the likes of the Professor Robert Shelton's in the post-war period. 300 00:35:11,120 --> 00:35:18,080 He who devised something quite magical, which would still be revolutionary today for his patients in Wolverhampton. 301 00:35:18,080 --> 00:35:25,040 He would conduct outpatient surgeries in marketplaces. He would come to them because he knew it made more sense. 302 00:35:25,040 --> 00:35:29,570 Now I'm not suggesting for one minute we have to do that for every single human being that needs an outpatient appointment. 303 00:35:29,570 --> 00:35:34,310 But if we know that disproportionate amounts of demand are created in certain 304 00:35:34,310 --> 00:35:37,970 localities and that's a nice way of explaining what I'm trying to get at, 305 00:35:37,970 --> 00:35:45,470 then we need to be alert to how we need to design our workforces to meet that demand straight away. 306 00:35:45,470 --> 00:35:50,780 And then the working prototype starts small because you only have to have an 307 00:35:50,780 --> 00:35:55,040 impact on relatively small numbers of people to see these big system changes, 308 00:35:55,040 --> 00:36:03,200 both in terms of performance improvement, cost reduction and improvements in their lives and the lives of the people trying to help them. 309 00:36:03,200 --> 00:36:09,310 Because what I've also experienced doing this work is the sheer frustration of people at the front line. 310 00:36:09,310 --> 00:36:13,290 Including the very junior doctor who invited me here today. 311 00:36:13,290 --> 00:36:20,530 Because he's been attuned to this work, and he sees these pimple patients coming in a lot and he you can tell they're coming in, 312 00:36:20,530 --> 00:36:28,920 you can predict when they're coming in because this work is really predictable. It doesn't, though, changing the process. 313 00:36:28,920 --> 00:36:39,000 This is a typical Ayeni process or process. The whole system and systems in health care are designed to make you wait. 314 00:36:39,000 --> 00:36:52,560 210 patients receive at least two types of process, and if we think about it, triage came about from the battlefield. 315 00:36:52,560 --> 00:36:59,400 It was chaotic, so it made sense to marshal resources in an intelligent and managed way. 316 00:36:59,400 --> 00:37:06,830 But if we also think about the health care demand in human being terms is really predictable. 317 00:37:06,830 --> 00:37:10,370 There's no value to Trish. And what we should have learnt, 318 00:37:10,370 --> 00:37:16,940 and we have really learnt that we haven't then acted upon it is a couple of years ago we had the junior doctors strike. 319 00:37:16,940 --> 00:37:21,860 The mother of necessity meant that we had to do away with triage. 320 00:37:21,860 --> 00:37:24,430 We put the expert at the front. 321 00:37:24,430 --> 00:37:34,090 I'm a big believer in apprentice, the apprenticeship model of working, how I learnt this was learning this through my mentor. 322 00:37:34,090 --> 00:37:38,800 I didn't wake up one morning and think I'm going to develop something called humanising health care. 323 00:37:38,800 --> 00:37:43,030 I learnt it through trial and error, working with people that were more knowledgeable than me. 324 00:37:43,030 --> 00:37:54,310 I think perhaps we need to think about, as opposed to getting Junior's firefighting and ordering up barrages of tests and procedures to be safe. 325 00:37:54,310 --> 00:37:58,160 Then a scene, you may have a look and say, No, I want that done again. 326 00:37:58,160 --> 00:38:08,800 We haven't done this and then that's rework. Then perhaps the senior works with cohorts of juniors and the junior will work and learn quicker. 327 00:38:08,800 --> 00:38:20,660 Just some thoughts, because if you think about it like that, the process will change as well. 328 00:38:20,660 --> 00:38:28,340 And bear in mind what I mentioned earlier that you saw in the slide in terms of breaches of targets, 329 00:38:28,340 --> 00:38:34,730 these vital few are typically behind 30 to 50 percent of all the breaches. 330 00:38:34,730 --> 00:38:44,190 They're also behind a similar number of those that get admitted into observation and assessment units behind any. 331 00:38:44,190 --> 00:38:54,060 The best observation or assessment unit is really no observations. You know, if everything is predictable, don't treat for our target. 332 00:38:54,060 --> 00:39:02,490 That's what you drive by. Treat it as constraint. And understand who you need to work on in order to better meet that target. 333 00:39:02,490 --> 00:39:09,840 What I've done in the past is use an observation unit and put it to the front so that when we know these people are 334 00:39:09,840 --> 00:39:18,420 coming in as long as they haven't got a genuine medical emergency and typically in any A&E unit in any one year, 335 00:39:18,420 --> 00:39:25,350 only seven to 13 percent of people that actually need have a genuine emergency will need that. 336 00:39:25,350 --> 00:39:33,780 Then you don't put them through a triage process in any and in any case, as we know, when your life is really at stake. 337 00:39:33,780 --> 00:39:41,790 Heart attack, stroke, you don't go through that process because we don't have the time. 338 00:39:41,790 --> 00:39:48,450 He'd be dead. Back to miss vulnerable. 339 00:39:48,450 --> 00:39:55,450 I'm not going to say anything here. I'll just let you read this. True story. 340 00:39:55,450 --> 00:40:23,870 What you can do when the focus is on human beings, not activity. 341 00:40:23,870 --> 00:40:34,190 She recognised that. Things went wrong in her world when her principal carer, her mother, passed away and then everything just fell apart. 342 00:40:34,190 --> 00:40:41,660 No one was helping. And we just asked two main questions and then got to work on the back of that. 343 00:40:41,660 --> 00:40:46,550 What do you need? We did not lecture her. 344 00:40:46,550 --> 00:40:52,790 It happened on one occasion when she was admitted or attended A&E, and of course, 345 00:40:52,790 --> 00:41:00,420 if you didn't know the backgrounds of this lady, you'd see a grossly obese individual with needs. 346 00:41:00,420 --> 00:41:08,600 And so that response was to tell her that she needed to lose weight, but she had mental health problems and learning disability. 347 00:41:08,600 --> 00:41:13,640 So trying to rationalise that with that person is designed to fail. 348 00:41:13,640 --> 00:41:21,500 And then we have to do some rework to encourage her. To persuade her that she wasn't about to die within the next year to two years. 349 00:41:21,500 --> 00:41:27,220 But that's great learning. That's great system learning for everybody. 350 00:41:27,220 --> 00:41:34,440 And the focus was not on the obesity. Focus was on how can we help you? 351 00:41:34,440 --> 00:41:44,310 Manage better. And she recognised and she told us that she couldn't live on her own, so that's fine you want. 352 00:41:44,310 --> 00:41:47,670 And the pot of money we used for her was a very pot of money. 353 00:41:47,670 --> 00:41:53,950 She was refused eligibility criteria for on seven separate occasions. And this is what we do a lot in community mental health and social care. 354 00:41:53,950 --> 00:41:58,770 The best services often know when we put the referral in. 355 00:41:58,770 --> 00:42:05,700 Why don't we just say yes and see if we can actually save money by giving some service and help? 356 00:42:05,700 --> 00:42:12,520 And again, it's nobody's fault. This is the way this system is currently designed. 357 00:42:12,520 --> 00:42:16,660 I talked about Plunkett tipping another example. 358 00:42:16,660 --> 00:42:21,760 I got a little bit of profile a couple of years ago for the BBC because Adam Brimelow, 359 00:42:21,760 --> 00:42:26,020 who was at the time working for the BBC, got interested in this story. 360 00:42:26,020 --> 00:42:31,210 If you're interested, there's still a news article up there called and it just stuck with soaring demand. 361 00:42:31,210 --> 00:42:36,010 Have a read of it. The answer is no. And you off the back of that? 362 00:42:36,010 --> 00:42:40,490 Learn and read about Mr Miles Bauman. I'll explain why. 363 00:42:40,490 --> 00:42:45,490 Myles Bauman Because he came into this very health care economy. 364 00:42:45,490 --> 00:42:53,080 Plunkett tipping is when we start to see you in elective care and your elective care starts to 365 00:42:53,080 --> 00:42:59,950 increase and then disproportionate numbers of people then tip into urgent and emergency care. 366 00:42:59,950 --> 00:43:07,660 When I was doing this work in Oxford, 75 percent of your top five for planned care tippers. 367 00:43:07,660 --> 00:43:14,380 And when you get into the detail, you find actually the reasons behind much of this are actually in inefficient processes, 368 00:43:14,380 --> 00:43:22,750 whether they be in bookings, referrals, outpatient clinics. In the case of this man, he had three problems wrong with him. 369 00:43:22,750 --> 00:43:31,060 He needed a triple heart bypass bypass, but he had prostate cancer that was being treated by another hospital before he had the heart operation. 370 00:43:31,060 --> 00:43:39,550 We needed to make a quick assessment as to whether we took it as compacted wisdom tooth or not, because that posed an infection control problem. 371 00:43:39,550 --> 00:43:44,590 And that's where things went wrong. Two referrals from a dentist into the hospital got lost. 372 00:43:44,590 --> 00:43:48,890 What should have happened in a matter of weeks took seven and a half months. 373 00:43:48,890 --> 00:43:53,710 Hamlin's gets called on a wet Monday evening because he has a suspected heart attack. 374 00:43:53,710 --> 00:43:57,970 He tips he breached A&E. He spent two weeks in the cardiac unit. 375 00:43:57,970 --> 00:44:07,600 He got transferred to another hospital, spent another week at the very time that the consultant that was due to operate on him went on leave. 376 00:44:07,600 --> 00:44:12,790 He then got booked for the tooth junior doctor strikes for his procedure that got cancelled. 377 00:44:12,790 --> 00:44:16,000 Obviously, he managed to get his heart sorted out. 378 00:44:16,000 --> 00:44:22,390 Can you see the wasteful work activity and costs that the system creates because of the inefficiency? 379 00:44:22,390 --> 00:44:28,810 Why he was called Mr Miles Bauman is because the fourth intake consultant that saw him in 380 00:44:28,810 --> 00:44:34,420 his initial first two weeks tried to explain to him that because he had three problems, 381 00:44:34,420 --> 00:44:40,120 not one. He was quote like a wonky miles ball on a production line. 382 00:44:40,120 --> 00:44:48,000 He had to be taken off and put to the back. Now, he didn't have problems such as miss vulnerable. 383 00:44:48,000 --> 00:44:54,300 He didn't have emotional, psychological social issues, but he was touched at the end of this process. 384 00:44:54,300 --> 00:45:01,470 Now I've had this validated and verified by numerous clinicians, not least David Cameron's brother in law, 385 00:45:01,470 --> 00:45:06,450 Dr. Andrew Bishop of Hampshire Hospital, who when I talked him through this because he's a cardiologist. 386 00:45:06,450 --> 00:45:13,930 He just burst out and lost. And he said, I see these people's home in my clinics because we pick them up. 387 00:45:13,930 --> 00:45:24,040 So that's a real signal that we can do something about this because this problem is self-generating, it's caused through the acute hospitals and is, 388 00:45:24,040 --> 00:45:32,680 quote, turning the taps down or turning the taps off, making people wait longer in the belief that we can save a few bob. 389 00:45:32,680 --> 00:45:38,470 It was official guidance at the beginning of this year to deal with the winter pressure problem, 390 00:45:38,470 --> 00:45:48,990 but hopefully you'll be aware now that these are different patients to other people the pimple patients, so don't treat them the same. 391 00:45:48,990 --> 00:45:54,780 To conclude a little bit about technology. Technology needs to be the last thing you focus on. 392 00:45:54,780 --> 00:46:04,800 First, we need to improve processes and make processes effective before we think about digitalising anything. 393 00:46:04,800 --> 00:46:11,940 OK? If you digitalise an inefficient, ineffective process, you're just going to create a double negative, 394 00:46:11,940 --> 00:46:16,260 which is going to be more inefficiency and more costs. OK? 395 00:46:16,260 --> 00:46:23,480 Think of how easy it is to procure equipment and supplies in hospitals. 396 00:46:23,480 --> 00:46:28,520 It's the same principle if you combine technology with a process flow, 397 00:46:28,520 --> 00:46:33,760 which means we put the wrong person at the front and then you deal with the person who's is not an expert telling, 398 00:46:33,760 --> 00:46:38,270 you know why you can't have a piece of kit. And we do that several times. 399 00:46:38,270 --> 00:46:45,490 It's exactly the same as with simple patients. The activity in the costs get worse. 400 00:46:45,490 --> 00:46:54,420 So to conclude, patient demand is stable in health care systems, but it's uneven. 401 00:46:54,420 --> 00:46:59,580 Small numbers drive all the mayhem and are behind all the performance issues. 402 00:46:59,580 --> 00:47:04,200 All the morale sapping work and all the costs. 403 00:47:04,200 --> 00:47:13,740 We need to focus improvement on initially those small numbers of patients to be see big impacts and big benefits. 404 00:47:13,740 --> 00:47:23,070 Studying patient demand is the first thing we should do. And then intelligence service redesign needs to be around cohorts of patients, 405 00:47:23,070 --> 00:47:30,030 and we can do this because they are geographically clustered and they are predictable, not arbitrary pathways. 406 00:47:30,030 --> 00:47:41,640 And if we do that, I think we can begin to then understand how we think about care integration because this is my last point, which I'll finish on. 407 00:47:41,640 --> 00:47:47,970 Integration of care is seen as the panacea for everything we have to now do. 408 00:47:47,970 --> 00:47:53,850 And it has been the case for decades. But if we're being honest, no one really has got a clue how to do it. 409 00:47:53,850 --> 00:47:58,620 What most people and I include myself here don't need integrated care. 410 00:47:58,620 --> 00:48:05,130 I just need when I need health care services and effective transactional response. 411 00:48:05,130 --> 00:48:08,790 But these top five percent needs something different. 412 00:48:08,790 --> 00:48:18,480 They're the ones behind the activity in the costs. They're the ones that need integrated care services to work when they need it to work. 413 00:48:18,480 --> 00:48:26,520 And last point on digital, it needs to be not by default, not to replace human beings, but to complement them. 414 00:48:26,520 --> 00:48:33,270 And so by design, to make people's lives easier as opposed to harder. 415 00:48:33,270 --> 00:48:39,790 I said I'd finish with a quote and I will. I think what he said then was right. 416 00:48:39,790 --> 00:48:45,250 I still think that's the case today. If you don't believe me, 417 00:48:45,250 --> 00:48:50,350 you can read some of these quotes on the left hand side is the senior nurse that worked 418 00:48:50,350 --> 00:48:59,250 with me and her team on this vulnerable and the mist on rules and Mr. Vulnerable. 419 00:48:59,250 --> 00:49:06,900 And on the right hand side is a quote from an associate director when I did some patient cohort streaming of Aisne. 420 00:49:06,900 --> 00:49:19,030 So. More effective process around these vital few means that you actually achieve the target by not driving performance by the target. 421 00:49:19,030 --> 00:49:25,510 You can have these slides, by the way, see, that's not a problem. Thank you for your time this morning. 422 00:49:25,510 --> 00:49:36,405 I finished just on time. Happy to take any questions you might have.