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.
Hamish is a senior management consultant.
He really has dedicated his time in delivering better service outcomes and cost reductions across NHS and adult social care.
So music to the ears of management to, as you see, are abandoned in the audience this morning.
Hamish has pioneered a new way to better understand and improve services and systems from the perspective of the patient,
which is really very novel and interesting. So he fuses operational research on patient improvement to achieve better health care.
In a nutshell, and who are you looking forward to you telling us about it?
Hamish, and thank you for coming all the way. Good morning, all.
Thank you, Fadi. As fully outlined, I'm not a clinician and you hear me.
My background is management consulting. Sorry, that's right.
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,
past president and present, no doubt future. I have actually worked in the NHS in a management capacity and impact services.
And before that, I spent slightly longer university, so I wanted to be an academic and hopefully you'll see this through this work.
It was five years ago through a combination of personal experience. My father died of vascular dementia and professional experience.
I saw the the dysfunctional ization of what we've done in health care, and it's no clinicians fault.
It's just the way we have badly designed, managed and thought about how we try to improve health care.
I passionately believe in the last 40 years. We've done a number of things very badly.
We've tried to commercialise health care. We've tried to over medicalised, over specialise and then we fragment lies.
If that's even a word health care, when actually, I think what we need to do is we humanise it,
bring it back to the reason why we have health care and I mean health care.
And in the general sense, I, for one, for example, don't see these arbitrary distinctions between adult social care and community services.
I've never met anyone who can tell me the difference between the two, and I've worked in both primary care too.
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.
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.
I'm going to give you two quotes, one to start with and one to finish with.
The first one is a management guru who I have a lot of time for and a lot respect for.
It's a short, pithy quote, but I just want you to capture that and remember this as we talk.
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.
Contrast it with current conventional approaches and then outline what it isn't.
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.
I've covered specialist hospitals such as Moorfields and I've covered district panels.
I've covered community mental health, have covered primary care. I've even done this in adult social care and children's services.
And the amazing thing is the pattern is the same everywhere.
But it will change convention and equally,
how we go about driving and delivering improvement in service organisations and health care is a complex service organisation has to change too.
On the start with the red herrings, as I call them a commonly held health care beliefs, I don't think anyone would disagree.
Well, I'm going to ask, does anyone disagree with those three beliefs?
Because we hear about these all the time. One is that we've got an ageing, growing elderly population.
Statistically, numerically, that is true. People are getting older.
Second, that people want more and more. You and I demand more and more of expectations on health care services.
And the third one is because of the first two.
There's more demand on the system. Well, I'm going to challenge that third one, because empirically, that's not true.
OK, I will challenge the second one because we don't collect the data in any such sophisticated,
intelligent way to be able to tell us actually whether that's empirically true. That's an anecdote I have experience of.
I believe therefore you're demanding something I can't give you. That's not the same thing.
By the way, the friends and family test is not an intelligent gauge of expectation.
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.
Maybe with one two three four co-morbidities with complex conditions and not cause much problems to the health care system, OK?
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.
Be off the rails and cause an awful lot of demand on health care services.
I think this is a universal truism. I think it applies to all health care systems.
I've given talks in a number of other countries and because they see the UK now and it just as world leaders,
they tend to copy, but they tend to copy all bad ideas and concepts as well.
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.
It's the belief that you can design,
manage and improve complex service systems such as health care on an understanding only of activity work activity.
And off the back of that, you can drive down costs. And that will improve services.
We do this year in year out in cost improvement schemes, in patient flow programmes and in commissioning well,
they spend an awful lot of time doing exactly the same in their equip programme, equip schemes.
And then we think we we then have to drive things harder and we make more assumptions.
I think this is fundamentally the wrong thing to do.
I call this back to front thinking, or it's like trying to drive your motor vehicle via the rear-view mirror.
There's two guaranteed outcomes of this and this is convention how we do it.
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.
I think the outcomes are that we save up to my services. Dreadful phrase.
We give poor patients experience. It results in higher costs and it reduces staff morale.
It demoralises people. Humanising health care, on the other hand, is actually, why don't we just stop and ask,
who are the people we're doing work activity two and how much is that costing?
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,
and then improvement is not about spending an eternity in management meetings,
devising more paperwork and then trying to project manage that paperwork and never seeing anything happen in the real world.
It's about management, people working with clinicians and medical staff and frontline redesigning services around cohorts of patients.
Not making big assumptions around arbitrary pathways.
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?
And the answer is none. OK, because everyone that has diabetes will have two, three, four or five other conditions as well.
And so even if you have a world class diabetes service, if everything else doesn't work, they will still fall through the gaps.
And that's what you see points of principle.
I'm not going to go through each of these, but effectively this work is about understanding.
Patient demand is the first point. How many people cause us to do, how much work activity leads to how much costs?
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.
OK? Understand the former to understand the latter.
And you do exactly the same in improvement. OK. And the last one, I think, is really important that systems inform patient behaviour.
I think it is the case that for the majority of people, the way they behave,
whether they be professionals or patients, is a consequence of how they're treated.
Others may disagree, but I think we have to show that empirically,
I hope this work relies on the preto principle of which I'm sure you're all very well aware of.
It's funny that we don't use it, though, in systems and understanding and designing them because it's a natural law.
Not my word phrase, but Joseph Duran, who is now departed American management guru.
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.
It is the case that demand patient demand is on the even small numbers drive all the activity and all the costs.
But yet we don't design and manage and improve our health care systems based on that knowledge in any sensible, systematic way.
How humanising health care works and I hope you like to the dumbbell diagram is.
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,
but it's about combining quantitative analysis with qualitative analysis, understanding what and why things work the way they do.
Once you do that and fuse what cooperation research techniques actually gives you everything you need to know in order to improve your service.
The second stage is iteratively redesigning systems and services around cohorts of patients, not pathways.
To improve outcomes, reduce costs and create greater sustainability.
And then the third phase is effectively sustaining and scaling that.
So can we increase the volumes of the cohorts of the patients and take into areas where we hitherto haven't done so far?
That is distinct from how we conventionally do analysis and do improvement.
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.
And I will come back to technology at the end of this presentation.
But for me, technology is the last thing you think about. Not the first thing.
OK, technology works on simple, routine processes and procedures often.
What we do is we make some mistake of taking a complex process and thinking we can digitalise it with disastrous consequences.
I'll come back to that later. So far, so good.
That's the theory and the approach out the way.
Now I'm going to talk about how you analyse health care and when you analyse health care from this point, what you find.
As I said, I'm going to use a real life example. This is a large district general in the south of England.
But I'll let you into a little secret. I have done this work in Oxford and just in not too distant past,
and the patterns are exactly the same, whether they're a teaching hospital or a district hospital.
What do I mean by demand?
Demands for me is person shaped how many interactions a human being has with a service in any minute, hour, week, month, year?
And here's the trick. Multiple years. So this work looks at time series data, something I find in management.
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.
It also turns on its head the idea of population health management. What do I mean by that?
Well, in this constituency, this hospital thought it catered for half a million.
Now, where it got that figure from was the combined populations of half a million people,
but it didn't actually see anything like half a million people coming through its doors.
Every year, it saw less than one hundred sixty three thousand.
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.
The absolute demand is absolute human beings who enter this hospital in any shape or
form that might be for several outpatient appointments or 180 visits in any one year.
You'll see the mess that we've got. Rising demand is not truth.
Because that population growth is actually less than the locality population growth that the hospital served.
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,
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.
Well, we capture demand incorrectly. It's activity that we record, monitor and measure.
Why? Because our health care system, certainly in England, is based on tariffs work activity, meaning more activity, more money.
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.
About a third of the population will use the acute in any shape or form.
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.
I did a couple of years ago where I talk about primary care and I was here.
Thoughts on that. Before I move on.
Because that does challenge convention. You can't improve healthcare services, looking activity and cost.
They are lagging indicators of what you've done.
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.
This is the same hospital, this is a decomposition chart for one year using my pack framework.
So that is showing you every body that came in in a financial period 12 months into this hospital and how they filtered through.
We do not do this in health care analysis, and I think we need to.
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,
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.
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.
That's about 13 percent. And the rule of thumb,
I found doing this in eight or nine areas now is that that tiny percentage varies between twelve to about 14 percent everywhere.
And then when it comes to how many do we admit the challenge isn't even 60 odd thousand people,
it gets lower to 20000 people, which equates to about four percent.
OK. Because you can't actually improve health care systems on a hundred and sixty three thousand people,
but that's fine because you don't have to in urgent and emergency care.
The other interesting thing in health care is that it is complex.
It is more complicated than, say, retail, because you're dealing with different customer bases in elected plan care.
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.
When you see both of them appearing in the system, that's actually telling you something.
And that's A. I'm going to talk about later in this presentation.
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.
That's the signal that the design of the elective services isn't working.
So a number of those patients. However, when you fuse the data together and what do I mean by that?
Well, in the acute world, it's how many times do we see you in the urgent care system versus the plan care system?
You come at the pyramid of consumption, which is what I call the vital few.
It's the same here as well. This hospital actually rested on eight thousand five hundred unique human beings.
They were behind a third of all the work that was done year in, year out.
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.
In the top one percent, this work actually challenges the Kaiser Permanente logic as well.
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.
Elderly people whose job is you've got to manage them, who run their complex co-morbidities.
In other words, they're old. They've got loads of things going wrong with them, and therefore you have to case management.
Thus, statistically and empirically not true, of which we'll explain in a few moments time.
What you're seeing here are two protocols applied using the pack framework over 12 months looking at A&E attendances and admissions.
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.
Now, if we're wanting to do something to improve our performance on the four hour target,
for example, and achieve perhaps the the triple aim of the NHS,
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,
and it will be the same here as well. Every year, five percent of the work is actually just over 3000 people.
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.
OK, so if we want to do something sensibly in a separate for a world or a vanguard well or care integration world,
let's go find out about these 3000 people. What's happening in their world.
And how do we need to redesign that? Flipped over to admissions.
You see, the numbers get even smaller. Keep your mind's eye on the one percent, the three percent, the five percent.
Again, even when it comes to admissions activity in emergency care,
we're dealing with just over a thousand people, nearly behind 20 percent of everything we do.
Why are those numbers 218, six, five two and one thousand eighty four important?
Because that's the big problem. This is emergency bed capacity in this hospital.
Now I will challenge it because this is also a true truism I found in every hospital again
that we don't have a bed capacity problem as much as we've got a service capability problem.
We never asked the question how many of the same people are in our beds year in, year out?
What I found is when you get to the five percent figure, they're typically behind 40 percent of all the capacity.
Now, I can be candid when I showed this to the chief operating officer at this hospital.
I got a reaction and that reaction was that she left the room for five minutes.
I thought that was a good sign. I thought she'd come back and say, Hey, miss clear your desk on Monday morning.
We need to find out everything we need to know about 218 people because this is going to solve my winter blood pressure problem.
She came back, I can finish the talk, and the only comments she made was that she criticised a typo in my concluding slide,
which says something 218 people behind 15 percent.
Now, conventionally, including in this hospital, we will look at their capacities.
We won't look at numbers of patients, we won't look at the percentage.
Better breakdown of those human beings will just focus on activity numbers, and those activity numbers go up and up and up.
And then we'll sit in meetings and we'll have some guesstimates and ideas and brainstorming or brain
showering or brain thoughts about what we can do when actually we don't need to do any of that.
Just go find out how we need to redesign services that are going to improve human beings lives the case.
I'm going to show you in a minute who's one of these two hundred and eighty?
That reference cost at the bottom is what's called soft reference costs.
It grossly underestimates the true cost of providing a service.
So as clinicians have told me, including here, you can multiply that three, four or five times to get the real cost.
That's the other problem in health care. We need to work out true system costs, not use estimated reference costs.
We can't do that, but it requires some effort.
I said this work challenges Kaiser Permanente, and it does because empirically, when you ask, Okay, who are these vital few?
How old are they? You find that two thirds of them typically are under 65 70 years of age.
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.
I did some work in Oxford some years ago on the transfers of care,
and it was a problem of one thousand nine hundred people, and this hospital sees nearly 230000 people in any one year.
OK. On the other side, the other thinking is all these people have got common chronic conditions and that's
why they're coming into law or assistance stands for ambulatory care conditions.
They're the common chronic things, the 18 or 19 conditions that we know people have a lot angina, diabetes, dementia.
What's interesting is when these people come in and get admitted, it's not so common chronic conditions.
Well, explain what it is for in a moment. Patient flow, we're all familiar with the term.
We need to improve patient flow. Every hospital has a patient flow programme.
The big problem is because we think that more activity means more money.
Therefore, we just need to flow more patients more quickly. We never take the time to work.
How are we making a profit or a loss in every single human being that comes through?
And the nifty trick here is when you link financial data via activity data sets.
It's all there. We just don't do it all our NHS number unique identifier.
You begin to find out the real cost and whether we're making a profit or a loss on
you and the real staggering feature and these are those cohorts in all their glory.
Depending on whether they've used a lot of urging,
a lot planned care is actually the one I've ringed in red are the vital few cohort groups, the eight thousand five hundred.
In this case, they're the ones behind the operating deficits and every single hospital, and the range is particularly significant.
The top five out of few will always be behind between 70 to 100 percent of the net
operating deficit of the hospital and by definition of the health care economy as well.
When you follow these people out into primary and community mental health, the read over in community mental health is 75 to 85 percent.
In other words, they are the same people and they're the same people in primary care as well.
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.
I'm going to be quiet for 30 seconds. This is a real life example, this vulnerable.
I have what I call a Pindell patient who you see a lot of in urgent and emergency care.
For sure they have medical problems, but we need to deal with them holistically and not in a very siloed fashion.
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.
What do I mean by activity obsession disorder and where the system creates its own wasteful work?
Well, the example in her case, as you read through, she did have chronic conditions.
You'll note she was a large lady. So she did have diabetes.
But when she needed to have her repeat medications,
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.
She equally couldn't find her local pharmacy. So what the protocol was that she would phone 999.
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.
You see this in the case notes. So this work is qualitative and quantitative.
You have to go through case notes, and I've spent many hours in basements going through this.
It's a fantastic mindful of data and resource tells you everything, but we never use it.
The ambulance would come out quickly discovered it wasn't fit for purpose.
So a bariatric ambulance would then be called. The bariatric ambulance could actually take this woman back to the hospital,
but it couldn't physically get her out of her downstairs social housing flat.
So then the fire brigade would be called. You laugh and it is comical, but this happened really, really often.
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.
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.
Ambulance should be taken into and they should be met by junior consultant who may not have known her or her case history.
And what do you think then happened? Remember, she only went in to get repeat medications.
She was disproportionately admitted, and when she got admitted, she wasn't taking up one bed.
She was taken to. She was given to us because both the hospital and the CCG is effectively given up.
They didn't know what to do. That last point about not meeting eligibility criteria is around continuing health care funding.
She was assessed as not being suitable for this on seven separate occasions.
I'll come back to that later. Improvement.
Convention is analyse activity, activity, obsession, disorder and then off the back of that,
we do a lot of conventional project management, are people familiar with the term PPMO project management office?
It's what I call reporting to talk and talking to report,
often in board level meetings that results in no change in the real world, as I'm sure you're all familiar with.
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.
Standardisation is fine when the problem to solve is that you've got loads of standard patients.
But if you haven't got standard patients, a standard pathway is going to create a mismatch in both activity and costs.
There is a great cybernetic genius HP Ashby in Oxford in the 1930s that devised the law of requisite variety,
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.
Demand, as I call it, the best way to meet that variety of demand and need is by a variety of response.
And if the variety of need is predictable and this is predictable, demand in health care is really predictable.
Then the responses can be equally as predictable. OK.
But trying to fix, you know, the non-standard patient into a standard pathway never works.
So what I think we need to do is understand patient demand, then understand the nature of the activity,
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.
That's the prototyping less talk, more action, less boundaries between management and clinicians who work together.
You have skills I do not have, and I may have some skills that you may not have.
And then the name of the game starts with a vital few is to customise their care.
In other words, give them what they need to solve or manage their problems better for some will be to solve them completely.
OK. For others, it's about managing them in a more intelligent way.
Improvement, therefore, looks like this. Asked the question for every single human being, what matters?
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?
What do you need from us? How do we help you as opposed to telling you we can't help you pushing you away?
And that's why they pinball. Performance metrics, we use a lot of averages in the NHS, the average length of stay,
but an average of an average when you're dealing with these numbers of people is a very, very dodgy number.
So we need to compliment those average metrics with more intelligent means.
How often do we get it right? First time or second time? The third time, a fourth time?
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.
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?
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.
That's extortion. The high numbers.
Given the health care demand is predictable and then profiling don't benchmark with someone 200 miles away whose demand profile will be different.
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.
How much are we doing and how much are we doing better than what we did last year?
And who are we seeing a tangible difference on the bottom line?
Think about costs as the last thing. Not the first thing. Paper prototyping were what prototyping is.
Actually, what you find is all these people are clustered in geographical entities.
They're not spread over localities, they won't be in Oxfordshire, either.
And so I know they're not OK in this hospital, 20 percent of the ambulance demand was coming from 1500 people.
These top five lived within a seven, six or seven mile radius of the hospital.
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.
I think we could still use, you know, the likes of the Professor Robert Shelton's in the post-war period.
He who devised something quite magical, which would still be revolutionary today for his patients in Wolverhampton.
He would conduct outpatient surgeries in marketplaces. He would come to them because he knew it made more sense.
Now I'm not suggesting for one minute we have to do that for every single human being that needs an outpatient appointment.
But if we know that disproportionate amounts of demand are created in certain
localities and that's a nice way of explaining what I'm trying to get at,
then we need to be alert to how we need to design our workforces to meet that demand straight away.
And then the working prototype starts small because you only have to have an
impact on relatively small numbers of people to see these big system changes,
both in terms of performance improvement, cost reduction and improvements in their lives and the lives of the people trying to help them.
Because what I've also experienced doing this work is the sheer frustration of people at the front line.
Including the very junior doctor who invited me here today.
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,
you can predict when they're coming in because this work is really predictable. It doesn't, though, changing the process.
This is a typical Ayeni process or process. The whole system and systems in health care are designed to make you wait.
210 patients receive at least two types of process, and if we think about it, triage came about from the battlefield.
It was chaotic, so it made sense to marshal resources in an intelligent and managed way.
But if we also think about the health care demand in human being terms is really predictable.
There's no value to Trish. And what we should have learnt,
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.
The mother of necessity meant that we had to do away with triage.
We put the expert at the front.
I'm a big believer in apprentice, the apprenticeship model of working, how I learnt this was learning this through my mentor.
I didn't wake up one morning and think I'm going to develop something called humanising health care.
I learnt it through trial and error, working with people that were more knowledgeable than me.
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.
Then a scene, you may have a look and say, No, I want that done again.
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.
Just some thoughts, because if you think about it like that, the process will change as well.
And bear in mind what I mentioned earlier that you saw in the slide in terms of breaches of targets,
these vital few are typically behind 30 to 50 percent of all the breaches.
They're also behind a similar number of those that get admitted into observation and assessment units behind any.
The best observation or assessment unit is really no observations. You know, if everything is predictable, don't treat for our target.
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.
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
coming in as long as they haven't got a genuine medical emergency and typically in any A&E unit in any one year,
only seven to 13 percent of people that actually need have a genuine emergency will need that.
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.
Heart attack, stroke, you don't go through that process because we don't have the time.
He'd be dead. Back to miss vulnerable.
I'm not going to say anything here. I'll just let you read this. True story.
What you can do when the focus is on human beings, not activity.
She recognised that. Things went wrong in her world when her principal carer, her mother, passed away and then everything just fell apart.
No one was helping. And we just asked two main questions and then got to work on the back of that.
What do you need? We did not lecture her.
It happened on one occasion when she was admitted or attended A&E, and of course,
if you didn't know the backgrounds of this lady, you'd see a grossly obese individual with needs.
And so that response was to tell her that she needed to lose weight, but she had mental health problems and learning disability.
So trying to rationalise that with that person is designed to fail.
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.
But that's great learning. That's great system learning for everybody.
And the focus was not on the obesity. Focus was on how can we help you?
Manage better. And she recognised and she told us that she couldn't live on her own, so that's fine you want.
And the pot of money we used for her was a very pot of money.
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.
The best services often know when we put the referral in.
Why don't we just say yes and see if we can actually save money by giving some service and help?
And again, it's nobody's fault. This is the way this system is currently designed.
I talked about Plunkett tipping another example.
I got a little bit of profile a couple of years ago for the BBC because Adam Brimelow,
who was at the time working for the BBC, got interested in this story.
If you're interested, there's still a news article up there called and it just stuck with soaring demand.
Have a read of it. The answer is no. And you off the back of that?
Learn and read about Mr Miles Bauman. I'll explain why.
Myles Bauman Because he came into this very health care economy.
Plunkett tipping is when we start to see you in elective care and your elective care starts to
increase and then disproportionate numbers of people then tip into urgent and emergency care.
When I was doing this work in Oxford, 75 percent of your top five for planned care tippers.
And when you get into the detail, you find actually the reasons behind much of this are actually in inefficient processes,
whether they be in bookings, referrals, outpatient clinics. In the case of this man, he had three problems wrong with him.
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.
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.
And that's where things went wrong. Two referrals from a dentist into the hospital got lost.
What should have happened in a matter of weeks took seven and a half months.
Hamlin's gets called on a wet Monday evening because he has a suspected heart attack.
He tips he breached A&E. He spent two weeks in the cardiac unit.
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.
He then got booked for the tooth junior doctor strikes for his procedure that got cancelled.
Obviously, he managed to get his heart sorted out.
Can you see the wasteful work activity and costs that the system creates because of the inefficiency?
Why he was called Mr Miles Bauman is because the fourth intake consultant that saw him in
his initial first two weeks tried to explain to him that because he had three problems,
not one. He was quote like a wonky miles ball on a production line.
He had to be taken off and put to the back. Now, he didn't have problems such as miss vulnerable.
He didn't have emotional, psychological social issues, but he was touched at the end of this process.
Now I've had this validated and verified by numerous clinicians, not least David Cameron's brother in law,
Dr. Andrew Bishop of Hampshire Hospital, who when I talked him through this because he's a cardiologist.
He just burst out and lost. And he said, I see these people's home in my clinics because we pick them up.
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,
quote, turning the taps down or turning the taps off, making people wait longer in the belief that we can save a few bob.
It was official guidance at the beginning of this year to deal with the winter pressure problem,
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.
To conclude a little bit about technology. Technology needs to be the last thing you focus on.
First, we need to improve processes and make processes effective before we think about digitalising anything.
OK? If you digitalise an inefficient, ineffective process, you're just going to create a double negative,
which is going to be more inefficiency and more costs. OK?
Think of how easy it is to procure equipment and supplies in hospitals.
It's the same principle if you combine technology with a process flow,
which means we put the wrong person at the front and then you deal with the person who's is not an expert telling,
you know why you can't have a piece of kit. And we do that several times.
It's exactly the same as with simple patients. The activity in the costs get worse.
So to conclude, patient demand is stable in health care systems, but it's uneven.
Small numbers drive all the mayhem and are behind all the performance issues.
All the morale sapping work and all the costs.
We need to focus improvement on initially those small numbers of patients to be see big impacts and big benefits.
Studying patient demand is the first thing we should do. And then intelligence service redesign needs to be around cohorts of patients,
and we can do this because they are geographically clustered and they are predictable, not arbitrary pathways.
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.
Integration of care is seen as the panacea for everything we have to now do.
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.
What most people and I include myself here don't need integrated care.
I just need when I need health care services and effective transactional response.
But these top five percent needs something different.
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.
And last point on digital, it needs to be not by default, not to replace human beings, but to complement them.
And so by design, to make people's lives easier as opposed to harder.
I said I'd finish with a quote and I will. I think what he said then was right.
I still think that's the case today. If you don't believe me,
you can read some of these quotes on the left hand side is the senior nurse that worked
with me and her team on this vulnerable and the mist on rules and Mr. Vulnerable.
And on the right hand side is a quote from an associate director when I did some patient cohort streaming of Aisne.
So. More effective process around these vital few means that you actually achieve the target by not driving performance by the target.
You can have these slides, by the way, see, that's not a problem. Thank you for your time this morning.
I finished just on time. Happy to take any questions you might have.