Monday 26 May 2008

Case Study - Assistant and Advanced Practitioners in Radiology

As medical care becomes more proactive and subtle, so better and more rapid diagnostics are needed. This typically falls to the imaging disciplines, such as Radiography.
NHS Modernisation Agency's Changing Workforce Programme (CWP) ran an Accelerated Development Programme to assist the implementation of these roles, and one site was City Hospitals, Sunderland.

Why this was needed?
Increased numbers of tests have not been accompanied by increased numbers of radiologists; radiologists take many years to train and the increased volumes of referrals meant that for example in City Hospitals Sunderland the waits for routine barium enemas had increased to 30 weeks.

What happened?
Radiologists ran barium enema lists themselves under the supervision of a radiographer, with their reports checked by the supervisor rather than the whole reporting process remaining with the senior radiographer.

What difference did it make?
Waits dropped from 30 weeks to 2 weeks over a period of 11 months. Turnover of staff in role dropped by 10%, and agency spend by 47%.

Lessons learnt
Staff want to do the best job they can, so giving them more opportunity and the responsibility to know their own limits and ask advice can deliver tremendous wins for all parties.
The same staff handing more patients means lower cost per patient - this has to be offset against the cost of training to enhanced levels but the results were conclusive that it was cost-effective.
We also audited the number of changes the radiologists made to radiographer reports and found that the radiographers achieved excellent reporting with only a few changes needed.

Case Study - enhancing the role of Medical Secretaries

NHS Modernisation Agency's Changing Workforce Programme (CWP) ran an Accelerated Development Programme (2002-04) to roll out enhanced roles for Medical Secretaries.

The Need (Why did we do this?)
European Working Time Directive was beginning to impact on doctors' hours - whereas previously doctors could work any number of hours (helped by the "on call" shift not being particularly busy so the doctor could sleep) a combination of factors (including more call-outs at night) meant this position was no longer teneable. The result - anything that could be done by someone else should be done by someone else, to make the remaining hours as effective with limited resource as possible.

What did the Medical Secretaries start to do?
Instead of simply typing up notes and tapes, and taking phone calls often only to ask the doctor to ring the patient or GP back, Medical Secretaries began to join ward rounds with the consultant and doctors taking notes as they went around, and to make appointments/ change lists/ give diagnoses where the diagnosis confirmed what was expected by the patient or GP, and so on.

What difference did it make?
On doctors: the range of freed up time was between 0.5 and 15 hours extra time made available per week, showing how much time had been taken up with administration tasks some of which the doctor was ill-equipped to manage. For GPs this enabled between 4 and 27 extra patients to be seen per week. Result: proper rest and recuperation in time off.
On secretaries: apart from completing administrative duties much more quickly and with greater accuracy (often not having to undo the doctor's attempt at administration before doing it right), the development of the role provided more career opportiunties for this group of staff - applications per vacancy were noted to have increased.
On patients: although no quantitative studies were done, changes to appointments and adding extra patients could be done much closer to the time of appointment, and discharge letters were sent out to GPs much quicker with no systemic delays.
On costs: the numbers of administrative staff broadly remained the same, and as administrative staff developed their skills so their pay went up: however services continued to be delivered to the same number of patients at a time when the number of doctor hours were restricted back to 56 hours. The 46 sites that were involved in the ADP thought it very valuable and have continued to spread the enhanced role, though the actual cost per patient appointment for the whole team has not been possible to ascertain.

Sunday 18 May 2008

Case Study - funding for training ECPs

In olden days, physicians delivered care in hospitals, and primary care was delivered by witches. OK very olden days, but it took a long time before it was acceptable for a doctor to deliver care in the patient home (Edinburgh Medical School 1760s), and certainly the 'scoop and run' ambulance service originally designed to recover the wounded from the field of battle in the Crimea has no intention of delaying a patient reaching the safety of the hospital right up until now.
But things have changed. Hospital A&E began filling up due to a number of factors, the principle ones being a maximum 4 hour wait (access to care) and less easy access to GPs (new GMS contract). In rural areas where hospitals are often distant from the patient need another factor contributed - ambulances could be tied up taking a patient to hospital which played havoc with response time targets.
What was needed, so Warwick Univ, East Anglia Ambulance Trust (EAAT), Joint Royal Colleges Ambulance Liaison Committee (JRCALC), and just about everyone else but completely independently, decided, is a practitioner who can
  • respond to a request for unscheduled care at the scene of the accident or need
  • treat minor injury or illness on the spot and discharge the patiet fully treated (or stabilised to see their GP in due course) or refer the patient to a non hospital pathway
  • thus saving both attendance at A&E and possible admission
EAAT put a community nurse and a paramedic into the same car to see how it would work. Warwick Ambulance Trust designed a training course to teach paramedics the bits of nurse training and nurses the bits of paramedic training - both resulted in an advanced practitioner (single person) with years of experience delivering health care and the minor injuries, minor illness and referral bits of a nurse and trauma and live sustaining bits of a paramedic. A few arguments later and the name Emergency Care Practitioner or ECP was born.

How much benefit did they bring (and how much did they cost)?
I embarked on a detailed exercise to find out how many patients the average ECP would divert from A&E by treating at home or referring to another pathway, and how valuable this would be. At the same time both Sheffield Univ (ScHARR) and I researched how much the average ECP cost to train, including equipment, car, backfill, etc.
The results are published in "The ECP Report: Right Skill, Right Time, Right Place" (Sept 2004). Each Whole Time Equivalent ECP saved around £26,500 overall whilst working on emergency responses, taking into account the number of saved ATTENDANCES at A&E, their higher salary and cost, the times they had to call an ambulance for the patient, etc. We had no idea how many admissions they would save so we didn't include it in the calculations (this came later, ramping the benefits up in "Measuring the benefits of the emergency care practitioner" (July 2007).
Each ECP cost around £40,000 to train including backfill whilst on training, uniform, equipment, medicines, etc. This means it takes less than 3 years (allowing 1 year whilst they qualify) to get your investment back.

The explosion in numbers
With clear numbers, ambulance trusts began training ECPs and there are now (4 years later) nearly 1000, which indicates an investment by tens of NHS Trusts of £40million.

Difficulties encountered
It hasn't been plain sailing.
The benefits (A&E avoidance is given above, but they also worked in Out of Hours and A&E or Walk-in Centre settings) didn't benefit the ambulance trust who paid for the savings, they benefitted the Primary Care Trust. Ambulance Trusts either had to swallow a considerable sum in training, or negotiate for a paymet from the PCT.
At the same time ambulance trusts were hit with a new response time target and perceived that experienced paramedics spending perhaps 2/3 of their time on non-ambulance duties starved them of staff to meet this target (I modelled London's response times and showed they could do even better by training up a critical mass of ECPs - but see next)
Politics got in the way. Driven by a few people who hadn't invented the ECP, ambulance trusts began to clamour for an "advanced paramedic" who could avoid A&E admissions but not do any of the other ECP things like Out of Hours or Walk-in Centre. Research showed that it was the rotation (especially time spent in A&E) that really caused the change of behaviour but this was politics, not evidence.

Where are we now?
In spite of the above ECPs are providing care in large numbers throughout England, employed by ambulance trusts, primary care trusts, GP surgeries and private companies. The title isn't yet regulated because this is a long and drawn out process, but the evidence is there that this new practitioner, the first successful really new practitioner for decades, really is a cost-effective solution delivering excellent patient care. Of course none of this could have happened if it hadn't been an excellent solution, but without clear numbers it would have been difficult for trusts to justify putting ££millions into training up ECPs to deploy them.

With massive and heartfelt thanks to my friends on the ECP national team who made the ECP happen in the first place and gave me the support I needed to prepare the benefits case: Chris Wintle, Belle Connell, Mark Bilby, John Gosnold, George Alberti, and so on; and at Changing Workforce Programme and Skills for Health who kept on supporting ECP programme.

Sunday 11 May 2008

Running an Aims and Outcomes workshop for multiple projects

The New Types of Worker project has commissioned me to run a programme with a number of third sector organisations to help them make the move from development grant to sustainable commissioned services. It is one of the most exhilarating projects I've done, because the projects themselves are so varied and fascinating.

In essence, the 4 month programme consists of:
Month 1 - get to know each project and the people, bring them all together to network, confirm the aims for each project and how they will know when they've reached these aims.
Month 2 - coaching to ensure each project is collecting evidence to show they are progressing
Month 3 - coaching to report the evidence and demonstrate impact and cost/ benefits
Month 4 - practice session (as a workshop) with commissioner representatives who can say "when you show that, it makes us feel you're really going to contribute. When you show that, it doesn't add any value"

For this blog I'm presenting the outline of the Month 1 workshop

Aims of the workshop
recognise that development grants are exactly that - development. At the end of a development grant the project should have approached commissioners of services for sustainable funding based on delivery of a specific service
recognise you are not alone - others are in the same place

set milestones:
  • agree everyone's understanding of AIMS,
  • what success looks like,
  • how you can measure this,
  • the mechanics of collecting measures
Invite between 4 and 6 new projects (each probably supported by a development grant or funded internally, each having confirmed that they don't know how to find ongoing funding because if they can get ongoing funding they don't need this programme - this is for the really difficult cases)

Timing and Agenda
10:00 meet, refreshments, networking
allows people to go into the office first if they must, time to catch breath, sit in groups with their project, get things off their chest

10:30 each project has 5 minutes to introduce themselves and explain what the project does
everyone finds out what every project is about in a structured manner, with no interruptions as there will be plenty of time for feedback and questions through the day.
structure of presentation is:
  • name of project
  • people presenting at the workshop
  • objectives
  • successes
  • barriers
11:30 discussion on the nature of funding, the need for funding in order to provide a service, priorities of commissioners in terms of
  • National Indicators to achieve
  • demonstrating value for money
  • dividing a finite pot of money between competing priorities and competing providers
  • the must-do (delivering core services) vs the nice to (most of the innovation is not core services)
what makes their offering believable to commissioners will be evidence - how much, how many - so the importance of assembling and reporting this in an easily accessible way
gets everyone to the same understanding of the issues, gives people a bit of time to digest what they have heard about each project and who they will want to network with afterwards

12:00 refreshments and networking time
can ask questions on the last session, but also talk to projects facing the same issues as your own

13:00 in groups of 2 – 3 projects, each project focus of attention for 30 mins or so, focus on
  • their own achievements
  • outcomes and measures
  • process for gathering measures
  • actions and timetable

as each project is focus of attention, the other projects in their group help them to understand what they have actually achieved (people often miss the most obvious achievements as we assume they are “normal” or “not important”). Facilitators support the group deciding what are the outcomes they wish to measure and how to measure them; the final outcome of this section should be for each project to have an action plan both for connecting with the most likely sources of funds and talking about what they have achieved, and a plan to assemble the evidence to illustrate these achievements

Break part-way through to share feedback and "borrow" ideas, drinks/refreshments

2:30 feedback from tables (what was difficult, how difficulties were overcome, next steps for each project)

some of the best feedback is from an independent peer. Sometimes you don't present the best things you are doing because they seem "normal" to you; other times the obvious solution may be so big that you can't see it right in front of you. By making each project centre of attention we got really powerful input from credible people (people in the same situation)

3:00pm what support is now available to selected projects:

  • Follow up action plan after 4 weeks (1-2-1 facilitator plus project) – from deciding measures to collecting measures
  • Next coaching session after another 4 weeks – using the information collected to make a story which illustrates the impacts and benefits both anecdotally (selected case studies) and quantitatively (how many, how much, how effective)
  • Next workshop 3 months after the first – networking and sharing what you learnt; presentation to a panel of experienced advisors who will say what they like, what they want to see more of, what isn’t relevant to funding bodies. All projects will form the audience for these presentations so all can learn from the advice given to each project. Consolidation of the feedback given
  • Note a key component of any business case is the information presented – does it meet the priorities of the potential funding body and does it illustrate that you are competent and likely to deliver on your promises. This applies whether the presentation is in written form, in person, or in any number of other ways

3:30 workshop closes

this structure partly works because it allows people to talk to people in the same situation. It isn't a "teacher-pupil" relationship where the presenter "tells" everyone and they either do it or they don't; people have time to get comfortable with their peers before receiving input and we got fantastic results really quite quickly.

Facilitators are needed to deal with queries and to keep time - moving projects on when their 5 minutes (at the start) or 30 minutes (during discussion) were up, and explaining what was expected at each stage in the form of outputs.

Clear explanations and guidelines are vital to get people away from what they perceive are their priorities - typically the things that keep them awake at night (and often not the real priorities at all). Provide a clear structure and expectation and people will be really creative and productive

I hope you find this interesting and fun to do. Third Sector and Public Sector work is brilliant because people aren't really in competition with each other and are so generous with sharing and contributing - Hugo

Monday 5 May 2008

Building an Evidence-Based Business Case - NHS version

How your aims may intersect with the organisation's aims
Resources, Money, Staff, Management Buy-In - everybody wants it. To be fair, without it innovation won't happen. But how to get it?

NHS as an organisation has to deliver services 24 hours a day, 365.25 days per year (don't forget the extra quarter day!). This means the people at the top have to be operational, and innovators have to convince them of the safety, quality and achievability of our solutions.

But it isn't all about money - if it were we wouldn't have increased spend on NHS from £42billion to £100billion since 1997.

So how to create a business case to convince these operational people?

Before you start
1. To ask myself: What is my proposal? Understand WHY (values, ethics, high level NHS values)? Why should it be supported? What are my chances of success (the hairdryer model)?

It isn't what you say, it's who you involve
2. Identify stakeholders and the wider stakeholder group - Who will benefit (not "the patient", which organization has a vested interest in this aspect of improved quality? Eg if it is to do with Public Health then it is the Public Health bit of the PCT, if to do with improving patient flow for elective care then the Hospital will be most interested). From this, who are the best sponsors and who are the gatekeepers? How do I involve patients and front-line clinicians?
Who you should involve - Public, Clinicians, Management, Data, Father Christmas3. What are their priorities? You should refer to organisations plans - eg LDP, business plan etc to understand priorities. Do the benefits from my proposal support one or more of their priorities/wider NHS priorities e.g. Selbie 6? In what way? If none of my benefits support any of the priorities of the organization then consider going no further (or try harder to find a link). What about non-NHS organisations eg Local Authority, National Government, Charities

Nobbling the right people

4. think about the journey my business case will travel, which committees. Who is the best person to help (typically a Director or Senior Manager)? - this is the SPONSOR
5. Who has evidence, audit or other information that I can use to build my case?
6. Who would like to support me, or who would be offended if they weren't involved? Keep your friends close and your enemies closer – how do you get your case onto people’s agendas – make the links?
7. Talk to the people who would like to help and who have the information I can use, and start building the case. Identify the weaknesses and talk about them early. At what point do you need to switch from pull (consensus – lets all join in) to push (this is the way we’re going!)

Writing the case

8. Assemble a team – involve patient or patient rep, and cross-check you have the right stakeholders e.g. third sector, independent providers. Agree what the problem is you are trying to solve. If more than one, then identify which is the most important and keep the others in reserve. Agree on what the options are. Do PESTE (political, economic, social, technological and environmental issues) and/or SWOT (Strengths, Weaknesses, Opportunities, Threats) on the options. Pick the best one or two.Strengths/ Weaknesses/ Opportunities/ Threats for a number of options
9. Work up a more detailed benefits/risks/costs/timescales on the best options. Be clear about scope. Delegate each task to the person best able to do it - play to people's strengths and flatter their skills
10. Think hard about this one - if you say you are going to make savings, say how you will realize those savings. For example, if you are going to save money, can you actually get that money out of the system? How? If it means fewer working hours, then what are you going to do with the hours saved that the panel will think is worth while (eg ECPs on 999 responses save hospital attendances, but A&E costs the same amount to run. So the savings come initially because you stop the rise in the number of A&E attendances rather than because you reduce the number of attendances, and the rise would cost money. Then the ECPs have impacts on other pathways which might cost money but are cheaper than an alternative, or which might save money but how can you realize those savings?)
11. Work out a 90 second message that you can all agree, and try it out on each other. You will probably need slightly different messages for different audiences but make sure they are sufficiently similar that anybody hearing any message recognizes that it is for the same proposal. Try out your 90 second messages on a couple of guinea pigs, if necessary referring to notes, so that all of you have practiced at least once and can say it under stress (in a chance encounter with the Chief Exec in a lift, for example). Keep everyone informed, including ‘observers’ (with a passing interest) so they can input as appropriate and get involved if they want
12. Write a summary of the business case in the format above (Context, Proposal, Benefits, Costs) that you all agree with, that fits onto no more than a side of A4 or a side and a half, and that carries the message. Get someone who isn’t connected, preferably from outside NHS, to read it
13. Fill in the detail in accompanying appendices (eg Options Appraisal, Workforce Strategy, Finance and Costs, Corporate and Clinical Governance, Affordability & Risk, Glossary of Terms)
14. Go back to your Sponsor (or get the person you have as an intermediary to go back to them) and try out your proposal. If they don't like it then find out how they think it could be improved.

Presenting to a Committee
15. From your sponsor and anyone else, find out which committee is the best one to review your case, and which budget the investment will come from. Who do you know on this committee? Who can you contact? Hopefully your sponsor is on this committee but if not then you need a second sponsor who is on this committee. Don't send proposals to the wrong committee - that just waste's people's time.
note that you may have to present to more than one committee,
  • because you may have committees which pre-filter proposals, ie deciding which proposals have sufficient merit to go before the board?
  • you need the support and information from a sub-committee reporting to a main committee in order to get the change or investment you seek
16. When is the best time to put your case before the committee? At the start of the year when they have the new budget? At the end when they have money left over? Immediately after a scandal in the media? This will depend on how much and how long it takes to get benefits amongst other things. Work out a strategy to put your case before the right committee and to contact (the team or through intermediaries) as many members of that committee as possible. Most important question: Are you the right committee? Second most important (you may need to talk about the proposal first) Will they support it? Does it need changing for them to support it? Often a committee wants to see evidence that you have consulted front-line staff and service users, and if you can get these stakeholders involved in presenting the case it will help considerably
17. Once you've been through this process, if most of the people you've spoken to on that committee support your proposal and you've had no serious objections then you will have no trouble. If you have any serious objections, even one, you need to understand why they object. It could kill the proposal
18. Note the proposal that goes to the committee, after people have commented and suggested changes, may be a bit different from your original idea. Is this a problem? Have the suggestions made it better?

I know it is a fairly long process but writing a business case is even longer and there's no point in putting a lot of effort into the business case but not being prepared to put a little bit more into making it robust.