Healthy Innovation Conference Brochure

Healthy innovation
Bank of America Merrill Lynch

5 Canada Square
London
E14 5AQ
Tuesday 26 February 2013
08.30 16.15
#healthyinnovation
@reformthinktank
Professor Lord Darzi KBE, Earl Howe, Jane Cummings, Ciarn Devane,
Dr Victor Dzau, Wayne Felton, Dr Nicolaus Henke, Jamie Heywood, Sir
Thomas Hughes-Hallett, Anant Kumar, Steve Melton, Tim Murphy, Javier
Okhuysen, Sir John Oldham, Cally Palmer CBE, Amy Pott, Viren Shetty,
Stephen Thornton, Adrian Wooldridge, Pedro Yrigoyen
Innovative delivery in healthcare
What makes a disruptive innovator?
Innovative delivery models: Accessible primary
care, better hospitals and coordinated care
Delivering innovation in the NHS
Healthy innovation
1 www.reform.co.uk @reformthinktank #healthyinnovation
Contents
Programme 2
The Reform team setting the agenda 5
Innovative delivery in healthcare 6
Innovative delivery models: Accessible primary care 8
Innovative delivery models: Better hospitals 10
Innovative delivery models: Coordinated care 12
Delivering innovation in the NHS 16
Reform More for less 18
Reform Join us in 2013 19
Register your support 20

Kindly supported by:
Reform
45 Great Peter Street
London
SW1P 3LT
T 020 7799 6699
info@reform.co.uk
www.reform.co.uk
The Reform Research Trust is also grateful for a grant towards
the costs of the event from the Health Foundation
Healthy innovation
08.30 09.00 Registration and
breakfast
09.00 09.15 Welcome and
introduction
Nick Seddon, Deputy Director, Reform
09.15 09.45 Innovative delivery in
healthcare
Professor Lord Darzi KBE, Chair, Institute of Global Health Innovation, will deliver a keynote speech
describing the work of the Global Health Policy Forum and the progress made since the Global Health Policy
Summit in August 2012 towards the challenge to deliver high quality, affordable and accessible healthcare.
Chair Nick Seddon, Deputy Director, Reform
09.45 10.45 What makes a
disruptive innovator?
Innovators are already transforming how healthcare is delivered and organised. These pioneers have challenged
established models of care and professional assumptions to develop radically different services that are
cheaper, more accessible and safer. There are common factors in that make disruptive innovators in healthcare
successful. This session explores what it takes to be a disruptive innovator in health.
Dr Victor Dzau, Chair, International Partnership for Innovative Healthcare Delivery
Jamie Heywood, Chair, PatientsLikeMe
Viren Shetty, Senior Vice President, Strategy and Planning, Narayana Hrudayalaya
Adrian Wooldridge, Schumpeter Columnist, The Economist
Chair Tom Kibasi, Partner, McKinsey & Company
10.45 11.15 Coffee
11.15 12.00 Innovative delivery
models: Accessible
primary care
Effective primary care can produce healthier populations at lower cost. However in both the developed and
developing world access to primary care can be limited and quality can be variable. Modern technology has the
potential to transform traditional primary care services based on family physicians, bringing safe and high quality
care closer to the patient and using a wider range of clinical practitioners.
Pedro Yrigoyen, Co-Founder, MedicallHome
Sir John Oldham, GP and National Clinical Lead, Quality and Productivity, Department of Health
Wayne Felton, Strategic Director of Healthcare, MITIE
Chair Will Tanner, Senior Researcher, Reform
models: Better
hospitals
General hospitals are at the core of many health systems, where an increasing variety of medical services and
specialities have been consolidated into single campuses. However this business model has proved highly
inefcient and does not always ensure quality and safety. Specialisation of services and hospital franchises offer
ways to maximise productivity and improve services for patients.
Javier Okhuysen, Co-Founder, SalaUno
Anant Kumar, Chief Executive Ofcer, LifeSpring Hospitals
Steve Melton, Chief Executive Ofcer, Circle
Chair Thomas Cawston, Research Director, Reform
12.45 13.30 Lunch
13.30 14.00 Innovative delivery in
the NHS
Earl Howe, Parliamentary Under-Secretary of State, Department of Health will deliver a keynote speech
that setting out how the NHS will achieve faster innovation in healthcare services to improve productivity and
quality for patients.
models: Coordinated
care
The fragmentation of traditional health systems has been a driver of costs and waste, and prevented patients
receiving high quality care. However with patients often needing to obtain services from different providers and
specialties, old professional boundaries have become obsolete. High performing systems are now able to
coordinate care around the needs of patients and encourage population health.
Tim Murphy, President, Beacon Health Strategies
Ciarn Devane, Chief Executive, Macmillan Cancer Support
Jane Cummings, Chief Nurse, NHS Commissioning Board
Amy Pott, Director of Market Access, UK and Ireland, Baxter Healthcare
Chair Pam Garside, Co-Chair, Cambridge Health Network
Programme
At Baxter, we focus on saving and
improving the quality of patients lives.
Building on our 80 year history of medical rsts,
we innovate every day to bring the next genera-
tion of therapies, technologies and service to
patients and healthcare professionals around the
world. Whether in hospitals, clinics or at home,
we are there where you need us with our unique
combination of expertise in medical devices,
pharmaceuticals and biotechnology.
Baxter Healthcare SA
Postfach, 8010 Zrich
p +41 (0) 44 878 60 00 f +41 (0) 44 878 63 50
www.baxter.com
Life. Health. Care.
BAXTER INTERNATIONAL INC.

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Life. Health. Care.
At Baxter Healthcare, we focus on saving and improving the quality of patients lives.
Building on our 80 year history of medical frsts, we innovate every day to bring the next generation of therapies, technologies and
service to patients and healthcare professionals in the UK.

Working through partnership and consultation with the NHS, we are delivering QIPP through our Evolving Health programme. Visit
our website to fnd out more www.baxterhealthcare.co.uk
Healthy innovation
15.00 16.00 Delivering innovation in
the NHS
While the lessons of innovative healthcare are known, diffusion and adoption of best practice remains slow. In
particular, the rate of innovation is faster in the developing world compared to the more developed healthcare
systems such as the NHS. Legacy infrastructure, entrenched professional cultures and perverse incentives have
made the radical innovation that is needed harder. Overcoming these barriers to innovation is a key challenge for
policy makers.
Sir Thomas Hughes-Hallett, Executive Chair, Institute of Global Health Innovation
Stephen Thornton, Chief Executive, Health Foundation
Dr Nicolaus Henke, Director, McKinsey & Company
Cally Palmer CBE, Chief Executive, The Royal Marsden NHS Foundation Trust
16.00 16.15 Closing remarks Nick Seddon, Deputy Director, Reform, and Sir Thomas Hughes-Hallett, Executive Chair, Institute of
Global Health Innovation will sum up and close the event.
circlepartnership.co.uk
We believe hospitals
can be better
The Reform team
setting the agenda
Health systems around the world are
facing a crisis, with governments
struggling to improve quality and access
without blowing their budgets. While
nearly all Western governments have had
to embark on rescue missions to restore
their public nances, rising healthcare
costs have been singled out by the IMF
as the greatest risk to scal sustainability.
Delivering high quality, accessible and
affordable healthcare will be the public
policy challenge of the 21st century.
However existing models of care are
no longer t for purpose. Innovative
solutions for healthcare delivery are
badly needed.
Pioneers from around the world have
started to champion the health services
of tomorrow. There are many family
resemblances and common approaches
that dene these disruptive innovators.
Typically they have grasped the
importance of human capital and
reformed the workforce to improve
productivity. Many have used technology
and data to measure performance but
also make healthcare more accessible to
patients. Often these innovators have
specialised to deliver high volume at low
cost, others have used protocols to
standardise services.
From Bangalore to Boston these
trailblazers in more for less had to take on
the old ways of doings thing. Many brought
changes from outside healthcare and were
resisted by the established players.
While primary care should produce
healthier populations at lower cost, the
traditional cottage industry of doctors
practices is no longer t for purpose.
Yet everyday technologies have the
potential to bring expert health advice
closer to the patient. In Mexico,
MedicallHome promises immediate 24
hour healthcare advice to over 1 million
households via mobile phone, all for $5
(3.20) a month. This is the kind of
game-changing idea that could reduce
pressure on our GPs and make a real
difference to patients.
The general hospital, the core of many
health systems, is also falling behind the
times. Advances in technology and
medicine now mean that a better way of
delivering specialist care is in reach. By
specialising and standardising treatment,
complex surgery can become an
industrial production line at volume and
quantity, but greatly reduced cost. At
Narayana heart hospital in India they
perform 35 surgeries a day on average, at
one tenth of the cost of NHS hospitals. At
LifeSprings in India, the specialist
maternity hospital has streamlined its
procedures and clinical protocols leaving
doctors productivity four times higher
than non-specialist providers and prices
are up to 50 per cent lower than market
rates. At Salauno clinic in Mexico,
cataract surgeries are offered for less
than a third of the cost of the NHS by
using the lessons of lean assembly
production line methods. In all cases the
clinical outcomes are the same if not
signicantly improved. Some have
claimed that the NHSs falling position on
international league tables whilst budgets
are being squeezed proves more money
is needed. In fact these pioneers from
India to Mexico show that we can
harness radical techniques to deliver
improved outcomes at minimised cost.
With the job of health systems moving
towards meeting the challenge of chronic
conditions new health services are
needed. Coordinating historically
fragmented services around the needs of
patients is the key innovation for the NHS
and other systems. However this is no
group hug. Integrating services that are
organisationally and professionally
different requires new entrants with new
skills. In Rhode Island, Beacon Health
Strategies, has worked with providers to
create an integrated care pathway for
mental healthcare services, which were
previously highly fragmented at great
cost. In one year the cost of mental
healthcare hospitalisations for children
was cut by 20 per cent. Clearly new
entrants must be allowed to drive the
pace of innovation.
The NHS cannot be left behind in this
global arms race for innovation in
healthcare. The scale of the nancial
challenge demands transformation but
the NHS continues to rely on the grip of
the centre to balance the books. Instead
of driving change from the centre, now is
the time to set the innovators free. For
innovation in the NHS to succeed
providers need the freedoms to change,
the opportunity to compete and the
rewards for doing things differently.
Reform is immensely grateful for the
support and collaboration of Lord Darzi
and the Global Health Policy Forum,
which has enabled us to hold this timely
and important international conference
showcasing healthcare providers that are
achieving more for less.
Nick Seddon ,
Deputy Director,
Reform
Cathy Corrie,
Researcher, Reform
Andrew Haldenby,
Director, Reform
Tara Majumdar,
Researcher, Reform
Will Tanner,
Senior Researcher,
Reform
Thomas Cawston,
Research Director,
Reform
Healthy innovation
Professor Lord Darzi KBE
Three strands of innovation
in the healthcare sector

Health services need to change. The
creeping epidemic of chronic conditions,
and an ageing population, present new
health needs for which our episode focused
health service is poorly suited. As the recent
Francis report emphasised, citizens rightly
expect high quality services that are also
compassionate and patient-centred. Put
these factors together with long term
fnancial pressures and it is hard to see
how the NHS can remain sustainable
without innovation. More of the same
simply wont do.
Innovation can of course mean different
things. I might mean new technology or
drugs. I could be talking about new clinical
practices or business processes. But whats
needed most is scalable service innovation:
in other words, fundamental improvements
in how healthcare is delivered that can be
disseminated throughout the health system.
I think there are three particularly
important types of service innovation on
which the NHS should focus in the coming
years, drawing on what works elsewhere in
the world.
The frst is workforce innovation. Chronic
conditions require a different skill and
workforce mix, orbiting around primary
care. This means fewer specialists in
hospitals, but more nurses, allied health
professionals and paraprofessionals (e.g.
ftness and nutritional experts) out in the
community. Interestingly, workforce
innovation is most advanced in countries
like India or Brazil where the key challenge
is a shortage of skilled professionals. We
have much to learn from their experience.
The second type of innovation is
self-care. In industries like air travel and
banking, consumers now assume many
tasks that were previously the responsibility
of providers. Similar opportunities to shift
the boundary between provider and patient
abound in healthcare, mediated by
technology and enabled by patient up-
skilling. Not only could self-care offer the
potential of more cost-effective services,
there is also evidence that it improves
outcomes for those that suffer from asthma,
chronic obstructive pulmonary disease,
diabetes and other common conditions.
Patients involved in their own care are often
more satisfed too.
A fnal area is around personalised
medicine. It is hard to overstate the changes
this paradigm shift could entail for health
systems. New preventative, diagnostic and
therapeutic services will need to be designed
that are tailored to individuals specifc
genomic and specifc biomarkers. Patients
will need to understand their particular risk
profle and what they can do to prevent
disease. For other members of the health
ecosystem, such as pharmaceutical frms, a
whole new way of doing business will need
to be found.
Unlocking the benefts of these service
innovations will mean radical change at each
level of the system. Policy and regulation
needs to be modernised to take advantage of
more effective workforce models, to allow
patients to maximise the care they can
deliver themselves and to enable the
research and therapies that will make a
reality of personalised medicine. The
professions need to embrace rather than
resist workforce innovation, empower their
patients and translate the immense power of
genomic, proteomic and metabolomic data
into clinical practice. But it is perhaps the
patient who will have to change the most.
Future health services will not revolve
around consultants in hospitals; instead,
they will facilitate the active involvement of
users themselves in providing their own
care, drawing on a detailed understanding of
a personalised risk profle, working with
nurses, pharmacists, nutritionists, ftness
experts and other advisors more often than
with the specialist doctors of today.
So whilst we desperately need service
innovation, there is no guarantee it will
happen. Stagnation is as likely as progress.
This is one reason why conferences like this
one which aim not only to showcase some
of the best innovations from around the
world, but also to catalyse their uptake in the
NHS are important. This is also the
mission of the Institute of Global Health
Innovation at Imperial College London,
which I direct. The sources of the next phase
of progress in healthcare are becoming
apparent. Now all we have to do is have the
courage to tap them.
Professor Lord Darzi KBE, Chair, Institute
of Global Health Innovation
Earl Howe
Innovative delivery in the
NHS
The NHS is full of brilliant people with
brilliant ideas. It has a long and proud
record of innovation and creativity
stretching back across its 64-year history.
Innovation embraces both the great
discoveries like penicillin and new
techniques such as keyhole surgery, but also
smaller changes in ways of working to
improve patient care, for example the
development of community matrons.
The NHS has an impressive history of
inventions and new ideas but the adoption
and spread of these ideas is too slow, and
sometimes even the best of them fail to
achieve widespread use. Patients have the
right to expect better health, better care and
better value from their NHS.
Like many other health economies, the
NHS faces a tougher fnancial climate. This
means that simply doing more of the same is
no longer an option. We need to do things
differently. Innovation is an essential tool in
helping address the challenges of an ageing
population, chronic disease, health
inequalities and rising public expectations
especially when resources are constrained.
The NHS Chief Executives Review of
Innovation, Innovation, Health and Wealth
led by Sir Ian Carruthers, Chief Executive of
NHS South of England, was designed to seek
views on how the NHS could help accelerate
the spread and uptake of new ideas and
innovations on the ground. Although
responses came from many different
Healthy innovation
Innovative delivery in healthcare
organisations and individuals, with very
different interests and backgrounds, the
feedback received was very consistent. Our
approach has been to focus on a limited
number of actions:
We should reduce variation in the NHS,
and drive greater compliance with NICE
guidance
Working with industry, we should develop
and publish better innovation uptake
metrics, and more accessible evidence and
information about new ideas
We should establish a more systematic
delivery mechanism for diffusion and
collaboration within the NHS by building
strong cross-boundary networks
We should align organisational, fnancial
and personal incentives and investment to
reward and encourage innovation
We should improve arrangements for
procurement in the NHS to drive up
quality and value, and to make the NHS a
better place to do business
We should bring about a major shift in
culture within the NHS, and develop our
people by hard wiring innovation into
training and education for managers and
clinicians
We should strengthen leadership in
innovation at all levels of the NHS, set
clearer priorities for innovation, and
sharpen local accountability; and
We should identify and mandate the
adoption of high impact innovations in the
NHS, and make compliance a pre-
qualifcation requirement for access to
CQUIN payments
On 10th December 2012, Sir David
Nicholson published Creating Change
Innovation, health and wealth: One Year
On. This demonstrated that of the 31
recommendations made in Innovation,
Heath and Wealth, 25 have already been
delivered and the remainder are on track.
We recognise that whilst much has been
achieved, there is more to be done to
develop a culture of innovation that is
spread right across the NHS.
Innovation is not just about the future of
the NHS and health and social care, it is
about the future of our countrys economy.
The aim is to make the UK a strategic
partner of choice for global stakeholders
because of its unique health service,
supportive fscal environment and world-
class talent and facilities. This will generate
wealth for the economy whilst maintaining
and enhancing the health of the nation.
The NHS remains a major investor and
wealth creator in the UK, and in science and
engineering in particular. NHS success in
adopting innovation helps support growth
in the life sciences industries. That in turn
enables these industries to invest in
developing the technology and services the
NHS needs for its own further development.
It is clear the NHS must raise its game in
developing more effective and more
cost-effective interventions if it is to stay one
step ahead of pressures rather than running
to catch up. In doing so, cost-effective
innovation will not only help to provide the
very best quality of care but will also
invigorate the economy.
Earl Howe, Parliamentary Under-
Secretary of State, Department of Health
Dr Victor Dzau
What makes a disruptive
innovator?
As we look at the challenges facing health
systems around the world, it becomes
increasingly clear that relying on the same
approaches, methods and ways of thinking
from the last century is not going to drive the
change that this world so desperately needs
in healthcare. When I look at my own
country, the USA, which spends 17 per cent
of GDP on healthcare, I know that
something needs to be done very differently
to avoid what will be an unmanageable
situation for many in a matter of years.
Naturally, change has been happening.
For example, the passage of the Affordable
Care Act led to the creation of the Center for
Medicare and Medicaid Innovation, set up
with the remit of testing innovative care and
payment models, and encouraging the broad
adoption of models that provide improved
healthcare at decreased costs.
For a challenge as great as the one were
facing around the world, I believe that we
need to think and act boldly. The term
disruptive innovator may make some of us
feel uncomfortable, and may make some
entrenched organisations feel threatened,
but ultimately, nobody has ever achieved
radical change without creating this sense of
unease. Such is the importance of this topic
that two years ago, Duke Medicine,
McKinsey & Company and the World
Economic Forum co-founded and launched
the International Partnership for Innovative
Healthcare Delivery (IPIHD), designed to
identify these types of innovators and create
a platform for accelerating the growth and
adoption of disruptive innovations in
healthcare delivery.
We have found and learned from some
remarkable models of care from around the
world. Examples include LifeSpring
Hospitals, which delivers babies for a
fraction of the cost of other hospitals in
India by driving process standardisation and
right-skilling of the clinical workforce, and
MedicallHome, a Mexican healthcare
company working in partnership with a
telecommunications company to create
access to advice and triage from doctors as a
monthly service accessible via mobile
phone. We can learn a great deal from these
and other models that can help us
understand what epitomises a disruptive
innovator. For me, there are three
underlying facets to this.
Vision, drive and commitment are
pre-requisites to impact to be a true
trailblazer in healthcare you must be able to
clearly envision the change you want to drive
and have a steadfast commitment to forge a
new path in this direction. Secondly, you
must be able to apply game-changing
principles and lessons centred on tangible
value creation for the health system.
Examples include re-purposing existing
technology and networks to drive effciency,
smart use of human capital in the value
chain and building care around the patient.
Finally, disruptive innovators must be able
to navigate the turbulence of the health
system effectively to ensure widespread
adoption and avoid becoming an island of
innovation in a sea of stagnation.
These unique individuals and
organisations cannot work in isolation. They
need to be connected to each other through
peer networks that can support and nurture
their work, as well as to partners and
collaborators that can accelerate the
potential impact of their breakthrough
ideas. Only through taking an ecosystem
approach to addressing the challenges in
health systems with different stakeholders
can the need in health systems around the
world be met by the radical new thinking
that disruptive innovators are bringing to
the pitch.
Dr Victor Dzau, Chair, International
Partnership for Innovative Healthcare
Delivery
Healthy innovation
Pedro Yrigoyen
MedicallHome and over-
the-phone healthcare
MedicallHome was launched in Mexico in
1999 to bring 24/7 access to medical advice
by phone for paying subscribers. Through a
partnership with telecommunications
provider Telmex, MedicallHome offers
over-the-phone triage to 1.2 million families
(over 4 million individuals). For a fxed cost
of USD $5 per month, subscribers have
immediate access by phone to qualifed
doctors who use Cleveland Clinic protocols
to diagnose and make treatment
recommendations. Subscribers can access
the MedicallHome network of 6,000 doctors
and 3,200 healthcare delivery sites or
request an in-home doctor visit, all at
reduced prices.
MedicallHomes founders have also created
two mobile applications for smartphones and
are also launching a Medicall portal market,
through which non-members can buy
discounted medical services.
The MedicallHome model is currently
being launched in Colombia and Peru with
local telecommunications companies and
the founders are working toward replicating
it in Ecuador as well. They are also working
with large employers in Mexico to
implement the model as an employee
beneft, which could reduce absenteeism f
or employers.
MedicallHome addresses three primary
challenges in the healthcare system in
Mexico. First, access to medical care is a
problem, especially in rural areas. There are
too few doctors and nurses and rural
patients must often travel long distances to
access care. Second, the cost of seeing a
doctor (typically about USD $30) places a
burden on low-income individuals, who may
avoid seeking care because of the cost. Third,
there is high variation in quality among care
providers and it is diffcult for patients to
identify the best physicians.
The MedicallHome system uses an
existing resource (telephone network) in
order to increase patients access to medical
advice and to eliminate unnecessary travel
to, and payment, for doctor visits.
Nearly two-thirds of the calls are resolved
over the phone, increasing the effciency of
the care delivery system and saving patients
both travel and money. For the calls that
merit referral, patients can choose a doctor
or clinic based on location, price or specialty,
and receive a discounted rate for the visit.
The system provides consistent quality of
care, verifying clinicians in the referral
network and using triage protocols from the
Cleveland Clinic for the phone service.
MedicallHome is currently in discussion
with both Federal and State governments in
Mexico over ways to create more widespread
healthcare cost savings. Medicall believes
that pre-screening primary care contacts by
phone could signifcantly reduce the costs of
the national health system. Navigating the
political realm of the established
stakeholders in the public health delivery
system has been challenging and they have
encountered resistance to innovation in this
area. Because the social security program for
health has a very high political and popular
profle, Medicall believes that change will
require the support of federal leaders.
Pedro Yrigoyen, Co-Founder,
MedicallHome
Sir John Oldham
Technologically driven
primary care
The passionate champion of primary care,
the late Barbara Starfeld, defned primary
care by enumerating its key functions:
Serving as the frst point of contact for
all new health needs and problems;
delivering long term, person-focused
care; comprehensively meeting all
health needs except those whose rarity
renders it impossible for a generalist to
maintain competence in them; and
coordinating care that must be received
elsewhere.
Primary care is a highly effective means of
healthcare delivery in terms of cost and
quality, and will never be more necessary
than in the next few decades. The digital
revolution can transform the means by
which the point of contact can be made,
yet healthcare is the industry where
technology is still usually an add-on to
the existing means of service delivery,
as opposed to fundamentally changing
the operating mechanism.
Healthcare lags behind societal changes
in the way that service industry interacts
with its users. Healthcare demand will rise.
In Western industrialised countries this
coincides with a lower long term economic
trend that will constrain the response to that
rising demand. In addition, it will shortly be
the Facebook generation that will have long
term conditions; they will wish to interact in
a different way; much more involved in
managing their own care and pulling in
knowledge remotely when they want it. In
emerging economies the penetration of
mobile technology far exceeds the
infrastructure for traditional healthcare
delivery, yet demand for healthcare is rising
in these countries also not least from an
increase in the diseases of greater affuence.
These pressures, in my view, mean it is
inevitable that access to, and utilisation of,
Healthy innovation
Innovative delivery models:
Accessible primary care
Healthy innovation
healthcare will have to be more
technologically driven.
The seven challenges that must be
addressed for primary care globally to
realise its potential are:
1. Poor patient access and perceptions
2. Insuffcient coordination and integration
3. Low professional prestige and limited
availability of the workforce
4. Lack of infrastructure investment
5. Misaligned incentives
6. Under-utilisation of information and
technology
7. Variable quality standards and regulation
All of these challenges can be, and have
been, overcome. Around the world,
innovative models of primary care exist that
offer lessons on how to improve things.
Some of the best examples are from
emerging countries who have been much
more innovative in the means of healthcare
delivery because they have had to be.
Disruptive innovation in the West and for
the NHS will require reverse learning and a
willingness and humility to do so.
There are case studies, from different
continents, which show how change can
come about. For example:
Allow patients to access clinicians by
email, phone or Skype, to increase
convenience and reach;
Use whole primary care teams (including
nurses and assistants) to deliver lower
skill healthcare tasks;
Use lay community outreach workers to
raise awareness and support change in
behaviour;
Scale-up access to primary care where it is
required in under-served areas.
Policymakers can use these lessons to
improve primary care. Three aspects in
particular will be considered: action on
incentives, information and technology, and
quality standards and regulation. These are
the areas that governments across the world
can most consistently infuence.
Governments cant innovate but can affect
the climate for innovation to occur. This
applies equally to the NHS.
Sir John Oldham, GP and National Clinical
Lead, Quality and Productivity,
Department of Health
Wayne Felton
Improving the care
pathway
In October 2012 MITIE Group entered the
health and care landscape for the frst time
with the acquisition of the fourth largest
provider of homecare in England and Wales.
It is clear that the system is facing a
considerable challenge: 4 per cent annual
savings against an ageing population that
will see the number of people over the age of
85 double within the next 20 years.
The scale of this challenge demands a
transformation in how services are
delivered. This has been possible in other
sectors of the economy such as the insurance
industry. When faced with escalating costs,
reduced income and greater demand,
insurance companies brought all of the
stakeholders together into one single
process with the common aim of delivering
improved customer satisfaction at a
signifcantly reduced cost. Implementing
changes to the industry was only possible
because it had control over all the key
elements of the provision of insurance. This
is not always the case in health and care,
where the separation of budgets is the
principal hurdle to allowing services to be
reengineered, and can sometimes mean that
the full potential of some services is not used
to reduce costs and improve quality.
Certainly this is the case for homecare
providers. There is an excess of one billion
home visits a year. That is an incredible
number of regular contacts with the types of
individual that drive a huge proportion of
our annual health expenditure. These home
visits provide a signifcant opportunity to
conduct the basic checks that could provide
early warning of an event that would result
in a greater cost to the health budget overall.
Yet contracts are let that drive homecare
away from delivering greater value; no scope
for innovation is allowed, the focus is purely
on the cheapest hourly rate.
One major opportunity would be for
homecarers to support the management of
patients with chronic conditions. By way of
example, 2,800,000 people in the UK are
currently diagnosed with diabetes, 90 per
cent with Type II Diabetes. These patients
require regular and frequent monitoring of
blood sugar, insulin levels, weight and blood
pressure, and other clinic visits for diabetic
retinopathy, renal function and podiatry, in
addition to those health problems associated
with poor circulation. This is a signifcant
burden in time and travel to patients visiting
multiple clinics, and also to the health
service. The cost of diabetes to the NHS is
over 1.5 million an hour or 10 per cent of
the NHS budget for England and Wales.
This equates to over 25,000 being spent on
diabetes every minute.
In total, an estimated 14 billion pounds
is spent a year on treating diabetes and its
complications, with the cost of treating
complications representing the much higher
cost. The prevalence of diabetes is estimated
to rise to 4 million by 2025. Many of these
patients have problems with mobility, so
even the most basic checks require the use of
the ambulance service. This cost ranges
from a taxi fare to a more signifcant amount
for a two man ambulance. How many of
these visits could be covered by a trained
healthcare assistant supported by the
appropriate telehealth? They could provide
a number of these checks at home in
addition to their existing duties, at little
marginal cost, directly submitting the
results into the GP/hospital database.
Currently decisions are made that impact
on elements of the care pathway to the
potential detriment of other parts. A decision
not to provide a home visit to an individual
could certainly impact the likelihood of that
person being admitted to A&E.
We look forward to the national
introduction of personal health budgets, as
they have produced positive results for
patients in the trial sites. It is encouraging to
see that the budget fgure will be produced
as a result of a multi-disciplinary assessment
of the individuals needs. However, it is less
clear how community services paid for by
these budgets will be commissioned. If
brokers are to support decision making with
recipients, how do the brokers keep up to
date with available services? Will there be
the same quality checks on providers? A
multi-disciplinary approach to the sourcing
of social and community care would surely
help in the quality and choice of services
available. This may enable some of the
benefts above to be realised.
Private providers are part of the care
pathway, eager to provide a high quality
service and work collaboratively with the
NHS and social services to improve patient
lives. We hope that private companies are
seen as partners facing the ongoing
challenges and fnding joint solutions for the
beneft of patients and carers.
Wayne Felton, Strategic Director of
Healthcare, MITIE
Anant Kumar
There has to be a better
way
Like many social businesses, the genesis for
LifeSpring began with a simple belief:
There has to be a better way. At the time, I
was working in the contraceptive social
marketing program of HLL Lifecare Limited,
an Indian state-owned company that
manufactures and markets contraceptive
products. Whilst working in the family
planning clinics of both private and
government hospitals in Hyderabad to
promote family planning services, I was
continually disturbed by the conditions in
which low income women were delivering
their babies. The government hospitals I saw
were under-resourced and overcrowded,
leading to diffcult conditions for both
patients and medical professionals. There
were not enough beds, doctors, or space to
cope with the number of people needing
care. Pregnant women would wait in long
lines outside the hospital, often having to
pay bribes for minimal services.
Then there were the private hospitals
offering services that were of high quality
but priced out of reach for lower-income
families. However, low income women
would often sell assets or borrow money at
high interest rates to fnance a delivery in
private hospitals, as they preferred to receive
a higher standard of care. LifeSpring was
thus born to fll the gap between the existing
options: a hospital that could serve poor
women with affordable, dignifed healthcare.
I knew, however, that fnancial sustainability
was crucial for a scalable model.
In 2005, we launched our frst hospital as
a pilot. Women would pay a low, all-
inclusive price for a complete delivery
package, and would receive high quality
healthcare services. We would also focus on
customer care, recognising the women as
empowered customers as opposed to
recipients of charity. LifeSpring offers
services that cover the whole range of a
womans pregnancy, as proper antenatal
care is essential to minimising complications
during delivery.
Our low cost model is based on the
following main characteristics: service
specialisation, a no-frills set up, high asset
utilisation, and para-skilling (breaking down
a complex process into simpler tasks that less
skilled professionals can perform repeatedly).
Our prices are one-third to one-half of the
prices charged at other hospitals offering a
similar quality of services.
An additional innovation of our model is
the way we apply frameworks from the
private sector to our work. Extensive data is
collected at LifeSpring, for example from our
customers and operations. We use this data
to streamline operations, keeping costs as
low as possible, and we analyse our customer
socio-economic data and feedback to better
understand their healthcare needs.
Our frst hospital reached operational
proftability in 18 months, ahead of our business
plan forecasts. In 2008, LifeSpring received
joint equity funding to scale up our model. Our
investors are Acumen Fund (an American social
venture fund) and HLL Lifecare Limited. With
their $3.8 million in equity, we were able to
grow from one to six hospitals in our frst year
as a private limited company.
LifeSpring has also beneftted very
signifcantly from a partnership with the
Boston-based Institute for Healthcare
Improvement (IHI). IHIs expertise in
clinical quality improvement has helped
LifeSpring decrease our rates of maternal
and neonatal morbidity, improve clinical
protocol adherence and strengthen a culture
of safety in all of our hospitals. In addition to
these clinical outcomes, our quality
improvement initiatives have
simultaneously increased operational
effciency, leading to a reduction in our
operating costs.
In addition to helping women to deliver
their babies in a safe and affordable way,
LifeSprings operations have indirect effects
as well. We are reducing the burden on
resource-constrained government hospitals
by attracting patients to our hospitals and, by
infuencing the quality of other providers, we
are catalysing an improvement in the quality
of care being offered by the wider market.
Anant Kumar, Chief Executive Offcer,
LifeSpring Hospitals
Steve Melton
Clinically led hospital care
Its now been over a year since Circle began
our ground-breaking contract to run
Hinchingbrooke hospital. Circle is an
employee co-owned partnership, with a
strong belief in clinical leadership, frontline
decision-making and fat management
structures. Simply put, we think the people
who know patients best should have the
biggest say in how hospitals are run.
Hospitals are curious entities so bring
unique management challenges. Many
businesses are either solution shops,
diagnosing and consulting like management
consultancies, legal or architectural frms, or
value adding processors like factories,
manufacturers or farmers. Hospitals never
separated these two functions, and are
therefore a complex hybrid. Whilst on the
one hand the professional services ethos is
vital to free those who know patients best to
make the best decisions for their patients, on
the other hand, hospitals need production
style processes to deliver effciency and total
quality control.
Our solution is the Circle Operating
System. This operating system splits
hospitals into separate clinical units:
clinician-led teams that are handed power to
act as small businesses in their own right,
with control over budgets, staff and rotas.
Each of these clinician leaders is given a seat
on the main hospital board, meaning that
whole tiers of management can be removed
between the board and the ward. Each unit
takes ownership of their own data, including
patient feedback, clinical results and
fnancial sustainability, and the clinical
leaders are accountable to their peers on the
board for their teams performance. In this
way, we create a professional services
environment that gives every member of the
team responsibility, and aligns them to a
common purpose. This fosters a culture of
engagement where staff own and solve
Healthy innovation
Better hospitals
problems, and learn to continuously
improve their service.
This system has already produced great
results in Hinchingbrooke. This year
Hinchingbrooke has consistently ranked top
full-service hospital and top A&E out of 46
in the East and Midlands region league.
Clinical mistakes have dropped by 60 per
cent. The hip and knee unit have reduced
their patients length of stay after an
operation from 5.6 to 3.5 days by learning
best practice from Circle partners in other
hospitals. Every ward and department has
started collecting feedback about patients
hospital experience, and in response weve
scrapped unfair parking fnes, over-hauled
menus, and installed bedside TVs and
entertainment systems.
None of this has been easy. It has meant
changes to some peoples roles and rotas.
Others have had to learn new skills, and
some have had to change their shifts and
working patterns. But by giving power and
responsibility to the clinicians and staff who
know patients best, and slashing the
bureaucracy that blocked their ideas from
being implemented before, were seeing
real progress.
For us, the task at Hinchingbrooke is a
marathon not a sprint. We chose to focus
frst on fxing quality issues, and were on
our way to balancing the books next year. Its
now time for us to plan the next lap on our
journey, which is making Hinchingbrooke
fnancially sustainable for the long term. We
know this will require an innovative
approach and some radical thinking to
provide comprehensive, joined-up health
services across the area. Thats why were
starting to think about how we can work
with our GP and community service partners
to deliver the regions healthcare in an
integrated way through a networked
approach between different services.
Fundamentally, Circle is about the power
of a partnership model to bring out the best
in healthcare professionals for the beneft of
patients. Were committed to doing so across
the country for many years to come.
Steve Melton, Chief Executive Offcer, Circle
Healthy innovation
Tim Murphy
Seizing the value
opportunity
Whether a resident of the United States or the
United Kingdom, we have all personally
experienced the disjointed nature of our
respective healthcare delivery sectors. From
the mind-numbing and repetitive obligation
to repeat the same details every time you
access a healthcare service, to the feeling of
confusion and anxiety when being instructed
only once on how a loved one should
transition their care from an institutional
setting back to the community. We each
experience healthcare as a set of discrete and
non-coordinated services rather than an
organised system of care. We tolerate this
suboptimal value chain for reasons ranging
from psychological (doctors have special
powers, who am I to question their care
instructions) to bureaucratic (impossible to
change the ways of the NHS, Medicare, you
fll in the blank). Unfortunately, this
tolerance comes with a massive price tag:
poor health outcomes, wasted time, effort,
money and most importantly people living
less well and productive lives.
Given this sad state of affairs, over the
past 20 years numerous efforts have been
initiated to combat poorly coordinated care.
There are many examples of better
coordinated care to achieve improved health
outcomes and cost effciencies.
Improvements in care planning through the
life cycle of complicated procedures (e.g.
UCLAs innovative kidney transplantation
programme), disease management health
coaching for chronic conditions (such as
diabetes and chronic obstructive pulmonary
disease), and the increase in home and
community-based services to avoid
unnecessary institutional lengths of stay are
some examples. In isolation, each of these
attempts does lead to improvements, but the
lack of an established toolkit of best
practices, dissemination mechanisms,
training in coordinated care, and an
accountability ethos for value improvements
limits systematic improvement.
There are many areas in the delivery of
healthcare services that could beneft from
integrated and coordinated care approaches.
End-of-life planning and the management of
major non-chronic disease conditions are
examples of very costly episodes of care that
are rife with opportunities to improve value
through better coordination and
communication of care, and should be
pursued with vigor. In addition, a massive
value opportunity exists in care coordination
for individuals challenged by multiple
chronic physical conditions, especially those
individuals also suffering concomitantly
with a mental health diagnosis. Individuals
with poorly coordinated care plans for
multiple chronic physical conditions,
combined with a mental health diagnosis,
will continue to spend a signifcant sum of
money year after year with limited
improvement in health status.
The following statistics put the care
coordination opportunity for individuals
with multiple chronic physical conditions
and a mental health diagnosis in context:
In the United States, 1 per cent, 5 per cent
and 10 per cent of the total population
consumes 20 per cent, 48 per cent, and 67
per cent of annual healthcare
expenditures, respectively;
Individuals in the 1 per cent higher
spender cohort, 5 per cent higher
spender cohort, and 10 per cent high
spender cohort, expend on average
$76,000, $36,000 and $24,000 per
individual annually, respectively;
Almost 50 per cent of the individuals in
the top 10 per cent high spender cohort
in one year will be in the top 10 per cent
higher spender cohort the next year;
Individuals with at least one chronic
physical condition and a functional
impairment (highly correlated with a
mental health diagnosis) account for 14
per cent of the total population;
These individuals consume approximately
46 per cent of annual total healthcare
expenditures;
Approximately 67 per cent of their service
costs are provided in an A&E or inpatient
setting.
The above statistics reveal that individuals
with multiple chronic physical conditions
and a mental health diagnosis are amongst
the highest consumers of healthcare dollars,
that they continue to be high consumers of
healthcare dollars year on year and that
their preferred setting to consume these
services is A&E or inpatient. Finally, the
usage and cost patterns suggest that they are
not improving their health status.
Effective coordinated care planning of
physical, mental and social support for these
individuals on an integrated basis is the key for
lowering annual expenditures and improving
their health status. The means to achieve these
objectives are more readily available to us
today than in the past. Specifcally,
Signifcant improvements in data
collection and relational databases have
spurred the creation of sophisticated data
warehouses that enable the development
of algorithms to identify individuals with
multiple chronic physical conditions and a
mental health diagnosis;
Once identifed, effective engagement
strategies are now more mature and
enable better involvement of these
individuals in a discussion of their health
and welfare needs;
These discussions typically yield into an
agreement for in-person health risk
assessment which will then inform a
person-centred plan, a roadmap to deliver
improvements in health status; and
Experienced care coordinators put in place
supports, services and communication
modalities to ensure that individuals,
families and caregivers are organised in
their efforts to meet the care plans
objectives.
Evidence has shown that the above
approaches can yield savings and health
improvements. In the United States, Beacon
Health Strategies, a company that provides
care coordination services for individuals
with serious mental illness (who are usually
co-morbid with one or more chronic
physical health conditions), has employed
these strategies to lower total healthcare
costs by 10 20 per cent. A particular case
study in the western area of New York State
of individuals served by Beacons care
coordination services showed:
59 per cent reduction in A&E attendance
62 per cent decrease in the average length
of stay in a mental health inpatient facility
34 per cent decrease in reported self-harm
incidents
44 per cent increase in reported gainful
employment
Coordinated care
Healthy innovation
The appeal of effective care coordination is
that it is not dependent on a breakthrough
drug or technology for savings. All it requires
is timely and reliable information that is
analysed to identify high-using individuals
who could beneft from committed team
support. When individuals trained in person-
centered planning coordinate the delivery of
healthcare and social support, then we have a
truly integrated system of care.
Tim Murphy, President, Beacon Health
Strategies
Ciarn Devane
Time for transformational
change
Macmillan Cancer Support has spent its frst
century raising awareness of cancer care
needs and fnding innovative models to
leverage the delivery of that care. To deal with
todays challenges of an ageing population, an
increase in co-morbidities and a NHS that
needs to signifcantly reduce its cost base, we
need to identify and promote more innovative
means of delivering care. Here are some of
our solutions.
First, we need to understand the
population. We now know that there are
over two million people in the UK living with
and beyond a cancer diagnosis; by 2030
this number will double. We also know what
this population looks like at a local level.
We are sharing this data with commissioners
and providers in order to help them
understand and cost the services that are
needed. Commissioning better evidence
on the population needs is essential to keep
going forward.
Secondly, we need to build awareness and
ensure the generalist community is
supported in its provision of cancer care.
Macmillan has worked in partnership with
GP Update to develop a one-day cancer
course for GPs. To date this has been
delivered in four locations in the UK to
approximately 300 GPs.
One of the biggest lessons from the
course is that GPs have a hugely important
role, not only in cancer prevention and
diagnosis but also in helping patients living
with the disease. To quote one participant:
As a GP you tend to feel that once a
diagnosis is made you dont have that much
involvement after that, but I think the thing
that struck me most from this course was
how practically I could improve care to
patients who already have cancer maybe
not immediately but further down the line.
We surveyed over 250 practice nurses and
found that 86 per cent felt that they could take
on a greater role for cancer with the right
training and skills. We are now running a
number of pilot courses to help increase their
confdence and skills to take on a greater role
for cancer. Evaluation is showing that practice
nurses who have undertaken the course feel
more confdent about communicating
effectively with people with cancer. They see
themselves as a catalyst in the practice to
provide better support and have an increased
understanding of the benefts of exercise and a
healthy lifestyle, supporting people to know
what they can do for themselves.
Thirdly, we need to engage the corporate
sector community in order to create new
relationships and integrate information and
support. During 2012 we launched a Boots
Macmillan Information Pharmacist role. In
the space of less than nine months over
1,000 pharmacists signed up and completed
cancer awareness training. As a result of
which, they can better support cancer
patients and their families in high street
locations across the UK.
Completing this package has given me
the self-confdence to tackle a
conversation with someone with cancer.
Not an easy task, but at least I now have
the knowledge to answer any queries/
concerns that they may have. If I dont
have the answer, I know where to
signpost themSo its not a question
of- to be or not to be a Boots Macmillan
Information Pharmacist, but, why
wouldnt you want to be part of a cancer
care network that can genuinely make a
difference to customers lives?
A Boots Macmillan Information
Pharmacist.
Fourth, we must encourage a shift to
supported self-management at the end of
treatment. A key priority for 2013 will be
implementing the survivorship recovery
package in every cancer care pathway:
assessment and care planning, treatment
summary and patient education event
(health and wellbeing clinic). From testing,
we believe this will make a signifcant
difference to peoples outcomes. We have
successfully worked in London to get this
included within their commissioning
intentions, which we will use as a model to
spread across England.
We know that 80 per cent of people living
with cancer arent physically active enough
to beneft their health. During 2012 we took
over the stewardship of Walking for Health,
the largest network of health walk schemes
across England, offering regular short walks
over easy terrain with trained walk leaders.
With more than 600 local schemes, Walking
for Health contributes to improving the
health of over 75,000 regular walkers
nationwide. Weve built up a body of evidence
to show that health walks are a cost-effective
way to improve the nations health. We will be
working to encourage health and social care
professionals to actively signpost to this local
and free service.
Fifth, we need to spread innovative
models of end of life care in order to enable
choice and reduce costs. The majority of
people in this country die on a hospital ward,
often against their wishes. Our research
shows that with the right support, 73 per
cent of people with cancer would prefer to
die in their own home while only 27 per cent
wouldnt. In Midhurst Surrey, we have
supported a community based model of care
that facilitates the use of integrated care
packages. Our evaluation of the service
showed that this model extends choice for
patients, clinicians, families and carers,
facilitating 71 per cent of patients to die at
home as part of an integrated specialist
palliative care service. Referral to the
specialist palliative care service was
associated with patients spending fewer
nights in a hospital setting and having fewer
A&E attendances. It is also associated with
fewer deaths occurring in a hospital setting,
which would save the NHS money on
hospital costs in the patients last years of
life. We are now pushing for this model to be
adopted widely across the UK.
Finally, we will need to begin pooling
third sector resources and expertise if there
is to be a push for change within the NHS.
We are a founding member of the Richmond
Group, a coalition of ten cross condition
charities, who are working together as a
collective voice to better infuence health
and social care policy. The Richmond Group
has the aim of improving the care and
support for the 17 million patients we
collectively represent.
The increasing prevalence of long term
conditions will place an unsupportable
burden on the tax payer if we do not redesign
how we deliver health and social care. For
the NHS this means a shift in thinking to
preventing illness and not simply curing
sickness. If this is to be achieved it will
require transformational change and system
re-design, rather than salami-slicing existing
services or incremental improvement. We
want ministers and commissioners to
therefore support our fve-point agenda for
the reformed NHS upon which huge
productivity gains are possible. We ourselves
want to be part of the solution. Involving
patients in decision-making improves
quality and saves money. Ultimately, higher
quality care is cheaper care.
Ciarn Devane, Chief Executive, Macmillan
Cancer Support
Healthy innovation
Jane Cummings
What good looks like
Now, more than ever, innovation has a vital
role to play in delivering higher quality care
and value for money while at the same time
driving economic growth. Patients often
need services from different providers and
specialities, meaning old professional
boundaries have become obsolete. The
publication of the Global burden of disease
illustrates that it is not limited to the NHS,
but is a worldwide phenomenon. People are
living longer, often developing long term
conditions. The treatments and services we
have at our disposal to reduce the impact of
these conditions on the quality of peoples
lives are expanding year on year.
To provide the care required for the 21st
century, there needs to be a radical shift in
thinking, assumptions, systems and
processes. This means care where the
hospital works with community services,
mental health services, general practice and
social care to provide for people with complex
needs by a team built around those needs.
Firstly, we need to make the individual
and their carers central to the purpose of
every organisation, profession and the
system. The strengthened NHS Constitution
now includes a patients right to receive care
that is coordinated and joined-up around his
or her needs.
The NHS Commissioning Boards role is
not to direct innovative models but to create
a framework within which they can emerge,
be enabled and be supported.
Patient stories repeatedly tell us about
many examples of fragmented care. Not only
does this offer patients and service users a
very poor experience of care, but it also puts
them at greater risk of harm due to poor
communication and information sharing,
both between patient and professional and
between different members of a
multidisciplinary team.
With the support of national partners
(Department of Health, Monitor, the Local
Government Association and the
Association of Directors of Adult Social
Services), the NHS Commissioning Board
has commissioned National Voices (an
umbrella organisation for a large number of
national health and social care charities) to
develop a single description and defnition
of what good integrated care looks like
for an individual. It incorporates a headline
defnition: My care is planned with
people who work together to understand
me and my carer(s) put me in control,
co-ordinate and deliver services to achieve
my best outcomes.
The ultimate aim is for all organisations
involved in the delivery and organisation of
health, care and support services to adopt
the narrative as a mark of what good looks
like and consider what steps they need to
do to make it a reality for people.
The new Clinical Commissioning Groups
(CCGs) have responsibility for driving
clinically-led commissioning to deliver
better outcomes and have a duty to promote
the integration of care.
Inevitably, there are local barriers to this
which we will all need to address, including
those of organisational culture. The
commissioning and delivery of integrated
care needs to become the practice norm and
not the exception, with the NHS
Commissioning Board and other national
partners, including in local government,
providing the tools, guidance and support to
enable this to happen. Each local system will
need to develop a model of coordinated care
that is appropriate to the local context.
There is no single right model.
At the same time, the new Health and
Wellbeing Boards offer an opportunity for
commissioners to collaborate in ways that
were not previously possible,
commissioning for their populations based
on an agreed Health and Wellbeing strategy
and shared priorities. Equally, both NHS
and local authority commissioners should
develop synergies to help avoid duplication,
maximise the quality of care and be
cost-effective.
The NHS Commissioning Boards
recently published planning framework
for 2013-14, Everyone Counts, sets out
important key steps for local planning. This
includes considering explicitly where and
how commissioning budgets can be
integrated whenever this will advance
shared priorities, and secondly taking the
practical steps to ensure that the people who
will beneft, including in particular
vulnerable groups and those with long term
conditions, receive an integrated experience
of care.
At national level, the NHS
Commissioning Board and its key partners,
including the Local Government
Association, Monitor, the Department of
Health, the Association of Directors of Adult
Social Services, Public Health England and
latterly the Association of Directors of
Childrens Services, are collaborating to
promote, encourage and enable coordinated
care and support. An early product will be
the publication in May 2013 of a Common
Purpose Framework for integrated care
addressing four key areas: what do we mean
by integrated care; what is the case for
change for integrated care, what are the
national barriers and enablers; and what
tools and support are required to help
deliver integrated care locally.
Our ambition is for an NHS defned by its
commitment to innovation, demonstrated in
both its support for research and its success
in the rapid adoption and diffusion of the
best, transformative and most innovative
ideas, products, services and clinical practice.
Jane Cummings, Chief Nurse, NHS
Commissioning Board
Amy Pott
Creating a continuum of
care
As one of the largest suppliers of products
and services to the NHS, with a unique
diversifed portfolio, Baxter helps support
the treatment and care of thousands and
thousands of patients at almost every stage
of the pathway of care from hospital, to
local community, to home.
With that in mind, we have a
responsibility to support the NHS in its
challenge to deliver excellent, outcome led,
patient centred care, which delivers value
for money for the NHS and for UK
taxpayers. Alongside this we are committed
to investing in the UK and contributing to
the wealth generation agenda.
Healthy innovation requires all
stakeholders to work together in an open
and transparent way to deliver new
solutions. The needs of the NHS are
changing, and we, Baxter (and our Life
Sciences Industry counterparts) need to
change what we do for the NHS to meet
these new demands. The Baxter Evolving
Health Programme has been developed to
partner with the NHS to help meet the
ongoing challenge of delivering quality,
innovation, productivity and prevention
(QIPP). We have worked with the NHS to
look at total care pathways in order to see
where cost savings can be made across the
whole service. We do, and will, challenge
ourselves to bring new perspectives, skills
and resources to the NHS to unlock cost at
the same time as improving patient care.
We have some great examples of
innovative solutions to existing treatment
Healthy innovation
pathways that have yielded cost savings to the
NHS, at the same time as improving patient
care and experience. These examples are not
limited to single patient types or clinical
settings, and are not about just introducing a
new product to an existing service. They are
about doing things differently managing
services and inventories differently, bringing
telehealth and homecare treatments together
for patients with long term conditions in a
meaningful way and adopting new ways
of treating patients that will reduce hospital
length of stay. All of these solutions require
thinking about the integrated continuum of
care, not simply a single treatment episode.
The next phase of the challenge is
working with the NHS to facilitate
innovations to be spread at scale and pace
throughout the entire organisation, so the
NHS as a whole can realise the benefts that
are possible. This will rely on the ongoing
strengthening of the partnership between
the Life Sciences Industry and the NHS and
making sure those partnerships are built on
trust not simply transaction.
Epistaxis:
Epistaxis, or nosebleed, is the most common
ear, nose or throat (ENT) emergency, and in
England over 27,000 patients presented to
secondary care in 2008-9. The mean length
of stay for epistaxis in the UK is over two
days. The aim was to reduce length of stay
without compromising the quality of care. In
2009-10, Aintree University Hospital NHS
Foundation Trust had 250 admissions for
epistaxis. Patients stayed a mean of two days
at a minimum cost of 400 per day.
Reducing this by just one day could yield
savings of around 100,000 for the Trust.
There is limited ENT experience in many
emergency departments. Frequently, nasal
packing is used as frst line treatment for
even small volume bleeding when a more
conservative or targeted approach would be
safe and effective.
Floseal is a paste-like haemostatic
matrix designed to stop bleeding quickly.
The median time to haemostasis is 120
seconds. The product consists of expansile
bovine gelatine granules coated in human
thrombin. The use of Floseal in persistent
epistaxis through studies has shown shown
statistically signifcant improvements in
both patient and physician experience
compared to nasal packing.
Baxter and Aintree jointly agreed that to
truly address the challenges within the
current treatment regimen the service
needed to be redesigned. This service
redesign was primarily intended to address
the training requirements within both A&E
and with the junior doctors who often found
it easier to use nasal packing and habitually
admit patients, rather than identify the
bleeding point and decide on a further
course of treatment. A new treatment
pathway was designed and implemented in
December 2010.
Baxter and Aintree worked in partnership
to implement training, materials and a
multidisciplinary approach to implement
the pathway and the introduction of
Floseal. Implementing the new pathway
had a direct impact on patients with some
requiring no additional treatment. The
emergency staff were also motivated by the
results to not use nasal packing immediately
as they saw the positive effects on reduction
in length of stay.
An audit conducted after one year of
implementation showed that compared to
the preceding three years, in 2010-11 the
total number of bed days due to epistaxis
was reduced by 30 per cent, and mean
length of stay was reduced by 21 per cent.

Dialysis Access Academy:
Peritoneal Dialysis (PD) is an underutilised
therapy in the UK despite the economic,
clinical and lifestyle benefts. NICE guidance
published in 2011 states that peritoneal
dialysis should be considered as the frst
choice treatment modality for people with
established kidney disease and that people
on long-term dialysis receive the best
possible therapy, incorporating regular and
frequent application of dialysis and ideally
home-based or self-care dialysis. Despite
all the legislation and guidelines, there has
been a continuous decline in the number of
people having their dialysis at home. Part of
the key to enabling growth of PD is to
provide the easy access to insertion of the
catheter required to perform the treatment.
A positive effect on PD uptake has been
reported where nephrologists insert
catheters under local anaesthesia (LA)
rather than surgeons using general
anaesthetic.
Baxter worked in partnership with
leading nephrologists to develop a robust
clinical training programme and pathway
redesign for the medical insertion of PD
catheters. This team agreed the structure
and content of an accredited four step
training programme for the medical
insertion of PD catheters using the
Percutaneous Seldinger technique. To date,
over 20 teams from UK renal units have
attended the course with excellent success
rates, and positive patient feedback.
Amy Pott, Director of Market Access,
UK and Ireland, Baxter Healthcare
Healthy innovation
Stephen Thornton
Delivering continuous
improvement
Healthcare is of profound importance to us
all, and ensuring high quality healthcare for
everyone is one of the greatest challenges we
face. To meet this challenge, health services
must be continuously seeking to understand
how they can improve.
At the Health Foundation we help people
to take a step back, innovate, and plan the
practicalities of change. We encourage
innovation from across the healthcare
system; a good idea is a good idea, no matter
how small it is or where
it comes from.
Our interest is primarily in the
innovation of how health services are
delivered. We understand that new
technologies are reliant upon innovative
behavioural change if they are to fulfl
their potential to improve care. A paperless
NHS, for example, will not only require a
digital infrastructure that allows sharing of
data across the service and with patients;
it will also demand changes in ways of
working and innovation in the delivery
of new approaches.
Approximately 60 per cent of GP
practices already have the technology in
place to allow patients 24-hour online access
to their own patient records, but despite the
Governments decision that all NHS patients
should have this access by 2015, few
practices have seized the opportunity. The
Health Foundations MyRecord project is
exploring how to support general practice in
making records accessible to their patients.
Having the technology in place is only the
starting point. Our project is tackling the
cultural, organisational and psychological
barriers to turning on patient access, as well
as exploring the factors that support
adoption of the technology.
But innovation is not only about brand
new developments. The challenge is as much
about embedding existing innovation in
routine care. The Health Foundation led the
frst major programme to improve patient
safety in the UK: the Safer Patients
Initiative. It was complex and large scale in
its approach to improvement, recognising
that change needed to take place across
whole organisations and systems, rather
than focusing on individual incidents.
This programme had a signifcant
infuence on participating hospitals and
their staff, on patient care, and on the
wider NHS system. However, achieving
organisation-wide change was extremely
challenging. We learnt that if something
is new to a team in a particular setting
they will see it as innovation even if it is
routine elsewhere. To implement ideas
across the whole of a trust that are in use
in a ward or a unit is innovative in itself
and requires local testing and adaptation
as well as an organisation that is ready to
implement change.
The experience of the National Patient
Safety Agencys Matching Michigan
programme, which sought to replicate the
Michigan Keystone programme led by
Professor Pronovost, also emphasises the
challenge of spreading innovation. The
Health Foundations Lining Up project sent
researchers into intensive care units to
observe the implementation of this nationally
organised infection control programme as it
was happening. The project has found that
the cultural context for an improvement
initiative is profoundly infuential and it is
seeking to learn how an innovation that
works in one setting can be successfully
implemented somewhere else. We will be
publishing this research in spring 2013.
When considering how to deliver
innovation in the NHS its important not to
forget the role of patients. We are working
with the renal team in Yorkshire and the
Humber to provide patients with the option
to undertake self-dialysis on a medical unit
and support them to do so. The project has
helped patients rebuild independence and
control, and introduced fexibility into a
previously rigid regimen. Changing practice
in this way demands new behaviours and
skills from both patients and health
professionals. Implementation of this
innovative way of undertaking dialysis has
to be sensitive to each individual patient,
taking account of their whole life their
confdence, motivation and well-being.
To learn more about the Health
Foundation and our work to improve the
quality of healthcare visit www.health.org.uk.
Stephen Thornton, Chief Executive, Health
Foundation
Dr Nicolaus Henke, Tom
Kibasi and Stephen Moran
Whats holding the NHS
back
The challenges facing the NHS are well
known: how can the service improve access
and raise the quality of care it provides
within an increasingly tight budget?
Innovations in healthcare delivery may
provide some new answers to long-
established problems. Working with the
World Economic Forum and Duke
University, we have created the
International Partnership for Innovations in
Healthcare Delivery. Its role is to support
innovators to scale up their businesses and
promote the spread of innovation around
the world.
Broadly, we observe three models of
innovation emerging. Franchise based
delivery models are businesses that replicate
proven operating models, can rapidly scale
into new delivery channels and deliver
consistent quality through standardised
operating procedures. Production
specialisation models deliver services at
dramatically lower cost by achieving
economies of scale, very high asset
utilisation and more effcient skill mixes.
Technology enabled delivery models include
the use of digital devices (e.g., voice, text,
data, video over cell phones) to deliver
healthcare services at a distance.
The impact can be dramatic. Aravind
Eye Care System delivers at scale (some 60
per cent of the cataract surgery volumes)
and does so at one-sixth of the unit cost of
the NHS, after allowing for the different
cost bases in England and India. It also
delivers higher quality outcomes with
fewer complication rates. Over a million
households subscribe to MedicallHome
Delivering innovation in the NHS
Healthy innovation
in Mexico, paying $5 on their phone bill,
and the telephone based advice service
solves two-thirds of the cases over the
phone. Hundreds of other innovations
can be found.
So what holds the NHS back from
embracing innovation? What would make
the difference? Here are fve things:
1. Dont let evidence be an excuse.
A proper evaluation of the evidence for
impact is always necessary and must be
part of any plans for new delivery models.
However, true innovation by defnition is
unlikely to have signifcant codifed,
peer-reviewed evidence of impact. The
private sector does not expect good
business ideas to undergo a randomised
control trial. Good management requires
good judgement, and the combination of
courage and common sense.
2. When you commit to change, do it at
scale.
Once the business case has been built and
is considered sound, leaders need the
courage to act at scale. Too many pilots
and small scale changes dont gain
traction or get picked up elsewhere in the
service because the profle is too small
and the impact not measurable. Indeed,
many changes can only have impact if
they are executed at scale.
3. Let people who think they can do it
better try.
The NHS needs to let new providers who
want to innovate at least try. Currently,
there are too many barriers preventing
new players entering the market. The
biggest single thing that could be done
would be to open up access to payments
for innovative players.
4. Reward risk taking and dont penalise
failure.
Quality of care must never be
compromised for innovation. Yet at the
same time, the NHS needs to incentivise a
culture where fnding innovative ways to
deliver that quality is both respected and
rewarded. Too often incentives are geared
toward maintaining the status quo.
Innovators should be celebrated and
rewarded. And opening up to innovation
means accepting some things will fail too.
5. Let patients judge success
Patients should be the ultimate judge of
what works and what doesnt. This means
giving them easy to understand
information on the quality and the
effciency of their providers. Patients
need to be able to give rapid feedback on
the care they receive and other patients
need be able to see this. Clinicians need to
be prepared to be visibly accountable for
their performance to patients. With the
right information, patients will have the
freedom to choose great care and
will demand the levels of innovation
they see in their wider lives from their
health service.
There is much to be done if the NHS is to
capture the innovation opportunity.
Dr Nicolaus Henke, Director, Tom Kibasi,
Partner, and Stephen Moran, Engagement
Manager, McKinsey & Company
Cally Palmer CBE
The NHS: Too big to fail or
too big to work?
The acceleration of technological advance,
especially in the world of cancer, an ageing
population and economic constraint all
mean that we must do things differently,
and fast, to deliver high quality healthcare.
At The Royal Marsden we have an additional
imperative, to contribute to better ways of
diagnosing and treating cancer globally and
to operate as a test bed of innovation and
good practice for the NHS. These things are
obvious and simple in concept. So why is
innovation so diffcult to achieve?
The frst problem is cultural. The NHS is
rightly prized for its ambition to deliver the
highest standards of care to everyone who
needs it, when they need it, in a
technologically advanced and sensitive and
caring manner. However, equity of access
and cultural adherence to a national system
of healthcare often translates as a need to
standardise everything: standardisation of
kit and infrastructure, standardisation of
terms and conditions of service,
standardisation of clinical practice.
However, standardisation and
innovation are not easy bedfellows. The
resistance to an organisation like mine
trialling new technology, new drugs and new
service models is considerable. We address
this locally by asking clinicians to operate as
marketeers, by taking fnancial risk, and by
using evidence to demonstrate that
innovation can improve productivity. Why
bring a patient back to hospital 20 times if
Cyberknife technology can produce a better
result in 3 visits? Why treat a patient with a
drug that wont work if a PET/CT scan and
individual tumour profling can ensure more
targeted and effective treatment?
The scale of the NHS can and should be a
wonderful advantage in the diffusion of
research and innovation. It is good to see
that organisations are connecting to spread
good practice and innovation through the
introduction of Academic Health Science
Networks, but it is vital that these acquire a
focus, a sense of purpose, and are subject to
rigorous evaluation of their performance
and output. They must secure the right
balance between engaging their partners
and delivering results for their communities.
In my own environment in West and
South London we have recently established
the London Cancer Alliance, covering a
population of 4.8 million, and including two
Academic Health Science Centres, The
Institute of Cancer Research and 17 provider
organisations. Its purpose is to develop
integrated care pathways across a much
larger catchment than ever before,
eradicating duplication and ensuring
patients have seamless and high quality
care, informed by the latest research.
It isnt the simplest organisation. It
cannot supersede the sovereign authority of
individual partners. However, it can, and
does, provide a platform for common data
and information to evaluate and improve
performance, and it is an excellent way of
extending and systematising collaboration
in research and innovation. The excitement
for clinicians is that they are able to set the
agenda rather than receiving direction on
service priorities and service models. The
excitement for scientists is that they have
ready access to a blend of clinical and
academic expertise across a wide clinical
and research network.
The NHS works best when it encourages
local innovation, fexibility and leadership.
Of course it must set parameters, universal
principles and context, but it does not work
well when it invents, reinvents and applies
systems and processes which are resource
intensive but ineffective in improving care
or encouraging innovation. The best
developments at The Royal Marsden are
those where we have had the freedom as
an NHS Foundation Trust to work to our
strengths, and with our local communities,
to make a difference. This covers everything
from developing the latest drug for advanced
prostate cancer for patients worldwide to
trialling real time feedback from patients on
their personal experience of care. We are
frequently asked why we are doing things
differently. A better question is what is
the evidence base and how fast can you roll
this out?
Cally Palmer CBE, Chief Executive, The
Royal Marsden NHS Foundation Trust
Healthy innovation
Reform
More for less: Case studies
of successful reform
More for less is Reforms new website
showcasing 35 case studies of successful
public service reform from the UK and
around the world. The website aims to
improve the quality of public service policy
by providing case studies of successful
reform in practice. Typically they deliver
higher performance at reduced cost; in fact,
the nancial pressure to deliver value for
money has been a catalyst for new thinking.

The case studies conclusively refute the
argument that cuts to spending will
necessarily damage public services.
Instead they show that public sector
leaders have used nancial pressure to
change their ways of working and face
down opposition.

In order to ensure that the microsite
continues to be relevant for policymakers
and useful for public service leaders,
Reform will regularly update it with new
case studies of value and quality in public
service delivery.

If you have your own examples of
innovative organisations delivering better
public services for less, please contact Will
Tanner at Reform. We are always looking
for new and innovative approaches to
public services to deliver more for less.
will.tanner@reform.co.uk
Share the case studies
using the hashtag
#moreforless on Twitter
Visit the microsite at
moreforless.reform.co.uk
Scan this code on your
smartphone to go
directly to the website
Healthy innovation
The public services law firm
Reform
Join us in 2013
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Reforms support has
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three key areas of domestic
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