Penny Dash: Facing the hospital challenge

Future of Hospitals

9 June, 2014

Penelope Dash

Senior Partner

McKinsey & Co

Nuffield Trust

1

What I will talk about today

Where have we come

from?

Where are we today?

Where to next?

2

Spot the hospital

3

What does it feel like to be a hospital today?

24x7 healthcare needs

…. 120 babies ……

New technologies

arriving almost daily ….

Major tariff pressures

….

The “incontinence”

challenge …….

Confused old ladies

who shouldn’t be there

………..

Ever increasing

standards….

4

No wonder hospitals are on the edge

5

So what could we do?

Drive productivity 1.

Tackle quality 2.

Tier and manage 3.

Reframe the hospital 4.

6

Compared to other industries, healthcare is still lagging behind in

efficiency gain

Optimise estates Support self

service/self care

Innovate the

workforce

Standardise

processes

Drive productivity 1.

7

Standardized processes and routine monitoring

Trackable

RFID chip

Transmitter for

equipment

localization

Transmitter

for staff

localization

Intelligent room

surveillance for

status

Maintenance status by remote hand held

8

Look at Aravind?

SOURCE: Rockefeller Foundation; Interviews; 2010/11 National Schedule of Reference Costs; 2010/11 Aravind Eye Care

System Activity Report; Global Insight; Conversation with Dr. Sathya Ravilla at Aravind; Team Analysis

UK-NHS

$PPP 1,400

Aravind

$PPP 250

UK-NHS

6%

Aravind

4%

Unit cost of cataract surgery in 2010/11

Infection rate per 10,000 patients

… at ~1/6th the

cost…

… and with better

outcomes

10%

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Innovate the workforce – what can technology do?

Say hello to intelligent pills –

digital system tracks patients

from the inside out

Nature

The doctor is out, but new

patient monitoring and

robotics technology is in

Scientific American

10

Lots of technology but slow adoption

11

Innovate the workforce?

GP obstetricians in

Australia

Midwives administer

epidurals in Canada

Primary care

paediatrics in the US

12

Optimise the estate ……… it is 20% of costs

13

Support self care – changing the paradigm?

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Tackle quality 2. ▪ How much experience does she have? How many cases a

year does she do? Is that enough?

▪ How up to date is she in the latest thinking/knowledge?

▪ What are best practice protocols for the conditions she is

managing?

▪ How good are her results? What are the main complications

in her speciality and how do her results compare to

colleagues in your hospital, the one down the road, the

leading edge centre, the best in class globally?

▪ How well are patients’ symptoms resolved? How often does

she publish her results?

▪ What do her patients think of her?

▪ How much research has she done this year? How many

articles were published?

▪ What do her medical colleagues think of her? Is she in top

10% of all doctors they work with or bottom 30%?

▪ What do other staff think?

▪ What do juniors think of her? How well do they assess her

teaching style, knowledge, impact?

▪ How efficiently does she care for and manage patients?

▪ Do you

measure this

every month?

Every year?

▪ How often do

you publish it?

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Tier 3. Complexity of care summary for maternity service levels

Service level

1 2 3 4 5 6

Emergency Care

Resuscitation, stabilisation and retrieval

Complexity of Care needs

Normal

Moderate complexity

High complexity

Antenatal Care

Outpatient care

Inpatient care

Maternal fetal medicine service 1

Planned Birthing Care

Gestation >37 wks

Gestation 34 wks

Gestation >32 wks

Less than 32 wks

Elective caesarean section > 39 wks gestation

Unplanned Birthing Care

Access to or onsite facilities for emergency caesarean section

Intrapartum EFM + fetal blood sampling (scalp pH I lactate)

Postnatal Care

Outpatient care

Inpatient care

1 Access to

Source: Standing Council on Health (2012) National maternity services capability framework

(http://www.qcmb.org.au/media/pdf/The%20National%20Maternity%20Services%20Capability%20Framework.pdf)

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A single campus where patients can access high quality integrated care and diagnostics

Primary care

GP surgeries

Community care

Full range of community services

Fast response teams

Re-ablement and day-care unit

Physiotherapy, SALT, OT

Wellbeing services

Health advice, weight watchers

Smoking cessation

Information centre

Social care

Co-located social care services

to create sense of place focused

in the centre of the community

Acute services

24x7 urgent/

emergency care MLU

GP OOH

Short stay acute medical unit

Day cases Outpatients

Diagnostics ISCAT

Reframe the hospital 4.

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101 GP

practices

50 community

care centres

39 Sure Start

centres

5miles

0miles

Reframe the hospital? 4.

And four major hospitals ………………..

Abingdon Community Hospital

Catchment

- 5 market towns in SW

- 140,000

Co-located services - Minor Injuries Unit

- Diagnostics (X-ray)

- Mental Health base

- Outpatients

- Primary Care

- GP practice

- out-of-hours base

- Inpatient wards

- 45 beds

- stroke, hip fracture, ‘generic subacute’

- close relationship with ‘acute Trust’

Reframe the hospital 4.

PRELIMINARY DRAFT 19 SOURCE: Rochdale EUCC Operational Policy 2012

Care Model: Rochdale ‘EUCC’ onsite MAU

Patients/conditions treated

Key goals and achievements

• Minor nose bleeds (not on Warfarin)

• Minor cuts, bites and stings

• Burns and scalds

• Infections (including abscesses)

• Foreign bodies in wounds, ears and noses

• Muscular sprains and strains to shoulders, arms and legs

• Fractures to shoulders, arms, legs & ribs

• Dislocations of fingers, thumbs and toes

• Minor eye conditions including conjunctivitis and foreign bodies

• Minor chest, neck and back injuries

• Minor head injuries with no loss of consciousness or alcohol-related

• Minor allergic reactions

• Minor ailments such as coughs, colds, flu symptoms, sore throat, earache, urinary tract infections and sinusitis

• Diarrhoea / Constipation

• Emergency contraception

Support services provided

• Basic Laboratory services

• X-ray diagnostics 08:00 – 24:00, 7 days a week

• Ante-Natal Ultrasound 08:00 – 17:00, Monday – Friday

• CT when coverage is available, 09-17, Monday – Friday

• MRI 08:00 – 20:00 Monday - Friday

• Step-up/ Resuscitation room

• Pharmacy support 7 days a week

• Retains 80% of old A&E activity and growing

• Patients assessed within 20 minutes of arriving

• Patients will be seen by a Clinical Decision Maker within an hour of presenting

Reframe the hospital 4.

COMMERCIAL IN CONFIDENCE – DRAFT FOR DISCUSSION

Urgent care centre (24x7)

• GPs work in minor injury

unit to ensure maximum

number of patients can be

safely cared for

• GP out of hours services

co-located and fully

integrated

• Diagnostics co-located and

x ray open 7 days a week

Outpatient clinics

• GP run fracture clinic

Therapy services

• Occupational therapy

• Physiotherapy

• Rehabilitation

• Podiatry

Maternity services

• 400 women managed

ante-natally per year

• 200 deliveries

Inpatient care

• 12 bedded older people

mental health unit

• 2 wards for 40 medical

and surgical patients (one

male, one female)

GP services

• One practice (~14

doctors) based on site

• Other practice on other

side of town but plans to

relocate

Base for community

teams

• Community mental health

teams

• Health visitors, school

nurses, district nurses

• Public health

Day case surgery unit

• Two theatres

Reframe the hospital 4.

COMMERCIAL IN CONFIDENCE – DRAFT FOR DISCUSSION

But …. Here’s what the doctors think ….

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So …….. What could a future look like?

100 major emergency

centres

300 local hospitals

600 health centres