World-class health care

National Health Service change leaders share experiences, opportunities with Oregon legislators and health care leaders

 

In March, during the final week of the historic congressional debate over health care reform, health care leaders in Oregon continued their quest to lead the way toward improving the health of state residents by meeting with leaders of England’s own historic health care transformation.

Helen Bevan and Paul Corrigan, of the National Health Service (NHS) sat down with legislators March 17 in Salem, and met the following day with health plan representatives, hospital administrators, nurses, physicians and students in Portland.

Bevan and Corrigan were in the United States to present at the Alliance of Community Health Plans’ Boards of Directors Symposium in Scottsdale, Ariz., March 21–23. They were invited to Oregon by CareOregon in collaboration with the Oregon Association of Hospitals and Health Systems and the Oregon Nurses Association. Corrigan also met with faculty and students at Portland State University’s Healthcare Management Program.

“We’re in a major transformational time when what we are used to in health care is disappearing,” said Dave Ford, president and CEO of CareOregon. “Cost and demand for health care services continue to rise, but the money to pay for them has declined.”

Although the United States spends much more per person on health care, we rank far below other developed countries in terms of health care outcomes. Additionally, those other countries achieve those outcomes while providing health care for everyone, while the U.S. has left as many as 45 million people without care.

“There are many lessons we can learn from the successes in other countries,” Ford said. “That’s the reason for inviting world experts on health care transformation to Oregon, such as Bevan and Corrigan from NHS and representatives of Jönköping, Sweden, in 2008.”

Transforming the NHS

Bevan and Corrigan have been intimately involved in the transformation of NHS care quality over the past 10 years.

The NHS was founded in England following World War II and has been a source of national pride. But by the late 1990s NHS quality stagnated, its failings were exemplified by surgery waiting lists of 12-18 months, scarce hospital beds and very high hospital infection rates.

Paul Corrigan served as special advisor to the British Secretary of State for Health and Prime Minister Tony Blair and oversaw the development of a major transformation of NHS since then.

The major challenge, Corrigan said, was that the system was so large, employing 1.3 million people. Transformation and improvement were made possible by restructuring the system so that it functions as separate smaller, more nimble, geographically focused, competitive organizations. These changes were designed to provide incentive for quality and cost improvement, and to make permanent the climate for change.

But the effort was not without opposition, even from within the governing Labour Party.

“Sometimes rules need to be broken,” Corrigan said, “because you can’t keep doing the same thing. Just telling people to improve care just didn’t work. Ideology didn’t work, so maybe economics will.”

Ten years later, quality improvement is a growing part of NHS culture and the system has recorded these dramatic improvements:

• 98 percent of patients can get a routine appointment with their primary care physician (PCP) within 48 hours or with another primary care professional within 24 hours.
• 97 percent of people with cancer start treatment within 32 days of referral by their PCP.
• 92 percent of patients get surgery in 18 or fewer weeks after their PCP’s referral.
• 98 percent of patients get through the emergency room—from arrival to hospital admission or treatment and discharge—in four hours or less.
• Cancer mortality rates have fallen by 19.3 percent since the 1995-97 fiscal biennium.
• NHS has recorded the biggest reduction in hospital infection rates in the world.
• NHS currently has the highest recorded improvements in public satisfaction since NHS surveys started.

 “Our system is not transformed,” Corrigan said. “It’s better than it was. There needs to be continuous questioning. The crucial thing is not to give up.”

Transforming the hospital ward

Helen Bevan is Chief of Service Transformation at the NHS Institute for Innovation and Improvement. Bevan is responsible for making sure that all levels of the 1.3 million-staff NHS have the skills and tools to make the continuous quality and access improvements in care delivery that the national strategy envisions.

Bevan shared with Oregon clinicians the NHS program for transformation at the front lines of care. “Releasing Time to Care” is a series of programs designed to equip front-line staff with the skills, time and authority to make changes in their own work environments. “The Productive Ward,” for example, focuses on the nurses and other staff of the hospital. It trains staff in quality improvement methods of analyzing their work processes to reduce the amount of “unproductive time,” such as walking back and forth to fetch supplies, so that more time can be given to patient care.

The result has been an increase in time for direct patient care; reductions in length of stay, infection rates and patient complaints; and increases in patient satisfaction and staff satisfaction. In the London area, the Productive Ward program is credited with increasing time for direct patient care by 500,000 hours a year, or the equivalent of 255 full-time nurses, with no additional costs. A key to this success, and success in the future, is hard wiring those change skills into daily work,” Bevan said.

U.K. lessons for the U.S.

Bevan and Corrigan acknowledged that American health care and the NHS are very different. What worked in England won’t work exactly the same in the U.S.

But there are lessons that can be shared.

Both the United States and England have systems in which up to 75 percent of the cost is caring for people with one or more long-term (chronic) conditions. Aging populations guarantee there will be a greater percentage of people with multiple chronic conditions. Both the United States and England have systems of health care designed around treatment of acute episodes of illness. In both countries, acute care is more expensive than the preventive care that could have avoided the need for much of the acute care. (England does have a lower number of hospital admissions than the U.S., but both could be improved.)

“We both have systems that feed the expensive part,” Corrigan said. “Strange, Very strange.”

What should be done as soon as there is a diagnosis of an expensive, chronic condition, such as diabetes or asthma, is to “surround them with prevention,” he said.

“That will require rethinking compensation for care,” he said. “Rather than paying doctors and hospitals each time a person with diabetes shows up at the clinic or emergency room, why not pay a health care provider—or a cooperative of providers—for taking care of them for a year? Then the financial incentive would be to keep these patients well and avoiding the most expensive care. An organization like CareOregon could put something like that into practice,” he said.

Bevan and Corrigan said they came here because the state of Oregon and CareOregon have international reputations for promoting positive health care change.

Bevan said she was excited to learn about the transformation work being done by clinics piloting the patient-centered medical home model of care, including the Primary Care Renewal clinics in CareOregon’s network.

“In the mainstream environment you are working in, it is astonishing what you are doing,” she said.

Paul was instrumental in developing all the major themes of NHS reform and in developing capacity throughout the NHS to implement them. From June 2007 through March 2009, Paul was the director of strategy and commissioning at the London Strategic Health Authority.

At present, Paul is working as a management consultant and executive coach helping leaders create and develop step changes within their organizations. He is working with a wide range of public services organizations and think tanks including Policy Exchange. Through his column for the Health Service Journal and his own blog, “Health Matters,” he continues to argue the case for reform of the NHS. He is currently an adjunct professor of public health at the Chinese University of Hong Kong. Paul received his PhD from Durham University. In 2009, he was appointed Commander of the Order of the British Empire (CBE).

Helen Bevan is chief of Service Transformation at the National Health Service Institute for Innovation and Improvement. This is an organization that supports the 1.3 million -member staff of the National Health Service. The goal is to accelerate the delivery of world-class health and healthcare by encouraging innovation and developing capability at the frontline of patient care.

Over the past 15 years, Helen has led change initiatives at local and national levels which have created improvements for millions of patients. Her role is to keep NHS improvement knowledge fresh, relevant and impactful at the leading edge.

Helen is a social scientist with a doctorate from Henley Management College. In 2001, she was made an Officer of the Order of the British Empire (OBE) by Queen Elizabeth for service to health care. Currently, Helen is working on strategies for large-scale change in the NHS, particularly on how to mobilize the entire workforce for quality and cost improvement.

For more about the NHS programs discussed by Paul Corrigan and Helen Bevan, including videos of their presentations and information about participating in Oregon’s “Releasing Time to Care” pilot, see the story on our web site.