How dare you take the liberty to use my information in that way!

I thought this issue was most relevant for my latest blog – we may never hear the end of the issues surrounding the ‘News of the World’. I want to relate privacy of my healthcare record to my own general experiences – starting with two scenarios.

1)      I recently went to a closing down sale at a furniture shop (Dwell) who took my name and address. I was told by the assistant that this was because it’s a sale item and the shop insists on knowing who sale items have been sold to. Two weeks later I started receiving magazines and special offers by post.

2)      When I sign up for a social network site (this could be Facebook, LinkedIn or some other website) I get asked whether I want my information to be public, partly shared, private or whether my profile is completely hidden so that others cannot find it.

Both, in my mind, are core examples of why privacy is so important: choice. 1) I may never shop at the furniture store again because I wasn’t given the option of opting out and my information has been misused and 2) I have a choice of who sees my information on a social site.

The same applies in the NHS – I want to be assured that my information is safe in the hands of the data controller and any decision to use it or share it I want to be aware of. This brings me to another reason for this blog, is a recent Information Governance query I received about using and giving out sensitive information: I don’t believe there can be a rule book for this issue but it’s a question of where you draw the line.

Let’s take some more examples:

1)      When I was teenager I spent time in and out of hospital for Scoliosis surgery. I don’t mind if the clinical (sensitive) information is shared to help with other cases but I want to be informed that this is the case

2)      Taking the above example: If during that time I wanted a parent to make or cancel an appointment I would be happy if the hospital allowed this as I find it unlikely that someone would go to the effort to maliciously cancel an appointment of mine.

a.       Besides, this person should know my consultant, my condition and its time for the administrators assurance

3)      Again, taking the above example, if I call to book an appointment and the administrator tells me I cannot have an appointment in a weeks time because I’m booked in for an appointment at the sexual health clinic I would be somewhat unhappy that my information had been shared inappropriately.

We must remember that the patient needs to know when information is shared and consent to it because they have the right to that choice.  Staff across the NHS making the right decisions doesn’t fall down to a need for this to be ‘spelled out’, it’s a training issue about process and interpretation of policy - the difference between what isn’t and what is sensitive information being one key part of that understanding.

I imagine that one of the reasons for patients to have their own record is to give a sense of trust that they are in control of their information. My point is to say that with a combination of robust training and robust process the culture of the organisation should reduce the risk of a privacy breach and win the trust of patients because employees understand the sensitivity and value of the information they are in control of.

Improving the quality of Imaging Services

I recently came across a paper on the NHS Improvement website about delivering a Quality Imaging Service for Children across the NHS. When thinking about changing the service model of the NHS to ensure that there is no variation and every patient gets equal treatment this paper is directly realted- it raised a number of interesting points about the Imaging Service:

• There is a shortage of professionals in the area of paediatric imaging – at the time the paper was written there were three major hospitals without paediatric radiology consultants
• There is no incentive for radiographers to specialise because there is no formal career structure in paediatric radiography
• Much of the routine, emergency and trauma work takes place in DGH’s with variation in levels of expertise and support offered from specialist centres
•  A review of children’s imaging services finds it “necessary to balance the need for local imaging, with the need for an integrated service offering specialist support and expertise, which may not necessarily be provided local to the patient’s home."

The paper continues to discuss a potential model of serv ice delivery across three levels, ranging from level 3 being a service that provides the minimum plain radiography and ultrasound (essentially a satelite imaging dept.) to level 1 being a service located in a children’s hospital/major teaching hospital providing all possible modalities and services. The key to such a model is the networks between the three layers – communication is vital and the children’s hospitals should provide that expert support when needed (IT links are also essential).

It’s also worthwhile noting that this service delivery model is similar to one that can work for paediatric pathology across a geographical area. The concept of having a specialist paediatric laboratory that offers a number of specialised (and expensive) tests is similar to that of level 1 of the Imaging Services model for Children. The lab will also offer support to a laboratory in a DGH, which will perform a number of less specialised tests on children (similar to levels 1 and 2). The model is an interesting one because it encourages networking and improves quality and (potentially) cost as specialist work is only performed by few hospitals with the expertise.

My next question is how much data is available about Imaging Services for Children and what the next steps will be. I think it will be an interesting space to watch.

Quality should always be at the core

Recently I was able to attend an Intellect (intellect.co.uk) event held in Fleet Street, London with Jim Easton (National Director for productivity and efficiency) speaking. It was made clear that the NHS cannot sustain itself with current funding levels and £20Bn is the ‘qualified estimate’ of how much needs to be saved, recurrently, between now and 2015. It’s a huge task ahead and Jim Easton has to lead one of the toughest challenges to face the NHS in England – it was noted by Jim that mental health services have changed radically for the better in the past 30 years and acute trusts now have 4 years to achieve the same effort – a very valid point.

With that thought I have two observations to make:

Firstly,

It’s absolutely vital to note that quality should always be at the core. The statement “cutting costs puts services at risk of poor quality” – I don’t doubt it one bit. I think in projects it wrongly comes down to the separation of cost and quality – I think sometimes it’s easy for there to become a disconnect because a new cost improvement has been defined and although quality is always considered at the start it doesn't necessarily get discussed in project monitoring – if something starts late it’s the finances that suffer and they become more prominent. Quality metrics are challenging to define but they are needed to report on.

If a new project to improve the services offered by the Trust is delayed it:

1. Puts the financial plan at risk
2. Takes away the opportunity for the patient to receive a service of better quality during care/treatment. This may mean a shorter stay in hospital, one less visit to the phlebotomist or fast referral to the correct specialist.

Secondly,

I’ll start by pointing to page 4 of this article:

http://www.health.org.uk/public/cms/75/76/313/577/Rising%20to%20the%20challenge.pdf?realName=mcy7Hg.pdf

The article refers to evidence found by The Health Foundation on whether increasing quality saves money. It identifies that poor quality is common and costly but says complex organisational change offer great potential for savings but there is risk of failure. The reason for less evidence is obvious – its change which requires engagement of stakeholders from possibly multiple organisations, the risk of failure is high (as identified), it’s hard to meausre the improvement and it’s a tough project/programme management challenge. These are all factors that can be addressed with the right skills and this change is possible – pathology is an example area of where huge savings are possible.

Changes in areas which improve the clinical service also stop protesters on the street because of cuts to front-line services; questions like-

• Does the patient need that pathology test or MRI scan?
• Does the patient need to be in hospital this long (http://www.hsj.co.uk/news/primary-care/discharge-delays-questioned-after-patient-deaths/5025224.article)?
• Do we need to pay that much for this special drug?
• Can we improve the scheduling of this service to reduce cancellations?

Some of these ideas and more are mentioned here: http://www.bmj.com/content/341/bmj.c7239.full

Happy new year

All the best for 2011. Happy holidays!

Steve

Pathology continues to move up the agenda

At the beginning of the month I was at a launch event for a new approach to sending pathology samples between UK laboratories conceived by X-Lab, a service that will be hosted by the HIS (http://www.this.nhs.uk/npex). I worked for a medical reference laboratory (Pathology Associates Medical Laboratories (PAML) – www.paml.com) in Washington State that offered a very similar service – essentially a tool that translates the pathology request from one system into a readable and translatable form for any other system (and back again). The concept is similar to that of a telephone exchange.

I mention PAML because they offer a service to hospitals – using CRM to manage client services, using Fedex style logistics to manage pathology sample shipping, etc. Some features of the service could be very beneficial to the UK pathology service– however this will lead me into a comparison between business models that is for another time.

Pathology service savings – now is the time?

With the potential to save huge amounts of cost and increase the quality of service, it has taken a long time for pathology to move to the top of the agenda. We have all known the change is coming, presentations and whispers at two conferences I attended in late-2009 (SBK Pathology Toolkit – Service reconfiguration and implementing change) and late-2008 (Laboratory IT Strategy conference) predicted the change. We’ve all seen the two Carter reviews as well.

It’s one way of saving cost and improving productivity without closing front-end services which could ultimately result in protests and national newspapers front page headlines. At the minimum organisations are starting to pass ideas around about how pathology services can save cost locally (even if at Trust Chief Executive Level), if not already entering into a challenging process of change.

How NPEx and the advent of GP commissioning could impact this

NPEx is a concept that, if used widely enough, could change the shape of the pathology market. Two key examples:

1) Choosing an alternative reference laboratory for specialist reference testing. Laboratory X is charging the Trust £91 per test but the NPEx system states Laboratory Y can offer the same test for £68. This raises a number of interesting questions:

• Why is it cheaper?
•  Is the quality of testing going to be as robust as Laboratory X if I switch to Laboratory Y?

2) After the release of the new whitepaper could pathology rise to the top of the agenda for GPs, just as it is for Trust Chief Executives right now? GP work is typically automated and bulk accounting for a high volume at low cost.

• If information is realised about NHS Trusts cost per test compared to Quest, Serco or TDL how will GP consortia react?

The second point is one that is prominent and non-dependant on the X-Lab system. If private providers take all of the GP work then pathology services within NHS Trusts will not be able to sustain themselves performing the expensive specialist work.

Some key points...

• As a result NHS Trusts are under pressure to understand their true service costs and make the needed changes to increase quality and productivity throughout; otherwise they may find themselves fighting to keep the GP work from the hands of private providers.
• The model of delivery has to change. Using paediatric allergy testing as an example – within an SHA region it is most likely being performed in most DGHs and specialist centres. Such a service can be operated from one or two specialist paediatric centres across the region because the work is cold. This will result in:
• Decreased service cost for DGHs operating the service
• Reduced cost per test across the test repertoire
•  Increased service quality for allergy testing
•  Now only operating in one or two specialist centres
• A new process that has been implemented
• Achieving maximum productivity

Some key questions for thought...

• Can the logistics cope and will this be a telling point for enabling GPs or hospitals to choose where they order a test?
• If consolidation is to happen will the technology be a stumbling block?
• How will NHS Trusts actually react to a changing market? 

Planning is the only the beginning

“Efficiency is the ‘main game’ in the NHS” and “the eight ways to save cash and improve care” are just two headlines I’ve seen recently on one healthcare news website (HSJ) regarding cost and productivity improvement. On my twitter feed the word efficiency is always ‘popping’ up. It’s interesting that the way to address efficiency has, in one way or another, been wrapped inside an acronym, QIPP, which still remains somewhat mysterious to me. Kate Hall, a Health Leadership Fellow, recently blogged on HSJ (http://www.hsj.co.uk/a-pinch-of-qipp/5021132.blog) identifying that QIPP and national workstreams were published so long ago yet she states:

“I’m not sure why there is little or no information published on them nor why it is not available for people to look up and heaven forbid, see how they can support, help or get ideas “

The only website I’ve found is on NHS Evidence (http://www.library.nhs.uk/qipp/) but resources are still short of what they should be and examples are not updated regularly enough. The one problem I find with QIPP is that it’s been made into something apart from driving productivity and quality improvement that means it could easily viewed, quite dangerously, as a project or programme. In PRINCE 2 terms I’m talking here, as something that exists temporarily, when it should be instilled in the hearts and minds of NHS leaders throughout the country. Few NHS organisations are talking about QIPP, they’re talking about Cost Improvement Programmes which may be due to the lack of resources and a lack of understanding for what QIPP is really about.

The obvious action for Trust directors at the moment is to plan for big change, in anticipation of what may be 6% of budget savings. With QIPP in mind it's positive that such a concept will encourage more analysis around cost and productivity improvement, however the problem still remains that the output from this needs to driven. This is where the problem lies because only the ‘easy wins’ get a high profile and the real meaty cost saving ideas are left alone for fear of multiple reasons – before you know it CIP values are falling away and become at serious risk of under-achieving.

Perhaps this is too simple a view – I intended to summarise it but the hard fact remains that implementation is challenging. It requires tough project management with solid plans and well managed risks with an understanding of change management thrown in the mix– right now that’s what NHS organisations need to realise savings and looking to QIPP is only going to produce ideas for this process – at the very best.

End of the most competitive season in history..

An epic Formula 1 season came to a close today. Listen to Alistair Griffin's 'Just Drive' with the highlights of the year here: http://www.youtube.com/watch?v=RsyOgYjrV8I