Changing the NHS – The need for a new Skills Mix – 7

Working through the inevitable unintended consequences that will happen in a complex system.

Understandably, most of those engaged in developing innovation spend most of their effort working out how it will work as a specific activity. In my recent series of posts about change I have added to this task by suggesting that they must also innovate in a way which requires changes in NHS financial. Today I’m afraid I’m extending that effort even further.

Whilst the NHS operates in a series of very separate silos, one of the crucial truths of the Service is that “everything is connected to everything else”. If you carry out a change in primary care, many of those changes will impact on community and acute care.

Because so much of care involves pathways that move through these different sectors, for patients a pathway – even a fractured and overgrown one, is very much their experience. This is why the long-term work of integrated care organisations is so important. At the moment fragmented parts of the NHS operate separately, and the patient experiences that separation – when what they need is integration.

This means that, as an innovator having thought through your particular innovation –say increasing the skill mix in people’s homes – will have to assess the impact of how your innovations will affect areas far outside of this part of the health service.

Today I’m making the point that whilst the innovator may spend a lot of time looking at an innovation in the NHS – say at point ‘b’ in the whole process, they must also recognise and help plan for the fact that point ‘b’ will have an impact on some of the rest of the alphabet.

There are two reasons why the innovator needs to think about this.

Let’s pretend for a moment that the NHS to which you are trying to sell your innovation is a conservative organisation that thinks it’s doing OK with its current way of working (let’s face it this is not a long way away from reality).

The conservative NHS gatekeeper is looking for a range of reasons to say ‘no’. If you’ve been following these posts, you will have already anticipated some of their arguments for blocking change.

For example, you have developed a new financial flow to show how within the whole system you don’t need new money. You’ve also included in your proposal how to develop the skills not just to implement the innovation, but also the skills to actually save the money that the NHS needs.

But now I am suggesting you must go further, and need to have an argument, if your innovation is implemented, for what the repercussions for the NHS down the patient pathway will be. Otherwise, the gatekeeper will say,  ‘I understand that this is a good innovation about the issue of ‘b’.  That is all well and good.  But from where I sit our health economy has particular problems in ’x’ and I am afraid you haven’t taken that into account.”

So, think about the patient pathway beforehand.

To take a real example. For some time, I have been working on the innovation of how we can better utilise domiciliary care staff to carry out much more health monitoring in the homes of the frail elderly. A very high proportion of them use domiciliary care as a regular part of their daily life. They may well see a social care worker 5 times week. Unless they are very ill, they will see a GP every 3 months or so and a community nurse every few weeks.

The domiciliary care worker is there nearly every day. The NHS only rarely.

Most frail elderly people will have two, three or four long term conditions. Each of these conditions will be on the edge of developing into an exacerbation where their health will become so bad, they may need to visit A and E. If this happens it is highly likeliy that they will be admitted to an emergency bed.

To continue that story, 10 days in a hospital bed can cause a 50% loss of muscle – a disaster for patient independence.

My suggested skill mix in this arena is to ask the domiciliary care worker to carry out regular heath monitoring of the people[1] involved. The innovation here contains,

    • the technology (both the health monitoring and the mobile technology for communicating the results),
    • training for the domiciliary staff and
    • some higher wages for the domiciliary care staff.

That seems enough to work on. If it could be implemented such an innovation would provide the basis for reducing the number of episodes where people are sent for long stays to hospital. That’s a good outcome.

But on its own it doesn’t work.

The outcomes from thousands more health monitoring tests taken at home will have to be recorded and processed. The whole point of this innovation is to ensure that for some of the people involved there will need to be speedy intervention to ensure that exacerbation of their condition is prevented, and that they don’t consequentially go to hospital.

So, for the innovation in domiciliary care to have any impact, there will need to be – from either primary or community care – the ability to receive results and act on them at speed.

Both of these parts of the NHS are under a great deal of pressure. In 2024 there just aren’t enough GPs or community burses to take on this task. An innovator in domiciliary care will therefore need to become an innovator in primary or community care as well for their innovation to work.

Or of course if they’re really clever, they could link up with someone who is developing a new skill mix in primary or community care. In my example there will be thousands of results of health monitoring not only being recorded but also communicated from hundreds of homes. New technology can do this with ease.

The receiving technology in – let’s say community health – will have the capacity to record all of these results and the technology itself will call attention to the need for action. Some of that action will need a highly skilled health professional to visit the person at home. Some will need the pharmacist who will then need to get the medicine quickly to the person.

If we weren’t innovators, we could say that all of this needs to be carried out by skilled clinicians. And given there aren’t any, our original innovation falls at this early hurdle.

Alternatively the domiciliary care innovator could recognise that they also have to become a community care innovator.

(And for all of this to work they will need to find ways of demonstrating how better management of emergency care beds in acute could, if they are no longer regularly full of the frail elderly who have had exacerbations of their long-term conditions, be made available for elective surgery to earn more money for the acute care provider).

My overall point here is that most innovators who have pitched to me have been genuinely stunning in their innovation in the one area they have worked on. This is especially true of technology innovations.

In the technology innovators language. They are POINT innovations (they improve a particular location – point – in the journey). But while the innovation may only exist at a single point, it changes the whole pathway.

If a wider pathway impact is needed, technology innovators will talk about this wider set of changes as PLATFORM innovations.

So, the difficult message for innovators is to either themselves work out whole pathway innovation – OR before they pitch their ‘point’, make sure they work with others to get larger-scale ‘platform’ innovation within which to place their ‘point’.

All of this is to say that, as an innovator, you are looking to work in a complex adaptive system of health. And whilst your specific change may look good to you, the system will need to work through all the change for the whole system.

Remembering always that that “everything is connected to everything else”.

[1] The reality of integration throws up something quite difficult semantic issues here. Social care, when it comes into contact with them, refers to these people as service users. The NHS when it delivers services to them calls them patients. I’ve been in meetings about integration where it has taken ages to work round this. So, let’s agree to call them ‘people’.