The right remedy for healthcare efficiency

The word ‘fail’ may be harsh when Spine and Choose and Book are widely regarded as global prototypes and NPfIT investment has helped transform a bunch of very good GP systems into comprehensively deployed world leaders. And the word ‘scrap’ may be inappropriate when the aforementioned Spine and Choose and Book will rightly continue and there is no clarity about what happens to the remaining years of the LSP contracts.

However, what is clear is that the vision of digitising and sharing medical records across all the hospitals in the country has not materialised, with only a few dozen making substantial progress.

The decision NHS leaders need to make is whether, given the history of the national programme, should they now focus on information technology locally or forget about it until a quieter day.

The impact of the global recession on NHS funding has placed the Quality, Innovation, Productivity and Prevention (QIPP) programme at the top of every chief executive’s agenda. The reduction in real funding growth, from a historic four per cent per annum, and a recent seven per cent per annum to zero will be very painful. In the past ten years productivity has only improved in two of those years (2005/06 and 2006/7) and the Secretary of State was booed at the Royal College of Nursing Annual Conference. Therefore, unless the NHS reverses its typical behaviour, we can expect a deficit of up to £20bn in five years and/or quality and service failures.

Furthermore the key drivers of cost inflation in the NHS are relentless. Technology is getting more expensive, lifestyles more sedentary and the population continues to age. A Dutch study in 2006 showed that a 90 year old consumes ten times as much healthcare as a 50 year old. An American study from 2003 shows that the over 75 population costs 5.65 times as much in healthcare costs as the 34-44 year old cohort. In the UK the number of people over the age of 65 is forecast by the Government Actuary Department to grow from 10 million to 15.5 million between 2010 and 2030.

If the NHS is to face up to this challenge, some of its great assumptions will need to be overturned. The NHS holds it to be axiomatic that cost is a function of quality and access. If funding falls, either quality must fall and/or access must be reduced, either by longer waiting or rationing the services offered. No other industry could take this attitude.

Yet, the data shows that this cannot be true. Through the power of benchmarking we can see that the in-hospital mortality rate for an emergency stroke admission varies four times between the best and worst hospitals in London, six times for an acute aortic aneurism and ten times for a heart attack (2005 data). If you compare this superficially to the apparent financial standing of the organisations concerned, there appears to be no correlation.    

If you take a slightly more scientific approach and plot it against the reference cost index for intensive care, you again see no correlation. And, if lifted to a much more strategic level, the Dartmouth Health Atlas in the US has demonstrated year after year that there is no correlation been higher health spending and better outcomes; it depends how you spend the money.

So, if the assumption that cost and quality are intrinsically linked is flawed and the data suggests that it should be possible to reduce costs and improve services in many organisations, what approaches might work? By looking more widely than health you can see that industries which have transformed their productivity, have generally applied one of two approaches. Either they have shifted their workforce to part of the world with lower labour costs – not a strategy available to the average general hospital; or they have applied information, technology and process redesign to transform the way they do business.

If the NHS is to emerge from this recession as a stronger, fitter institution, not decimated for the 21st century, it must deliver what the National Programme failed to do – the deployment of information and technology to create a better, cheaper NHS.

This paper looks at the potential to use information technology in hospitals to simultaneously raise quality and cut costs by improving process flows, safety and the application of evidence-based care. In the interests of focus, the use of technology to transform a health system deserves an article of its own.
improving process flows
Too much of the NHS has suffered from the delusion that IT systems would in some way fix underlying operational problems in their organisations. As a consequence, the NHS has computerised an awful lot of bad process and proved conclusively that if you lay expensive technology on top of poor process, you simply get expensive, poor process. However, used as a tool to support the transformation of organisational processes, information technology can be the vital ingredient.

Algorithms such as those developed by Oak Group in their MCAP tool and McKesson in Interqual have been widely used in retrospective reviews and shown that, in most hospitals, between 25 per cent and 40 per cent of the patients could be cared for in a lower intensity setting. But, real change will only come when these algorithms are built into an electronic patient record and can impact on real-time decision making.

As the NHS focuses on reducing length of stay and inappropriate admissions, it seems reasonable to assume that the sickness level of those patients still in hospital will go up. Therefore, as wards are closed, the staffing levels of those remaining may need to rise to reflect the changing case mix. Tools such as Clairvia’s workforce tool, when integrated into an EPR, can reflect the acuity of the patients on a ward in the recommended staffing levels allowing a safe and efficient balance to be maintained.

Studies show that a significant proportion of a nurse’s time is spent documenting the status of patients. In large part, this is no-longer necessary. Tight integration between devices and an EPR reduces errors and saves time.

But these and many other opportunities to use technology in health to transform working practices have been known for a long time. They have always foundered on the size of the change management challenge and the difficulty in driving out the costs. Technology needs to do more than allow a hospital to become efficient if there is to be general acceptance.
improving safety

The cost of errors within the NHS is widely understood, but little has changed. Adverse drug reactions account for some three per cent to five per cent of all hospital admissions and cost the NHS £500m per E
E year. The National Patient Safety Agency estimated the cost to the NHS of medication errors in 2005-06 at £750m per annum and reported that between 2005 and 2007 the number of medication incidents reported had doubled and that at least 100 patients are dying or suffering serious harm per year.

IT based closed-loop medicines management has been shown capable of having a dramatic impact on this. A study led by David Bates MD, chief of General Medicine at Boston’s Brigham and Women’s Hospital, demonstrated that Computerised Physician Order Entry (CPOE) reduced error rates by 55 per cent. Rates of serious medication errors fell by 88 per cent in a subsequent study by the same group. The prevention of errors was attributed to the CPOE system’s structured orders and medication checks.

Another study, conducted at LDS Hospital in Salt Lake City by David Classen MD, demonstrated a 70 per cent reduction in antibiotic-related ADEs after implementation of decision support for these drugs.

The NHS is just beginning to realise the potential role of medicines management in challenging the cost-quality paradigm. But, there are still only a handful of hospitals like Newcastle, which have gone down this route.

Medication is only one area where harm is inflicted on patients and the cost wasted through error. Everyone in hospital knows about the risks of transcription errors, hand-over errors and the simple failure of communication in a complex organisation. Technology can transform this and deliver quality and cost savings simultaneously.
evidence-based practice

The benefit to the patient and the budget from delivering evidence-based care is well known and it is here that the power of information technology offers the greatest potential to transform medicine and the cost and quality of healthcare.

Numerous studies show that evidence-based care is cheaper and better. Here are some examples.

A study in the US hospital chain Ascension Health, looking at evidence-based practice in the treatment of pneumonia between 2000 and 2005 considered 25,000 patients treated on an evidence-based pathway, and 35,000 who were treated outside of the pathway, and demonstrated that:
• Patients on the pathways had a five per cent to seven per cent mortality rate, compared to a nine per cent to ten per cent mortality rate for those not on the pathway
• Length of stay was around six days compared to seven days
• Average cost case in the final year of the study was $4,721 compared to $6,841.
At the high-tech end of healthcare, a study into the cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting showed that on the pathway the annual cost of care was around $15,000, whereas off pathway it was more like $25,000 without altering the overall morbidity or mortality in patients.

The difficulty is ensuring that evidence-based care is followed when the NHS still delivers ‘memory-based care’. W Stead wrote in 2005 that a doctor who finished medical school and residency knowing everything and from that day onwards read and retained two articles a night would find themselves only 1,225 years behind after 12 months. This is why, as highlighted in the Yearbook of Medical Informatics in 2000, the time taken for half the doctors to have incorporated a new piece of knowledge into their practice is 15-17 years.

It is beyond unreasonable to expect clinicians to always know what current best practice is and impossible for a paper and memory based system to ensure that all the members of a care team know the care pathway they should be using and follow it.

Only information technology can provide the support that clinicians need, and studies are clear about what works. A study published in the BMJ in 2005 showed that the provision of decision support significantly improved clinical practice in 94 per cent of cases and that ‘automatic provision of decision support as part of the workflow’ is seven times as effective as the second best approach – ‘provision of decision support at the time and location of decision making’ (not embedded in the workflow).

The most advanced EPR systems do not just give access to evidence-based guidelines, they push it into the workflow at the crucial moment. And some are able to go even further than that, moving beyond embedded decision support to real time monitoring of patients. 2010 saw Cerner launch its Sepsis detection system – an evidence-based, real-time algorithm that monitors all patients and brings together the latest vital signs with historic diagnoses and recent organ dysfunction data to determine whether the doctors and nurses should be warned that a patient is about to go into septic shock. Time is of the essence for the clinical intervention, and here the IT is helping the clinical team avoid a medical disaster and helping to reduce the long-term cost of care.


So, at a time of complex challenges facing the NHS, the service needs to adopt a bold strategy. A productivity gain of 20 per cent will not come from a series of paper cuts, it will only come from a fundamental re-engineering of the way medicine is practiced.

We know that very large savings can be made by improving processes, reducing errors and reliably delivering evidence-based care.

We know that information technology can not only help achieve these changes, but that they cannot be achieved without information technology.

Therefore, the NHS leadership, clinical and managerial, needs to be bold enough to say they love the NHS enough to make it change and that means transforming working practices and embedding information technology deep into the day to day working of hospitals.

Written by Professor Matthew Swindells, chair of BCS, the Chartered Institute for IT



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