A new and refreshing approach to understanding and improving healthcare systems. Hamish outlines his alternative approach to realising better healthcare services at less cost. It begins with looking at healthcare not from a conventional activity perspective but from a person-centred one.

1. Understanding Patient Demand:
A Better Way to Make Healthcare Systems Work
Hamish Dibley | 17 November 2016

2. Contents
1. Current Cognitive Conventions
2. (A Bit of) Theory and Methodology
3. How to Understand Healthcare Systems
4. How to Improve Healthcare Systems
5. Case Study: ‘Ms. Vulnerable’
6. Conclusions and Opportunities
1

3. Perspectives…
Improvement is all about adopting
the right perspective.
The way we currently perceive the
problems in healthcare systems…
…is the problem.
2

4. Cognitive Conventions

5. Conventional Beliefs
1. Ageing and growing
elderly populations
1. Rising public expectations
on healthcare services
1. Rising public demand for
healthcare services
3

6. Activity & Cost Conventions
ED Performance – Activity Analysis ED Performance – Activity Benchmarking
“Activity Obsession Disorder”
4

7. Conventional Improvement
5

8. Logic and Methodology

9. Thinking Perspectives
6

10. Understanding Demand
Before managing demand... Let’s understand demand...
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11. Patient Demand
8

12. Intelligent Analysis
Observation & Work Shadowing
Quantitative
Research
Qualitative
Research
Ethnographic
Research
Case Study Analysis
Demand Analysis
Workflow Analysis
Process Maps
Economic Flow Costing
9

13. Understanding Healthcare

14. Hospital Patient Demand
Secondary Care User Type 2014/15 2015/16
Users 34% 34%
Non-users 66% 66%
Measure 2014/15 2015/16
Secondary Care Users 161,951 162,552
Change on previous year +0.4%
Relative Demand for Secondary Care
Absolute Demand for Secondary Care
In discussing the nature of demand for acute healthcare services it is important to
differentiate between two types: actual and relative demand. Actual demand signifies the
total population of a locality that uses secondary care. Relative demand represents the
proportionate percentage of that population that access secondary care.
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15. Helicopter View
All Settings
Pat / Pop Activity Cost
162,552 599,573 161M
34.2% 100% 100%
All ED
Pat / Pop Activity Cost
63,181 92,175 12M
13.3% 15.4% 7.5%
All Inpatients
Pat / Pop Activity Cost
52,366 123,307 114M
11.0% 20.6%% 70.2%
All Outpatients
Pat / Pop Activity Cost
124,114 384,091 36M
26.1% 64.1% 22.5%
ED Not Admitted
Pat / Pop Activity Cost
49,329 65,195 8M
10.4% 11% 4.7%
ED Admitted
Pat / Pop Activity Cost
19,641 26,980 5M
4.1% 5% 2.9%
Elective Inpatients
Pat / Pop Activity Cost
24,567 38,805 41M
5.2% 6% 25.5%
Emergency Inpatients
Pat / Pop Activity Cost
21,712 31,116 59M
4.6% 5% 36.2%
First Outpatients
Pat / Pop Activity Cost
92,409 143,486 17M
19.4% 24% 10.7%
Follow Up Outpatients
Pat / Pop Activity Cost
85,794 240,605 19M
18.0% 40% 11.7% 11

16. Patient Cohorts
Profiling people according to their use of secondary care allows the segmentation of
patients into distinct and real patient cohorts or typologies. For the purposes of
understanding the case-mix of patients using hospital services, the work has grouped
patients according to their highest consumption in each of Urgent and Planned Care.
 Zero Urgent = total of no A&E
attendances or emergency admissions
 Low Urgent = total of 1 A&E
attendance or emergency admission
 High Urgent = total of 2-3 A&E
attendances or emergency admissions
 Very High Urgent = total of 4+ A&E
attendances or emergency admissions
 Zero Planned = total of no outpatient
attendances or elective admissions
 Low Planned = total of 1 outpatient
attendance or 1 elective admission
 High Planned = total of 2-6 Outpatient
attendances or elective admissions
 Very High Planned = total of 7+
outpatient attendances or elective
admissions
Number Overall Classification 1516
Number of
Patients
Average Number of
Encounters
Average Bed
Days
Cumulative SUS
Tariff
Cumulative %
SUS Tariff
1 Very High Urgent - Very High Planned 1390 19 15 £13,036,765 8.7%
2 Very High Urgent - High Planned 2326 9 13 £27,205,894 18.3%
3 High Urgent - Very High Planned 2374 13 4 £37,934,118 25.5%
4 Very High Urgent - Low Planned 832 7 10 £41,617,949 27.9%
5 Very High Urgent - Zero Planned 1584 5 9 £47,413,398 31.8%
6 High Urgent - High Planned 6544 6 3 £62,301,277 41.8%
7 High Urgent - Low Planned 3292 3 3 £67,584,078 45.4%
8 High Urgent - Zero Planned 9053 2 2 £77,884,041 52.3%
9 Low Urgent - Very High Planned 2257 12 1 £84,410,963 56.7%
10 Low Urgent - High Planned 8472 4 0 £92,067,903 61.8%
11 Low Urgent - Low Planned 5183 2 0 £94,098,186 63.2%
12 Low Urgent - Zero Planned 22522 1 0 £97,952,626 65.7%
13 Zero Urgent - Very High Planned 9044 10 0 £116,138,237 77.9%
14 Zero Urgent - High Planned 49467 3 0 £143,556,457 96.3%
15 Zero Urgent - Low Planned 34860 1 0 £148,408,132 99.6%
16 Zero Urgent - Zero Planned 3377 0 0 £148,408,132 99.6%
17 Unclassified - Unattributable 0 2239 274 £149,000,034 100.0%
18 Non User 313,077 0 0 £149,000,034 100.0%
 The top 5 patient cohorts (8,500 patients in red border) account for 32% (£48m) of all
costs. These same ‘vital few’ patients equate to 70% of the hospital’s net deficit.
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17. Venn, Pyramid & The Vital Few
Financial Year Total Patients Elective Patients Emergency Patients Both % Both
2014/15 39,739 24,760 18,895 3,916 9.85%
2015/16 42,018 24,567 21,712 4,261 10.14%
Text
10%
Cross-Over
Elective
Admissions
Emergency
Admissions
► Top 1% of patients
► This is 1,391 people
► They cost £13.6M per annum or 9.1% of total costs
► They use on an average of 14.8 bed days per annum
Top 5%
Top 3%
Top 1%
► Top 3% of patients
►6,091 people
► They cost £31.5 per annum or 21.1% of costs
► Top 5% of patients
► 8,507 people
► They cost £48M per annum or 32.2%
From 16 patient cohorts it’s possible to further refine the analysis and breakdown the
classifications. The 3 sub-groups are as illustrated via the ‘pyramid of consumption’ diagram.
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18. ED Attendances & Admissions
15.6% of the top cohort’s
attendances end ten
minutes before the target
For all other patients it’s
8.5%
Patients tend to wait a long time to leave ED – breaches are just a symptom of this
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19. Emergency Bed Capacity
1% 3% 5%
218
15.3%
21,031
£4.2 million
652
31.2%
42,927
£9 million
1,086
41.8%
57,635
£13 million
% Patients
No of Patients
% Bed Days
No of Bed Days
Costs
15

20. ED Breaches and Patient Flow
Patients in the
top cohorts are
twice as likely to
breachThe top 5
cohorts account
for around 50%
of all breaches
The top 5 cohorts
account for around
50% of all admissions
to assessment units
Increased emergency activity is
associated with Assessment Units
16

21. Patient Flow & Financial Deficits
Very few patient groups are
‘profitable’ particularly the
‘vital few’. They are flowing
patients they shouldn’t be
flowing! Hospitals cannot
grow themselves out of
deficit
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22. Improving Healthcare

23. Contrasting Approaches
BetterCurrent Approach
Analyse
Activity
PMO
Standardise
Pathways
STUDY
PLAN
ACT
Understand
Patients
Prototype
Customise
Care
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24. Intelligent Improvement
The problem is demand amplification of ‘vital few’ patients caused by poor system
and service design. Improvement means redesigning services and systems to work
for patient cohorts according to geographies, service functions, specialities and/or
conditions in order to ‘learn to improve and improve to learn’.
Clarity of Purpose
• What matters?
• What needs to be
solved?
• What needs to be
better managed?
Performance Metrics
• End-to-end time
• First-time resolution
• Representing
demand
• PAC profiling
Paper Prototype
• Develop design
• Develop processes
• Anticipate
economies
• Roles & resources
Working Protoype
• Initiate with small
cohorts
• Control groups
• Extend scope
• Extend volume
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25. Changing the Process: A&E
Triage Dr Review Tests Dr Review Treatment DischargeClerk
Nurse
Assessment
Ambulance
Consultant
Triage nurse job is
to decide how long
you should wait
How long is the waiting between each phase
of the process? Rework with the consultant?
 Current system is designed to make you wait!
 Two routes in – walk-in or arrive by ambulance
 Patients receive two different types of process
 Potential for inexperienced staff to order unnecessary tests
20

26. Changing the Process: A&E
Walk-in
Dr Review Treatment Discharge
Assessment
Team
Nurse
Assessment
Ambulance
Consultant
CDU
AMU
AAA
T
a
r
g
e
t
4-
Hour
The future utility?
 ED system designed for predictable patient demand
 Same route in – walk-in or arrive by ambulance
 Specialists with juniors placed at the front-end of the process
 Treat the 4-hr target as a constraint, don’t drive performance by it!
‘Assessment
Units’
21

27. Case Study: Ms. Vulnerable

28. Old System Response
• Personality disorder, emotionally unstable
• Complex physical health needs… cellulitis
and UTIs are just two of them
• In receipt of social security benefits
• Immobile and house-bound
• Principal career mum died in 2011 – ‘trigger’
• Neighbours jeer when ambulance is called –
repeat medical prescription debacle…
• Patient cannot care for herself
• Social care support doesn’t meet needs
• Most expensive ambulance user
• Regular ED attender and admitter – 30
visits (Jan-Sept 2016) for self-harm; falls;
collapses; shortness of breath
• GP and community nurse not
commissioned to customise care
• Person didn’t meet eligibility criteria for
further care and support
 44 year old female leaving in a ground floor social housing flat
 Morbidly obese – 45 stone or 286 kilograms
 Socially isolated with a sister who is not supportive
 A ‘top 20’ high consumer of healthcare services over many years
Issues Activity
Annual System Cost for this Person?
£224,000
22

29. New System Response
• Professional meeting with the person,
worked with the person not did to…
• Patient asked ‘what matters’: she ‘wanted
a normal life’ but ‘did not want to live on
her own’ – the goal/aim/purpose!
• Busted the myth she was going to die
within the next year or two
• Person holistically understood
Professionals sought a perfect package of
care around the person – do the right thing
• Care customised and patient-centred plan
enacted – new processes, roles, budgets not
limited by service and financial barriers
• Care team built around the person’s needs
• Senior person responsible for the care support
and care comes to the patient
• Plan is working – no further ED attendances and
care can be ‘flexed’ according to changing
needs
• Plan to work on the causes of obesity
 44 year old female leaving in a ground floor social housing flat
 Morbidly obese – 45 stone or 286 kilograms
 Socially isolated with a sister who is not supportive
 A ‘top 20’ high consumer of healthcare services over many years
Activity Outputs
Annual System Cost for this Person now?
£57,200
That’s a 75% cost reduction
23

30. ‘Ms. Vulnerable’: Cheaper to do the right thing
 Think Person Not Pathways




Think Needs
Think Systematically
Not Eligibility Criteria
Not Service Silos
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31. Conclusions and Opportunities

32. Healthcare
Performance
Issues
Conclusions
25
 Patient-centred analysis shows relatively consistent and stable demand for acute
care services
 Patient demand is concentrated within ‘vital few’ numbers of the local population
who consume disproportionate levels of activity and cost - ‘demand amplification’
is the greater problem not rising demand
 Attempts at improvement do not work as they rest on simplistic reductionist
thinking: too reactive and based on activity and cost assumptions
 Transformation starts with studying the ‘who, why, how, what, where, when’ of
patient demand and intelligent system and service redesign around patients, not
pathways
 Focus improvement on small patient numbers to see big system benefits
The Vital
Few

33. Contact Details
hamish@hamishdibley.com
O778 6980 863
https://uk.linkedin.com/in/hamishdibley
https://twitter.com/hamishdibley
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