Physician heal thyself: engineering a new national health system
Physician heal thyself: engineering a new national health system
The National Health Service turned 70 in 2018 – but, amid
the celebrations, its health is faltering. By working closely with local
hospitals and GPs, researchers at the University of Cambridge are developing
bold new ideas they believe will help the NHS thrive for decades to come.
Alongside the Chinese People’s Liberation Army, Indian
Railways and Walmart, the NHS ranks among the world’s largest employers. In
England, it treats more than 1.4 million patients every 24 hours and will this
year spend £126 billion. But as communities gathered to celebrate the NHS’s
70th birthday in 2018, reports continued to emerge on the ailing health of this
much-loved national institution.
Analysis by another national treasure, the BBC, revealed
that nearly one in five hospital trusts were failing to hit any of their key
waiting-time targets. Hospitals seemed to be lurching towards over-crowded
A&Es, bed shortages and queuing ambulances unable to hand over their
Two University of Cambridge researchers have a grand vision
to rethink the system to make it fit for the next 70 years – a vision that’s
rooted in research with local patients and doctors.
Professor Stefan Scholtes works at Cambridge Judge Business School and Dr Alexander Komashie is at the University’s Engineering Design Centre. Both are engineers by training, both have spent the past 10 years studying different parts of the local healthcare system and both are passionate believers that, as researchers, they can help make the NHS better.
The NHS faces numerous challenges but the real test, says
Komashie, is understanding how to design better delivery systems by working
with patients. “That’s where engineering comes in,” he says. “Engineers
excel in designing large systems that work well, from worldwide
telecommunications networks to the Airbus A380. What motivates me is
translating the engineering practice of a systems approach into healthcare.”
The first step is understanding the system requirements. “It
sounds obvious, but to design a system to do something you need to understand
what it is you want,” Komashie explains. “In engineering, a lot of
effort goes into defining what the system should do. When you understand that,
you can ask how the system is set up to deliver it.”
Komashie has applied this systems engineering approach to
adult mental health services within the Cambridgeshire and Peterborough NHS
Foundation Trust (CPFT), and ran a series of workshops for patients and
clinicians. Patients’ stories allow him to unpack each component of the
delivery system and represent them in visual diagrams so that services can be
improved in a systematic way. The project was funded and supported by the
National Institute for Health Research (NIHR) East of England Collaboration for
Leadership in Applied Health Research and Care (CLAHRC), hosted by CPFT.
“My goal is developing a new way of describing the
system, and hearing people talk about their experience of care helps me
understand it. If through patient and public involvement, we can get rich
enough stories, it gives us a window into the system behind the story,”
says Komashie, who has recently been awarded an interdisciplinary fellowship
for research into health systems visualisation at The Healthcare Improvement
Studies Institute (THIS Institute). “Hearing patients’ accounts of what
matters most helps to ensure the system designs and delivers the support they
Sarah Rae, CPFT Expert by Experience, worked closely with
Komashie in bridging the gap between the academic researcher and the patient
participants. “As workshop co-facilitator I gave the participants a better
understanding of the research by helping them to make the connection between
systems engineering and mental health,” she says. “Sharing my own
lived experience of mental health also helped the participants feel more
comfortable about describing their experiences authentically.”
Komashie is now taking the tools he developed in mental
health and applying them to vascular surgery and spinal cord injuries at
Addenbrooke’s Hospital in Cambridge and holistic neuropsychological
rehabilitation at The Princess of Wales Hospital’s Oliver Zangwill Centre in
Working with GP practices
Headlines about NHS waiting times, bed shortages and
ambulance queues invariably focus on capacity, which Scholtes argues is a
misdiagnosis. “People say we’ve got a capacity problem but that’s wrong.
We have a complexity problem. There are so many things going on simultaneously
but pulling in different directions. Complexity is killing hospitals.”
At Addenbrooke’s, for example, where Scholtes spent three
sabbaticals over the past 10 years, the hospital does everything from pulling
wisdom teeth to multiple organ transplants. He argues that delivering this
breadth of services in a system already at full stretch is impossible. Instead,
hospitals need to be “decomplexified” by delivering most of their
routine services in community settings.
It sounds simple, but it’s not. “The problem is that
there’s no landing space. We have 92 GP practices locally, so how can you move
work currently centralised in a large hospital to 92 small businesses? It’s
impossible. The only way to make headway is to scale up primary care so that it
can take on more responsibility,” says Scholtes.
This is exactly what he’s doing with Granta Medical
Practices, a large Cambridgeshire GP practice where he spent his most recent
sabbatical evaluating the practice’s innovative operational and business model.
A critical barrier to change in primary care is the
traditional GP partnership model, he says. By leaving GP partners with
unlimited liability, the model creates risk aversion and hampers transformative
change. In response, Granta is developing an innovative business model – an
employee-owned trust akin to the John Lewis Partnership – which could enable it
to deliver 70 per cent of routine outpatient activity in the community and cut
by 25 per cent the number of emergency bed days among its patients.
Dr James Morrow, CEO of Granta Medical Practices, describes
how Granta Medical Practices has gained enormously from working closely with Scholtes
and his colleagues at Cambridge Judge Business School: “Several of our
senior clinicians have participated in formal educational programmes through Cambridge
Judge and have brought back insights and skills from other sectors. Stefan’s
sabbatical with the practice has refined and clarified our thinking around not
just service delivery and user-experience but also helped with developing our
longer-term strategic goals as we embark on a period of rapid health system
But how can transforming Granta help the NHS as a whole?
This is where the University comes in, says Scholtes, who hopes to establish a
Primary Care Innovation Academy, drawing on research expertise from across the
The Academy would provide leadership and management
training for GPs, practice managers and lead nurses, and also ensure that
interventions taken to transform the local primary care system are robustly
evaluated. As such, it would add to the University’s increasing capacity in
creating the evidence base for improving healthcare. For instance, THIS
Institute is focusing on how to improve quality and safety across the system.
A “radically different” NHS
Addenbrooke’s Hospital itself has been transformed over the
past three decades with a major emphasis on recruiting clinical academics in
partnership with the University, who split their time between practising
medicine and carrying out research.
Professor Patrick Maxwell, Head of the School of Clinical
Medicine, explains: “Clinical academics have been central to the
development of tertiary referral services and a major trauma centre. This has
helped to create an excellent district and regional hospital with outcomes that
are among the best in the country. Currently our priorities include improving
prevention and early diagnosis of diseases, so that fewer patients need
Meanwhile, in January 2019, the NHS released its new
10-year plan, which included aims to boost ‘out-of-hospital’ care through
increased investment in primary medical and community health services.
All in all, Scholtes believes that, by the time the NHS
reaches its 80th birthday, it could look radically different: hospitals could
be doing 60 per cent of what they do now by focusing on cases that can only be
treated in hospital and on cutting-edge treatments and research, while more
integrated, scaled-up primary care practices will be taking full responsibility
for out-of-hospital care.
“If this work is successful, it has the potential to
bring the local health economy back onto a sustainable path by establishing a
new model of primary care that can be scaled throughout the NHS,” he
concludes. “It’s ambitious – but we can do it.”
This article was originally published in the University of Cambridge’s magazine Research Horizons.