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Systems design for quality health care: a futures perspective

A Note by the Director (ditchley 2001/04)
In association with RAND and the Nuffield Trust
 
10-12 May 2001
We met in Santa Monica from 10-12 May and, in addition to enjoying the generous hospitality of our hosts, RAND, we set ourselves an ambitious task.  We undertook to consider the economic, scientific, social and technological forces acting on our health care systems with a view to developing a plan of action to improve significantly the quality and consistency of health care and the level of patient safety.
We set our discussions in the context of an inflexion point in health care.  We recognised that advances in biomedical science, the looming developments in genetics, pharmacology, computing and nanotechnology were all acting as agents for change.  But we also recognised that, as yet, our systems were unable to deliver a consistently high level of error-free health care.  At various times during the conference we discussed the concepts of “quality” and “care” and came up with a variety of definitions.  One that appeared to command general assent was that, based on evidence, care should be of proven value to the individual and to the population.  It should be delivered with respect for the patient.  It should be error-free (a claim that came in for later qualification).  It should be affordable and give universal access to a basic level of care.
Three working groups considered these questions and elaborated a number of action steps needed to design better systems for health care.  As was to be expected the individual steps varied somewhat from group to group.  It was, however, possible to identify a common core of ideas.  These centred around:
a        The need to align the professional, financial and other incentives operating within the system so as to maximise the drive for improvements in quality and, at the very least, minimise the perverse incentives which frequently militated against this;
b       the enormous importance of Information Technology in assisting everyone concerned with the health care system, but above all clinicians in improving their operational decisions;
c        the need for a new way of training and educating those now entering the medical profession to cope with the enormous changes which would confront them when they started to move into positions of responsibility by 2015;
d       the need to provide consumers (patients) with accurate information which, among other things,  would stimulate them to demand action to improve the service they were receiving;
e        measurement and reporting lay at the heart of an ability to identify where errors were occurring and the need to deal with them as well as giving those funding the system the ability to control and direct their resources more accurately.
In general discussions a number of other ideas and suggestions were thrown up.  Prototypes might be established in both the USA and UK which would embody state-of-the-art technology with the aim of achieving Six Sigma quality levels.  Such prototypes might embrace either a defined geographic area containing between one to six million inhabitants or they might concentrate on a specific disease group.  They would be given twice the normal expenditure which would be directed at investment in whole integrated systems rather than marginal improvements.  Some warned against using Six  Sigma terminology on the grounds that it could build up excessive expectations and ultimately lead to disillusion when the sort of levels of quality achieved in industrial production were not reached.  Others thought that there would be no harm in setting ambitious goals.  Proponents of the idea went on to recommend the establishment of an “International Society for Six Sigma Quality Health Care”.  This might have a secretariat on the lines of the international staff at NATO who would develop a comprehensive marketing plan similar to those of major pharmaceutical corporations and a “sales force” of between 250 and 1,000 who would spread an identical message about the importance of quality in healthcare in their countries.
Six Sigma also provoked a discussion of risk and the need to have an informed debate about its implications both with politicians and the public.  If public understanding could be achieved for a certain numerically defined level of risk associated with different procedures and treatments, then the question of responsibility and accountability might be dealt with on a more rational and manageable basis.
The prototype proposal also gave rise to an interesting discussion of the constraints imposed by our respective legal systems.  Better informed patients were becoming more litigious and the costs to a publicly funded system were now very onerous.  Some of us called for changes to our legal systems.  This was balanced by those who thought that patients had every right to sue for some of the gross errors perpetuated upon them by health professionals.  There was also a recognition that, at least in the USA, Congress would be extremely reluctant to move in the direction suggested by the reformers.
A variety of suggestions were made about empowering the public.  There were those among us who saw the cultivation of a degree of dissatisfaction among patients with the outcomes in the present health services as a potent means of building pressure for change.  Others advocated an information initiatives to make the public more aware of how to use the healthcare system.  This might even include a suitable course in the school curriculum.  There might also be an attempt to develop a better understanding of the issues through the popular press – although some among us who had attempted this in other fields, expressed scepticism.  Among other pressures for change we identified competition as a potent catalyst.  This was probably more apparent in the US system with many providers than state-run systems like the NHS which, somewhat mischievously, was compared to the early Catholic church with its claims to universality and knowledge.  Was a Reformation imminent?  The possibility of choosing a single powerful matrix (as Alcoa had done with worker safety) in order to drive higher levels of quality through the system, was also suggested.
The role of information technology was thought to be central to improving the quality of health care.  It was already almost impossible for a clinician to keep abreast of advances in his or her field.  Even the present rate of advance in knowledge might soon overwhelm doctors and it was clear that it would not be possible for individual doctors to cope with the impending genetic revolution.  There was an urgent need for IT systems which would assist doctors, and to some extent patients, at the point of decision.  The striking phrase, “talking walls”, was coined to encapsulate this concept even though we were told that the technology for this particular aspect of IT was some way off.  But other systems were available or could, if the research was funded, become available more rapidly.  This provoked a plea for a visionary IT project, akin to that which put a man on the moon, to achieve a goal which would not only be of immense benefit to societies in industrialised countries but also to those in developing countries.
A subtext to our discussions was an argument between those who were in favour of a revolution in public attitudes and professional commitment to a major improvement in health care quality which in their view bordered on the scandalous with thousands of deaths a year attributable to unacceptable levels of service and those who thought that incremental improvement was a more realistic goal.  The “revolutionaries” pointed out that the problem had long been identified and had effectively been ignored for over 40 years.  The “incrementalists” argued that it was impractical to plan a wholesale dismantling of existing systems and that there had indeed been a number of significant advances in both the level and recognition of quality in recent years.
On the financial front those involved in fighting budgetary battles for resources within their respective administrations pointed to the difficulty of making the business case for quality improvements.  It was not easy to demonstrate cost savings which is what influenced Ministries of Finance, and indeed in some cases the marginal cost increases of some improvements might actually weigh against them.  It was also difficult sometimes to establish where the benefits of particular changes might fall.  The outcome might be an improvement to the health of a particular patient and the value of such improvements were almost impossible to quantify financially.
As our discussions drew to a close a number of ringing appeals were made.  For understandable reasons we had spent much of our time on improving the quality of healthcare for individuals.  But it was claimed, very large gains in quality had, and would continue to be made, from improved programmes of public health care.  This might particularly be the case for the genome revolution.  We were also urged to think about quality improvements in such countries as China and India which might be able to make use of systems developed in the industrialised countries.  The links between developed and developing countries were already apparent with resistant strains of TB and AIDS viruses reaching our countries and our export of BSE etc to developing countries.
In conclusion, we were reminded that throughout our societies we were experiencing accelerating change.  But medicine still seemed to be moving slowly.  Many of the recommendations made during the conference showed how much medicine was lagging behind.  Those within health services needed to take into account that they were operating within a fast changing environment.  Both the public and politicians would become impatient.  It might be useful to set up a society “for better and safer health care”.  The society might then argue for prototypes of one sort or another.  A key priority would be to penetrate and influence the medical schools.  Changes would have to begin from within the profession itself.  If those carrying the message of change really believed in it then the next generation would carry it forward and implement it.  If no attempt was made then the position would not change.  Society would advance but medicine would continue to lag behind.
My personal impression, and it can be no more than that, was that the liveliness of the discussions, the strength of the views expressed and the scope and invention of the proposals put forward, indicated a commitment to pursue, in one form or another, the goal of major quality improvement in health care.  Perhaps in the future we will be able to look back at advances made on the back of ideas and recommendations made at Santa Monica.  Meanwhile for those at our conference keen to find a mantra for change, I wonder whether the health profession might rally to the goal of providing each of their customers with
Access
            to
Seamless care
of
Proven value
delivered
In time
according to
Recommended practice
and to an
Excellent standard.
This report reflects the Director’s personal impressions of the conference.  No participant is in any way committed to its content or expression.
 
 
PARTICIPANTS
Co-Chairmen   : 
Kenneth I Shine MD
President, Institute of Medicine
Sir Maurice Shock
Chairman, The Nuffield Trust
 
CANADA
Mr Claude Forget OC

Independent Consultant
Ms Cynthia Ramsay
Health Economist;  Publisher, Western Jewish Bulletin
FRANCE
Professor Jean de Kervasdoué

Chair in Health Economics, Conservatoire National des Arts et Métiers, Paris
UNITED KINGDOM
Professor Sir Leszek Borysiewicz PhD, FRCP, FMedSci

Principal, Imperial College School of Medicine
Sir Nigel Broomfield KCMG
Director, The Ditchley Foundation
Dr Charlotte Dargie
Nuffield Fellow, The Judge Institute of Management Studies, University of Cambridge
Professor Liam Donaldson
Chief Medical Officer, Department of Health
Professor Richard G A Feachem CBE
Director, Institute for Global Health, University of California, San Francisco
Dr Nicholas Hicks MD
Strategy Unit, Department of Health
Dame Deirdre Hine DBE
Chairman, Commission for Health Improvement
Professor Reg Jordan 
Director or Medical Studies, Faculty of Medicine, University of Newcastle
Professor Julian Le Grand
Richard Titmuss Professor of Social Policy, London School of Economics
Professor Martin Marshall
Professor of General Practice, National Primary Care Research and Development Centre, University of Manchester
Dr Fiona Moss
Associate Dean – Postgraduate Medicine, North Thames Department of Postgraduate Medical and Dental Education, University of London
Professor Sir Michael Rawlins
Head, Wolfson Unit of Clinical Pharmacology, Department of Pharmacological Sciences, University of Newcastle;  Chairman, National Institute for Clinical Excellence
Miss Carol Robson
Deputy Director, The Ditchley Foundation
Professor Martin Roland
Director of Research and Development, National Primary Care Research and Development Centre, University of Manchester
Professor Clive Smee
Chief Economic Adviser, Department of Health
Mr John Wyn Owen CB
Secretary, The Nuffield Trust
UNITED STATES OF AMERICA
Robert H Brook MD ScD

Vice President RAND, Director RAND Health;  Professor of Medicine and Health Services, UCLA Center for Health Sciences;  Director, RWJ/UCLA Clinical Scholars Program
Shan Cretin, PhD, MPH
Senior Scientist, RAND
Cheryl Damberg PhD MPH
Director of Research and Quality, Pacific Business Group on Health
Ronald I Dozoretz MD
Chairman and Chief Executive Officer, FHC Health Systems
Dr Arnold M Epstein MD MA
John H Foster Professor and Chairman, Department of Health Policy and Management, Harvard University School of Public Health
Robert S Galvin MD
Director, Global Health Care, General Electric Company
Emmett Keeler PhD
Senior Mathematician and Health Services Researcher, RAND
Raynard Kington  MD PhD
Associate Director for Behavioral and Social Science Research, National Institutes of Health
Paul Koegel PhD
Associate Director, RAND Health
Jacqueline Kosecoff PhD
President and Chief Operating Officer, Protocare Inc
Ms Sheila Leatherman
President, Center for Health Care Policy and Evaluation, United HealthCare Corporation
Professor Theodore R Marmor
Professor of Public Policy and Management, Yale University School of Management
Michael McCoy MD
Associate Dean for Information Technology, UCLA School of Medicine
Elizabeth McGlynn PhD
Director, Center for Research on Quality of Health Care, RAND
Ms Ann Monroe
Director, Quality Initiative, California HealthCare Foundation
Joseph P Newhouse PhD
John D MacArthur Professor of Health Policy and Management, Harvard University
Mr David K Richards
Private Investor
Mr John Rother
Director of Legislation and Public Policy, AARP
Paul Shekelle MD PhD
Senior Research Associate, RAND;  Associate Professor of Medicine, UCLA School of Medicine
Mark Smith MD
President and Chief Executive Officer, California HealthCare Foundation
Mr Joseph P Sullivan
Chairman and Chief Executive Officer, Protocare Inc
James A Thomson PhD
President and Chief Executive Officer, RAND
Glenn P Tobin PhD
Executive Vice President and Chief Operating Officer, Cerner Corporation
Nancy S Wexler PhD
Higgins Professor of Neuropsychology, Department of Neurology and Psychiatry, College of Physicians and Surgeons, Columbia University
WORLD HEALTH ORGANISATION
Dr Herbert Zöllner PhD

Regional Adviser, Economics for Health, World Health Organization