Usually it tells you nothing. At best it lulls you into a false sense of security. At worst it can lead you to make harmful decisions. If the CQC is anything to go by they also describe a reality far removed from that which patients actually experience.
In applying the Vanguard Method in Health I have been trying to stitch together person shaped consumption, end-to-end over time. It's not an easy thing to do. The NHS does not look at information in this way. It is very revealing. For hospital data though, the pattern is unequivocal. In every system I have studied:
- about 1.5% of people consume roughly one quarter of hospital inpatient and day case resources
- 5% of people consume about 50%
- under 20% of people consume over 80%.
What I have seen would lead me to believe this is the same pattern in every wellbeing economy. What I conclude is that leaders in wellbeing economies are blind to this. They know, at a level of principle, that there are a few responsible for consuming the many. But quantification rules and numbers showing that targets are being delivered rule the day. So these people get lost in the melee that is day case rates, new to follow-up ratio's and ALOS. The target culture is driving the wrong behaviour, solving the wrong problems, driving in cost, causing waste and harming patients. The solution is to understand people in the context of how they live their lives. Not very fashionable perhaps, but no less true all the same.
In terms of numbers of people, they are small. Certainly small enough that , as a system, wellbeing economies could organise themselves much more effectively to understand their stories and solve their problems. From the data I have, the same proportions apply equally to use of other parts of the system. And they seem to be the same people. So to put it into context, in one Trust about 700 people account for about 20% of resource consumption. So when we talk about scale let's put into into context of reality. 700 people should be within the gift of wellbeing economies to design solutions for surely?
On the other side of the coin about 50% of admissions to hospitals stay less than 72 hours. Now, there are obviously many more of these people, but when I study these cases a significant proportion of these could be supported without the need for hospital admission. Perhaps more illuminating is that the closer they are to breaching 4 hours, the more likely it is that an admission will occur. At a level of overall system performance and solving peoples problems, I contend that the targets are not working.
So why do I keep going on about understanding? I reported before that in one experiment, not one person went on the prescribed pathway once we had understood them and the way they lived their lives. The chances of this being special cause for all of them is one million to one. And the hard facts? Well for that cohort of people there was a:
- 11% reduction in placements (nursing/residential)
- 16% reduction in acute admissions
- 42% reduction in community hospital admissions
I have seen that wellbeing economies are systemically incapable of understanding how to respond to knowledge about people. The system does not see people as people. This is a major design flaw and the main reason driving costs in the system. I would argue that it's also a main driver of harm to patients as well.
The system is currently all consumed by the chasing of targets, the delivery of the bottom line, the implementation of new models of care at scale and pace. But if we could better understand all the consumption, particularly in the context of how people live their lives, the opportunities for doing better things appear to be colossal. For me it completely changes the way we conceive of what works.
Reality then becomes what we are really doing for people rather than numbers on a spreadsheet.