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GPs go forth

Dr Lynne Maher: In her own words

Dr Lynne Mayer, head of innovation practice at the NHS Institute for Innovation and Improvement, tells Pulse senior reporter By Nigel Praities about her plans to streamline the health service.

By Nigel Praities

Dr Lynne Mayer, head of innovation practice at the NHS Institute for Innovation and Improvement, tells Pulse senior reporter By Nigel Praities about her plans to streamline the health service.

The NHS Institute has a bit of bad image amongst GPs as just being about cutting costs, is this warranted?

We do need to help people reduce cost – that is a national priority - but it absolutely cannot be at the expense of quality or safety or patient experience. What we are trying to do is to find ways and link people together so that people can learn from each other to increase quality and safety and make the patient's experience better at lower cost. That is our ambition. Cost is important., but not on its own.

Patient experience is a big issue at the DH at the moment, could you tell me about your work in this area?

I think quite rightly. I have been working in healthcare improvement for a long time and sometimes you get resistance to change. We have been doing quite a lot of work based on how can we better understand patient experiences of care and therefore how can we better redesign services.

With improvement, I think we have done really really well, but essentially what has happened is, from a professional perspective, we draw a care process and we redesign that care process. We do talk to patients in forum and groups, but actually we talk to them about the technical side of the process and not enough about how it is really experienced.

We actually started this piece of work, it is supposed to be a patient-led NHS, but the Healthcare Commission basically said "We have this ambition and yet it is frustrating for patients". We started to think about this, you know, how do you see patients? How else do you understand what is working for them and what their frustrations are? We looked at other industries that have customer focus, hotels, airlines, online shopping and the common thing among them all was that they all worked with service designers.

So we explored this and there looked to be some promise in their methods and how they really understand their experience and how they base the redesign on that. So we did a big test with a design organisation and some anthropological researchers so that we could really understand what was happening and document that.

We did it in a hospital and a service that the chief executive said was their best service in terms of targets and patients satisfaction etc. We did this piece of work based on this methodology of understanding the patient experience in terms of their narrative – a lot of it is story telling that is captured on film and is played back. We made 42 changes to their service. This is a hospital which is well known for very good safety record, but there were safety issues, timing issues which were hidden in processes, there was waste, there was dignity.

From there we have developed that into a methodology called the Experience-Based Design Approach. Our first set of pilots were mainly in secondary care, but we also have got a film that is just being finalised that is based on a piece of work that we did in Ealing. We got asked by Ealing to redesign their services for people living with MS in the community. The acute trust initially wanted to design services closer to home, but that is not what the people with multiple sclerosis wanted. Actually what they wanted was something totally different. On that piece of work, what they have got is actually what they wanted. Moving that neurologist closer would have been quite expensive and would not be what they wanted. We started this in the acute setting, but this worked in the community setting and we have just started a piece of work with a practice in Derbyshire to test it there.

Resistance goes when people hear the narrative and particularly if it is filmed. The narrative is very balanced and it is not all bad at all. Lots of really good things come out, where patients say ‘That has really made a difference'. But especially if it is a poor experience, because it is their patients saying this then they say ‘Well we have got to do something about this now'. We don't have some project lead telling them to change it, the people/consultants say ‘We need to change this now, we can't let that go on.' There is a big difference between hearing that from a patient, compared with someone going: ‘Here is the process and this isn't working well.'

This is interesting because there has been a lot of argument in primary care about the patient survey, the questions that were asked and how it relates to patient experience.

Absolutely. We are completely purist about this now. Patient surveys – any survey – are good because they give you certain data that is useful, but satisfaction does not equal experience. They are different things, and yet I still see the words used interchangeably a lot. ‘If we do something about patient experience then we will increase patient satisfaction' – it is different.

In our test with the researchers, we tested the Picker Cancer Experience survey against some of the depth and richness of the stuff that we got out. Both are good. Both gave good data, but they are very different. The real understanding of what the patient was going through came out of the narrative. You got some good stats out of the experience questionnaire, and it left quite a lot of gaps for patients to write in. But people don't, or they can't quite put it into words in the way that you would tell the story. We found it is really different. And we have found over again with people using the methods now, they send us emails now saying ‘We even have got an orthopaedic surgeon to change their ways' so it is having a big impact.

What we need to develop is come primary care examples, but the methodology can work wherever. We can send a film of people living with MS to you.

In the current financial situation for the NHS, can you still have high-quality care while reducing costs? How can PCTs avoid the ‘slash and burn' approach as their resources dwindle?

You will have heard about the Productives. The Productives came out of looking at other industries and adapting for healthcare. The big component of what we do, and what we help people to do. Our thought are, lets look at some of the challenges – we set ourselves up as an innovation organisation and have a very specific process. One of those is to ‘Really understand the challenge', so if we are talking about cash coming out and keeping quality up, well what does that really mean? What other industries have that problem? We are not the only industry to have that problem.

But do you think it is possible?

I do think it is possible, because there is a lot of things in the health service that can be done better and one really good example of this is around patient safety.

Patient safety incidents cost an absolute fortune. I don't have all the absolute figures off the top of my head, but there is massive waste in terms of extra treatments required, sometimes surgery. Antibiotics if it is an infection. Just general waste, which creates extra bed-days, extra district nursing, more visits to the practice, more drugs, whatever. Let alone being a terrible thing to the patient. Safety absolutely increases quality and takes out millions of pounds of waste across the whole system. It is a really good example.

The work around the Productives takes out waste and one of the things that people are asking us to look at is about backroom waste. Looking at audit trails, paper trails, duplication of effort due to poor communication and things like that, is hugely time-wasting and that costs money. You can often reduce a half time equivalent in admin if only systems supported people to work in the best way.

I have been in the NHS the whole of my life and I have worked in primary and secondary care and I don't think we have the systems set up as well as we could do to take that waste out. There are a couple of GP surgeries where they are paperless –Dr john Oldham's is one – that might not add up to much per one surgery, but if you put that across every surgery, that is a lot of money. Those smaller more incremental changes can make a lot of difference to the NHS.

How can you help GPs make these simple changes?

We are more blessed than those in the front-line because we have the time to think about these things and say ‘What are the real challenges here?'

We are very well connected with frontline staff and we try to hear it from their perspective. I work in an office, even though I am a nurse by trade, and we say ‘Who else might have this problem – lets have a look at them. How have they solved it? Let's look, lets do some testing.' Then see if there is a solution that we can show people. That is exactly how the Productives work, exactly how the patient experience works and some of our other products work.

One of the questions that came to us from primary care, ‘If I have got an idea how do I know if it is going to make a big difference or an incremental change?'. We are going ‘Oh, OK'.

Innovation literature is really hard to get your head around, so what we try to do is put ourselves in the shoes of a front-line staff nurse and in the shoes of commissioners and GP commissioners. How can we help them assess what a frontline innovation or improvement might be? From that we have developed a guide, which is a simple stepped process for commissioning. We have put together, a simple four Ws test. Who, what, when, where.

It helps you distinguish what kind of a difference you are making. It has been written very specifically for a whole range of commissioners. It was the first thing we published to support World-Class Commissioning, we were working on a version for front-line staff and Gary Belfield said ‘Stop what you are doing. Write a commissioning one.' So we did.

What we try to do is understand what some of the challenges are. What people are trying to grapple with, and what we can provide in terms of guidance, training and discussion. One big part of our remit is going to be helping GPs reduce costs while maintaining quality for patients.

One of your big programmes is the High Volume care programme, which looks at shifting care from hospitals into the community. This impacts on GPs in terms of taking on more complex cases and doing more follow-ups in the community. How can this be done without being even more of a burden on GPs?

The concept is good, but there are conditions in people where it is more appropriate. What tends to happen is that secondary care makes a decision and it goes out. It is more about understanding across the system about what is better provided closer to home that maintains quality and is reduced cost, because not all things are.

What the NHS has not been particularly good at is really working out the economic analysis from the wider point of view. If we are asking GP practice to take on this work, what does this really mean for them in terms of their the economic evaluation of their time, the receptionist's time, the nurses time and their general workload? So quite a lot of the focus with BCBV and High Volume care now is about doing more detail about whether this is economically viable as well as higher quality.

In the first couple of years, there was less of an emphasis on cost. Perhaps we focussed less on that in the early years, but it is a major focus for us now. What we are hoping to do is to help people make the right judgement about what can go out and where money might need to shift – that absolutely needs to happen. We need to resource up the community. That piece of work is being done now to see what is really better in the community.

So you are working on that at the moment?

Yes. We are getting much bigger learning about that economic analysis is a big part of our work right now. We are doing some work with nurses on this Ideas Channel, where they submit their ideas. And they have needed quite a lot of help to demonstrate the economic value in terms of how we can get cash out. They are quite good on the quality indicators, but not good on the economic analysis. That is across the NHS, really.

Again, we have flagged that as an issue and we really need people in the NHS to understand that more, from GP practices to the chief executive of a major teaching hospital. They need to have that capability to work at increasing quality and taking cash out. Unless they can do that they cant meet the challenges of the future.

Is this also looking in hospitals about having a good discharge team – for example – to support those patients?

You need things like that – but you have to look at things in the macro. Even if you make a reduction of 20 bed days, it is actually hard to take cash out unless you shut the ward. You have got to think in those terms.

We have lots of examples where someone says they have reduced their bed days by a day, but actually it doesn't meant they can shut the ward and still maintain the same level of quality.

What we are trying to do it trying to help people make that big step. What are some really big things we can do to reduce length of stay safety, so that we can shut a ward? That is taking cash out and it is that shift – we haven't thought in that way before.

It will be the same for GP practices. There is this shift of care towards home, but what can they do about taking cash out of system,. It is really radically supporting people to take more care of their own condition – particularly those with long-term conditions – to avoid them coming in every three months.

Do people who are known by the GP and are very competent and able to manage their LTC for three months – why do they still have to go in every month to collect their prescription? It is about thinking of those sorts of things. Absolutely not everyone with a LTC is fully able, but 80% are. Let's know that we need to care for the 20% slightly differently, but lets make a radical shift with a lot of people that can and want to not go to the GP every month to collect their prescription. That is time for the receptionist – give them three or six months. We are then having an understanding of what would trigger them to go it. It is that sort of radical shift.

Are you working on these kinds of ideas to prepare the NHS for the impending financial situation?

We are doing lots of work, we are not particularly looking at that kind of work with GPs. We are looking around for some things on this, but most of our work gets commissioned by the DH and they are not specifically looking at that now. But they did ask us to do some work on patient experience in GP surgeries.

Steve Field from the RCGP said: ‘I want to do something different, innovative and I want to do it in a different way, can you help us?' We love that sort of thing. He wanted to look around access to GP services and we said let's look at that from a different pair of eyes – from the patients point of view. We do quite a lot of work with design companies and we got one to work with us and to get some insights from patients that we brought back to GPs with people from other industries, to really challenge people's thinking.

Steve Field and the DH were really enthusiastic and when we held the joint day and brought other industries in – we do quite a lot of that and it always works – it created some debate and not necessarily all agreement. But the value of hearing people from other industries, their insights and challenges, just shakes their thinking up. Typically if you have always been a nurse or a GP that is the way you think and part of our role and part of our role is to help people to think outside what we call ‘mental valleys'. You need to – because that is where your learning is – but when we are talking about innovation we say ‘OK, lets go to another valley and think differently about that.'

How do I be creative and how can I think differently? Part of that is at the start is what you need to do is absolutely think outside of your mental valleys. We draw on theory from Edward de Bono and making connections with other industries – looking outside and seeing what they are doing – is one of the big things that we are taking on.

Although it is taking off in the States more than here, I would love to see it here, but where they are taking the analogy of the drive-through from McDonalds and they are using it for flu jabs. There is a hospital in Seattle that is doing drive-through flu jabs and they have put a marquee outside the hospital and the physicians are writing this up as a proper study as it is just working fantastically.

It is this thing again – 20% of the population it is not suitable for – but the 80% you can get them through much more quickly and cheaply, with less issue than having people queuing up in doctors surgeries. Typically in healthcare we would not want to associate ourselves with McDonald's because the perception is that it is bad. But it is thinking about some of the high-level things. There has been some discussion about drive-throughs for district nurses when they want to drop off specimens or pick up supplies. They have to park their car and go down to the lab, but if there was some drive through drop off point then it would take them probably about half an hour per day. That might be the equivalent of two visits. Things that are normal in other industries that we could take and apply, but making sure that things we add to process add value to patients. Because a lot of them say ‘Why are you doing that?' and we say ‘Well, we thought you would like it.'

The BCBV prescribing indicators are one of the areas where I have heard the most complaints from GPs. They feel it restricts their freedom to prescribe. Can you address those concerns and update me on how this programme will develop in the future?

At the moment what is happening is that we are just at the stage of business planning our work for next year, so we are in a bit of limbo and we are waiting through he approval process. So cannot say what we will be doing,. But we will be focussing on how we can help the NHS to promote high quality and reduced cost, it might be prescribing, but it might not be.

The information that we put out is generally guidance. We are an arms-length body to the DH and we provide guidance – we don't provide policy. Our products are based on the best advice we think there is, given the particular situation. We are not mandating people. All of our advice, some people won't like. Even for the patient experience work people say ‘I haven't got time to speak with patients' or ‘I don't like it for this reason.'

Not everything will fit with every context. There might be a prescribing guidance that we put out that does not fit with a particular context for a GP. Or there might be some advice about patient experience or commissioning that doesn't fit. What we try to do is say, here are some high-level principles and guidance that we think provides good value at high cost. This is how we write it and we try to produce as many case studies for many contexts. It is offered with the best will, and try and take it with the best will.

Could you tell me about the work you are doing with NHS Choices to do with patient feedback on GP services?

Essentially we are looking at how we can support patients to access services based on their choice. That will be through lots and lots of different routes, including armchair involvement – ‘My choice is to be at home and be able to access services'. Or supporting people to make informed decisions.

There is this big thing that we give patients loads of information, but this doesn't necessarily enable them to make an informed decision. Working closely with patients to ask them ‘What information do you need to make that decision?' rather than what the healthcare professional thinks the patient needs. Sometimes they are entirely different. We are trying to work from the patient's perspective so that we can respond in the way that is most useful to them. Other wise we spend loads of money on giving people information in glossy leaflets that they don't use.

A recent survey from the King's Fund looked at the information that patients use before they chose what hospital they want to be referred to and it found that most relied on their own experience and the GPs advice, rather than NHS Choices.

Absolutely. We learnt such a lot of information from our patient experience work. One of the great things about that work is the concept of ‘co-design'.

Rather than patients telling us what they wanted and healthcare professionals going off and designing it, we worked much more in the way that designers do. ‘Will you work with us?'. Some don't want to, but some really do get involved to the point where the patients were writing the patient information. Patients who have actually gone through the system. They said that most of the information was technically correct, but it wasn't helpful and didn't help them make the right decision. In the end patients were rewriting the literature.

The more we really understand what people want – professionals say ‘I am a patient too'. But we see it from a different mental valley. I am a nurse and I have been in the healthcare service all my life and I might think I know what someone who is going through a cancer journey may want in terms of support from their GP. But I don't really know, because it is not happened to me. The best people to ask are that persona and their family. Not me.

For all of our activity on cost and quality as well. Patients do not want a gold-plated service – they want an efficient and safe service. There is a GP working on safety and together with GPs our safety team here have developed a trigger tool that helps spot safety incidents. It is the only on in the world developed for GPs. English GPs are at the very fore-front here. That in terms of cost and quality makes a massive difference.

We have done a few stories about the mismatch between hospital and GP prescribing. How the costs of hospital prescribing is increasing, while primary care costs are decreasing. It is a common complaint from GPs that their patients are discharged from hospital on a branded medicine and then they have to switch them to a generic. How can this be improved?

I mentioned before is that we don't form policy and we are not a regulator, but the way we would go about that is helping to demonstrate the waste of that cost in the system.

We haven't done a specific piece on the waste and prescribing in secondary care. That might be a good piece of work to do, because most secondary care organisations do have prescribing policies advising to use generic medications, but I am not sure how much they are audited in terms of whether they have a cost-benefit analysis against that. That would be a very interesting piece of work to be done. Looking at the whole care – prescribing in secondary care and its impact on primary care. That would be an interesting piece of work.

There has been a lot of focus on GP referrals – which have been rising quite a lot over the past year or so – and you have indicators on best practice for this. Do you think reducing referrals in this way is safe or will patients get missed?

I think we need to look at this and really see what the problem is. You can't have a blanket statement of reducing GP referrals. I know we have targets – and we have targets particularly around people with long term conditions spending less time in hospital – but what you have to do is take that blanket down to specifics. Who are the high users of that service? And clearly it is often those with respiratory conditions in winter. What is causing that emergency admissions? They often come through the emergency route, even thought they also have an elective referral, because they have got into such a state at home because they did not recognise the trigger at home at which they should do something about their exacerbation.

I don't like talking about things in a blanket way, because you have got to understand the problem and take it one step at a time. For people with respiratory conditions, it is slightly different to people with diabetes. There is redesign work and support work that can be done with both of those – and are being done – in terms of how do they understand their conditions and what triggers what might require a visit to the GP or a referral.

I think sometimes PCTs do just look at the numbers, instead of what you just said…

I think that is right. We would try to change that mind-set and say, there is a number but what is really underlying that. What does the percentage or a volume mean – lets look underneath the numbers. We should to be making major changes based on one parameter. We have got to understand what the problem is under that parameter, otherwise that is not good value because we might be creating a solution that is the wrong solution.

For example, reducing referrals and increasing emergency readmissions?

Yes. What we try to do is say: ‘Let's make sure that every redesign effort is valuable.' Sometimes that is quite difficult because people want instant change. It is like the hare and the tortoise, it might seem slower but in the longer-term if you really understand what the problem. Find some solutions, test some of them. Test them. Implement the best one and you are going to add value. But if you rush and not really understand what the problem is, create a change and you will have unintended consequences that will cost you more money and you will be going round the cycle again because you will not have solved the problem.

Part of what we try and help people do is to try and understand what the problem is. In all of our work with primary and secondary care that is the kind of ethos we try and teach,. In all our work with commissioners, we try to get you to understand what you are doing now, what the challenges are and think of a number of solutions – don't just jump to the first one. Because you will more than likely design something not fit for purpose.

My last question is getting back to what the remit of this interview is about. The financial, situation of the NHS is only going to get worse and there are inevitably going to be some cuts in services. How can GPs get control of those cuts, rather than have PCTs forcing it on them?

I think you have answered your own question in a way. GPs need to look at what they are doing. Where is good practice happening? They know some of the case studies on paper-less surgeries, nurse-led services that are high quality and lower cost, and lower-cost prescribing.

It is about sitting up and paying attention – they are doing that over there. It may not 100% fit completely with the context in our practice, but what can we take from there for our practice? I think GPs need to take control of their own destiny and not wait for somebody to tell them.

They should be looking around. And saying: ‘Who is doing really well, on referrals and things like that? How can we translate that for our practice?' Your practice is always different, but look at what others are doing because there are going to be some elements you can use. If they did that, then it is their change, rather than anyone else telling them. Across the whole of the health service there are islands of excellence, if only that could be adopted more widely then we can make a real difference.

It is about making sure that we are not creating unintended consequences that give poor value or a poor experience to patients. There will be somewhere that has reduced referrals without any unintended consequences. Looking for that good practice and thinking how we can implement that. Good practice will lead to higher quality and that will lead to lower cost.

Dr Lynne Maher Dr Lynne Maher

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