Sources of Failure Demand in Healthcare
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This article gives a short introduction to failure demand and the sources of it in healthcare.
Improvement guru John Seddon describes failure demand as ‘The demand placed on the system, not as a result of delivering value to the ‘customer’, but due to failings within the system.’
In other words, and from my study and experience, in healthcare we are literally creating our own work – and frightening amounts of it. This is not work generated by patient need, but by our own response to that need.
The practical reality is that not only does this use precious resources, but it means in our improvement efforts often concentrate on the wrong thing. We often rely on making things more efficient (the general focus of most Quality Improvement initiatives) or asking even more discretionary effort from our staff – but what if we are making the wrong thing more efficient?
Understanding failure demand is all about questioning the work in the first place.
Root Causes of Failure Demand in Healthcare
Failure demand is not an individual issue. It is not about staff doing the wrong or right thing. It is about how the work has been designed e.g. how our systems, processes and organisations have been designed. I use the word ‘design’ deliberately, because the way things are now are a result of a set of decisions. The good news is that we can, if our leaders choose, make a different set of design decisions to radically transform the way we deliver care.
Fragmentation by Design
Anywhere where a patient is referred, or authorisation is sought, or part of a process / care is reliant on other services is a prime source of failure demand. Quite simply, important information falls between the cracks and confusion and delay is created when we pass responsibility for care between individuals, teams and organisations. Each individual team, staff group, department or service tends to concentrate on ‘its bit’ rather than view the whole. The result is individual departments can lower cost, while the total system cost increases. Of course, some referrals to specialist services (like a GP referring a patient to a hospital for an operation) are required, but in many, many cases these handoffs are not as a result of specialist service, but rather a result of deliberate design decisions.
The number of handoffs, driven by fragmentation, in patient care can be staggering, and for the service and the patient, really damaging. For example, in the space of just a few months a moderate to severely frail person can interact with tens of services and 100’s of different professionals. Each new service and professional requires a handoff and increases the likelihood of failure demand. It also means that the individual cost of interventions can be low, while the overall end-to-end cost can be staggering.
Why are there so many services and staff groups?
The bewildering number of organisations, departments, services and staff groups that make up our health services is a product of ideology. As W. Edwards Deming suggests in his Theory of Profound Knowledge it is often the Theory of Knowledge (ideology) of leaders that governs how services are designed. These ideologies are often unspoken and unrecognised as they are so normalised. We often just assume that this is how the organisational world works. In my days as a young manager I certainly assumed that services and organisations had to look a certain way (generally top down). The product of these dominant leadership ideologies is in the majority of cases fragmentation of our ability to respond to patient need.
The dominant ideologies and how they fragment services:
The professions such as GPs, consultants, nurses, midwives, accountants and managers all have strong individual identities. They often have their own professional bodies, their own standards for entry, their own view what their work should be and often protect their own interests. Some of this can be very useful, but in many cases this strong identity can be a source of failure demand. A closed view of ‘my work’ increases the number of other professionals that need to be involved in a patients care. Increasing the likelihood of failure demand.
Economic / Industrial
The influence of economic and industrial thinking has been profound on our health services. It is in the DNA of our NHS. Much of this thinking concentrates on reducing labour costs. This is achieved through division of labour and functional specification. This is the process of breaking work and job roles down into smaller chunks that can be simplified and specified. It means then someone lower skilled can do that piece of the work and / or we can specialise in a certain type of work. This leads to the notion of economies of scale. That if we can concentrate on fewer things and do more of them it will be cheaper. Perhaps this is the case in isolation, but not if it just creates cost elsewhere in the system. This all leads to a proliferation of departments, roles, staff groups and even outsourcing of some tasks and roles – increasing fragmentation.
Bureaucratic organisational design centres on the limiting of spans of control. It intends to limit change and maintain order, so you don’t lose control of an organisation. Almost every large institution, including the NHS, is based on these principles. A typical manifestation of this is the classic top down organisational structure. At the level of the work, it has led to the introduction of the professional manager, the separation of decision making from work and the increasing governance and specification of all work. It means that front line staff have to concentrate on their bit, as defined by someone else, and that bit only. It all increases fragmentation.
A note on integration and IT systems
Integration and new IT systems are often seen as the magic bullet for solving issues caused by fragmentation. We often invest in IT to join multiple staff groups and systems together – to reduce delays and stop information falling between the cracks. The fact is that these systems are massively complex and expensive. You would not need a complex IT system to cope with fragmented services if they were not fragmented in the first place.
Many services are integrating as a response to the fragmentation – to bring them under one roof. Unfortunately, in the majority of cases this tends to concentrate on pooled budgets co-location, co-contracting, co-location and single points of access. So the same list of job roles, teams, services and professional groups exist, just under the same banner. The fragmentation remains.
Continuing on the theme of ideologies, two further ideologies often create failure demand. In many cases through forcing managers and staff to act upon a short term view, rather than long term best interests of the service and patients.
Moral \ Ethical
Clinicians are often torn between doing no harm to a patient and doing what is in their best interests. Complicating this balance is the increasing workload and medical/legal pressure clinicians face. Picking up our example of frailty above, in some cases it is in the best interests of the patient to remain at home, but they are admitted because of the potential risk of harm (they may fall). This can in many cases lead to over-treatment, complications and of course increased handovers – all sources of failure demand.
Political ideologies come in all shapes and sizes, but there are dominant themes that lead to failure demand. Included in these are the push for short term results, often within the electoral cycle. This pressure for results can often lead to changes to organisations that may improve a specific process or service but, in fact, just moves the problem elsewhere. For example, meeting the A&E four-hour wait, but just moving the pressure to elsewhere in the hospital or to community services. Another theme that emerges is the drive for personal accountability – or some would say ‘someone to blame’. This forces leaders to look after their own interests rather than seeing the whole.
Generalist as Specialist
Perhaps driven by fear of litigation and staffing, many care decisions and interventions are deferred and referred for delivery by specialists and specialist centres. For example much of the pressure on Paediatric Intensive Care Unit (PICU) capacity is caused by cases being sent to them that could be cared for in local high dependency units (HDU). The Royal College of Paediatrics and Child Health state that on average 33% of all PICU bed days could be have been cared for in a an HDU
There are countless other examples. In primary care there is the notion that physical assessments must be done by a specialist or social care assessments cannot be done by healthcare workers. Or patients value a GP (a generalist clinician) who refers them to a specialist rather than managing their condition or presentation in the community.
Put simply, we frequently mix generalist work up (which still needs skill and a level of expertise) with genuinely specialist work. It increases fragmentation, as it requires larger number of different professionals and in the case of specialist centres, it drags patients unnecessarily away from their homes.
Social as Health
The social determinants of health dwarf the healthcare determinants of health. Most clinicians accept this, that generally a health and social response is required to help someone with most conditions. Yet our services are set up with an overwhelming bias to health. Of course it does depend on the condition. For example if a GP finds an indicator for cancer, then it is appropriate and desired to have a swift and hopefully effective response from the system. At least in the short term this will be health focused. But other conditions, such as diabetes, are much more dependent on a balanced mix of interventions – both health and social. It can often be social contextual pressure (life pressure) that undermines health advice and interventions.
Through a small-scale study I supported, GPs judged that 49% of patients were likely to be struggling in their context (severe social stressors) and 6% had a chaotic social context. In other words more than half of the patients seen were likely to have a life context that would deeply impact their ability to follow advice or make lifestyle changes. This dramatically limits the effectiveness of health dominant approaches to many conditions.
This dominant health focused design reduces options available to clinicians even if they identify a social need. It forces clinicians to treat the presentation rather than the underlying cause. Hence why we watch so many continue along a journey of declining wellbeing while we treat their individual presentations. Many of these individuals end up escalating in needs and complexity, requiring a hugely expensive intervention when we could have avoided it if we had the means of intervening earlier.
The so what?
This piece is all about raising the awareness of the implications of our design choices when we lead teams, organisations and systems. This is also pertinent as we find ourselves in a position where we have massive financial pressure and also continue to struggle to make lasting improvements. The problem may not be funding, it may that be we spend money on epic levels of failure demand rather than actual patient need – failure demand caused by our own deliberate design choices.
It is, of course, a balance. It depends on the work. For transactional bounded work, for example a common cancer intervention, then the current design may work. But for conditions and that are reliant on patient context and relationships, the current design severely limits our capability to respond to patient need.