Dr. John SandhamTechnology is an enabler to improve productivity.


What does that mean? I think if you look at other industries, for example the car industry. Over the last 80 years they've been improving their technology to the degree where it makes it cheaper and more efficient to run production lines. Healthcare isn't like a car factory. You often hear people coming in and talking about lean methodologies and how lean methodologies can work in hospitals.

I don't agree with that approach myself. I believe lean methodology will work in a factory. I think that the average NHS hospital is far more complex than a factory, especially on the emergency side, different processes. Technology does impact on the whole of the healthcare economy.

 Technology spend

 

At the moment, the NHS spends approximately £4.6bn a year on technology, technology consumables, replacement of technology and that includes the IT infrastructures. There's been pressure on spend.

If you see the blue segment in the pie chart, that's technology spent. If I took that blue segment away completely, what would happen to the NHS hospitals? Well actually, they'd stop working because without the technology there is no hospital because modern healthcare requires the technology. If we're going to reduce the capital budget by £1.1bn, which was in the last budget statement, then you can see that that £4.6bn, which is already quite a small piece of the pie, is going to be shrinking not expanding.

 

What can we do about it?

I think as clinical engineers, it's our responsibility to make sure that we speak to the executive level at the Trust and make them aware of the impact that that small piece of the pie has on the rest of the pie. I've sat down with chief execs and directors of finance and drawn a circle and put a little line from the centre to the outside and said, "Okay, the spend might be small in comparison with the rest of your budget but actually it impacts on all areas of productivity."

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Well the Department of Health has given a cost management directive to reduce non-pay spend, so that's everything that doesn't relate to salaries of £900m. This is just one cost directive of many, one cost saving initiative of many. It's very scary to think that we, who are already under pressure with regard to staffing, with regard to trying to advise hospitals on what equipment, what IT to replace, are having more pressure on us to save money without taking a more holistic view of how our piece of the pie impacts on the rest of the pie.


Poorly implemented technology projects can lead to higher risks and higher costs.

 

There have been many examples of poorly implemented technology over the last 20 years. A lot of them IT projects and one most recently at Addenbrooke's, which resulted in an epic failure and the chief exec and the finance director resigning. The Chief Exec was actually a very good Chief Exec. It's a shame that the system led to his resignation but I think that there are reasons why technology projects fail. It's not just at Addenbrooke's, it happens across the NHS and then that puts people off investing in technology because they say, "Well you said if we invest in technology it's going to save us money," and it will if it's done properly.

There are plenty of examples where technology, when done properly, will deliver benefits. The danger with technology enabled improvements is that people and process aspects are overlooked in the enthusiasm to get the kit up and running. This was a statement from the NHS Institute for Innovation and Improvement from 2007, so quite a few years ago now. They laid out the way that technology improvements should happen.

Not only should we be finding the technology, we should be involving a number of different stakeholders from finance to procurement, to clinical engineering, nursing, doctors and make sure that the processes lead to the technology improvement. It doesn't mean that there's going to be a cost saving in technology per se but there has to be a benefit to the organisation. Investment can lead to a cost saving but not necessarily on that technology piece of the pie.

 

Step Down Care

 

One example of this could be step down care by using hospital hotels. This is not currently being done. There are hospital hotels. UCLH, I know David, at your hospital they do put patients in hotels to free up beds. It's not quite the concept that I want to talk about here, this is just an example. I want to challenge all of you, as Lord Carter has challenged us, to come up with solutions to allow patients to be stepped down, taken out of a hospital bed and put somewhere else.

I had a meeting with a guy called Steve Cenci, who is the managing director of Compass Healthcare in the UK. We sat down and we came up with this model for developing step down care facilities. Now, what does that mean? Well at any one time, there are about 15% of patients in the average acute hospital that don't really need to be there. They're there because they can't go home because Social Services won't have them in their houses or they're there because they need observation for 24 hours but actually, they are ready to be discharged.

They could be discharged into a step down facility.  The cost per room of a hospital hotel - so this is a modular build facility that lasts 30 to 50 years, that doesn't need planning permission. So if you're in a hospital where you've got spare ground or spare car park space, you can bring one of these in on the back of a lorry, bolt it together and away you go, you have a hotel. They can be very smart buildings.

They're all en suite rooms and they cost £75 per day, as opposed to an average hospital bed of £130 a day. They also don't require any nursing care. If you had the nursing care for an average hospital bed, you're talking £350 per day. If you go up in care levels to surgical wards and maybe high dependency unit, you can go up to £2,000 a day.

It depends on the patient but on these low risk patients, you can move them into a step down facility such as a hospital hotel. This has been done in Scandinavia since 1988. In the UK we've seen resistance to change but I think this is a technological facility in that each room would have things like Pulse Oximetry, BP machines, traditional ward based equipment that would be used by the patient not by a nurse.

The idea would be that that equipment, if they needed to monitor their blood pressure for 24 hours, they could do it themselves. They could be in a nice smart room, be comfortable. They could have hotel quality food and services. The readings that come from those devices can be pushed automatically into the patient administration system.

Now the benefit of that is you don't need a nurse to go and take the reading but if you notice, through the monitoring software that monitors the information coming into the patient administration system, that patient is deteriorating, you can send a nurse across the car park to the hospital hotel to go and look at that particular patient, or you can get the patient back into the hospital. Most of these patients don't need to come back in.

There's an immediate cost saving but unfortunately, it requires an investment. Guess what? There's no money to invest. So we have to think of different ways to do it. I've talked about connecting patients to the technology and then pushing that information into the system. That means nurses and doctors don't need to write it down. It also means that the information going into the system is correct.

 

Connected technology

By connecting technology, it changes the productivity balance and can result in less cancellations and less re-admissions. You can end up then with more treated patients per day.

Because devices are becoming much simpler to use, you can allow patients, with a little bit of training, to use these devices, not only to go into a step down hotel facility but also, potentially, to go home with the same technology.


Connectivity of technology

 

Connectivity of technology, we've been running a project at Harlow Hospital now for over two years. We've saved, or we've not saved necessarily, we've had over 10,000 additional bed days at a much cheaper rate.

The cost of having a hospital hotel is £75 per day. The cost of sending a patient home to their own home is £48 per week. You can see if you can send a patient directly home from hospital and have them cared for, these are acute patients cared for at home by themselves with some support from a district nurse or their GP or possibly even the A&E consultant when they need it, then it's a different model of care. Then it's more productive. Then it is technology enabled.


The other interesting thing with connecting technology is there are also new software platforms such as AI platforms, Artificial Intelligence. So what are the benefits of artificial intelligence? In the exhibition Hall, OBS Medical are there. They market the Visensia system, which is the system that's shown here. Now, the Visensia system was a system designed at Oxford University. It takes the readings - I was talking about the technology pushing information into the patient administration system, well you can take the information out of the patient administration system.


Artificial Intelligence

It comes from medical equipment, you can push it into an AI system to enable doctors and nurses to make their decisions more easily. It's a decision enabler. They still make the decision but they can see, "Do I need to get this patient that's currently at home, back into the hospital?" because what's happening there in that particular project is we've enabled the hospital to send patients home with technology.

Patients have come across from about 60 different conditions, so this could be COPD, where they need to monitor their pulse oximetry. It could be blood pressure, where they need to monitor their blood pressure. It could be both. Some people have co morbidities but you send them home and you say, "Take the reading yourself." Now the software can actually look at the reading, it can look at the settings, the alarm settings that have been set by the A&E consultant and it can say, "Is the patient within the settings? If they're within the settings, do nothing."

This is managing patients by exception. The traditional way to manage a patient is to put them in a bed and go and take their blood pressure every hour. The nurse, or the nursing auxiliary keeps going back, back, back, keeps getting the same reading, the patient is okay and eventually, after three days, you discharge them. In this model you send them home and you take the readings. If their readings get worse and worse, you bring them back in. You give them the medication, you send them home and they take their own readings. You lose the cost of the nurse.

You have the cost of the software and you have the cost of the technology but the overall cost is far less than the cost of having them in the hospital. It also frees up those hospital beds. I said we freed up 10,000 bed days, guess what, I mean the hospital didn't actually empty those 10,000 beds, it filled them but not with A&E patients, it filled them with elective patients and actually they get paid more for doing their elective surgery. It's revenue generating for the Trust.

They end up with more money to put in the coffers which helps them to balance the books. There's been a lot of talk in the press about cost savings but not a lot of talk about how do we improve the revenue situation of healthcare organisations, especially the NHS. One of the ways that we can do that is by making sure that elective work is done on time because there's a cost to not doing it. The normal reason why elective operations are cancelled isn't because of junior doctor strikes, it's because of that bed being needed for an emergency patient.

There's often a flux within an organisation to say, "Oh dear, we've had too many emergency patients come in this week which means we must cancel the elective operations." The knock-on effect of that could be an already chronic patient becoming acute and therefore ending up in A&E because they haven't had their elective procedure. The knock-on effect of that can be higher costs because of a patient's condition deteriorating and therefore them being in the healthcare system for a longer period of time than they would have been.

Actually, we, as technology experts, can help to deliver change within the system. I think AI is still relatively new and connectivity is still relatively new. I'm sure that Jarkko, who is going to be giving a presentation later, his company, we use his software Medixine software that connects to the medical equipment. The information pushes out of our devices into Jarkko's system. He'll be talking about that a bit later.
 

Changing current working practices

 

Unfortunately, one of the things that is difficult to do is to change working practices. When I go and speak to doctors, when I go and speak to executives, depending on who you speak to they see technology enabling productivity as a benefit or as the enemy. When I go and speak to a chief executive in a hospital, and I've done this on more than one occasion, or a finance director, they say, "This means we can change the skill mix. Instead of a doctor having to go and check the patient, we can have the software monitoring the patient and then have a nurse check it and then only call the doctor."

 

Productivity benefits

It's improving productivity but reducing the need for the doctors time and the nurses time. Some doctors and nurses see that as a threat to their positions. Some doctors and nurses believe that patients want the doctor or the nurse to go and touch them and take their blood pressure because there's that link between the doctor and the patient or the nurse and the patient.

As part of this piece of work we've been doing, there's a piece of research been going on in the background. We've done satisfaction surveys of the patients who have allowed themselves to become part of this pilot, which is now going to become a full on tendered process for that particular hospital. During the pilot, 99% of the patients were happy to go home, 99% of the families and friends were happy that they had gone home.

They recovered more quickly and there was zero cross infection, whereas the rate of cross infection in that trust was nearly 10%. Patients going into the hospital were actually getting infections in the hospital and having to stay in there longer. The length of stay for those patients also shrunk. Whereas we found that the average length of stay might be 4.5 days, the average length of stay for the patient cohorts was more like 7 days. Not only were they on the system for a shorter period of time, they recovered more quickly, 99% of the patients were happy with that service.

Out of those 10,000 bed days, I think there were only about 7 or 8 bed days where those patients had to go back into hospital and be looked after in hospital. The decision making process, the algorithms that were used by the consultants in A&E and the nurses in A&E were very effective in applying a technological solution. I think that it's our responsibility to understand that we don't just fix equipment. We need to understand technology.

It's a different paradigm to what it was when I started in this job 30 years ago. I used to just fix equipment. I was good at it and I was working on the bench. It's a different world. What organisations need now is they need somebody that can advise them how do we understand all of that technology that's out there, whether it's software, hardware, how do we use that technology for the benefit of patients? How do we use that technology for the benefit of productivity and reducing cost? There are lots of ways to do that.

Again, the investment question, the cost saving question, the investor save question is a big issue because I walk in to see finance directors and they say, "We haven't got any money." This happened at Harlow two years go. We said, "We will pay. You just pay us per patient." We had to invest in opening a contact centre, employing the staff, training the staff, getting the Medixine software, getting the OBS Visensia software, linking it altogether, investing in software programmes to actually create the bridges between the different types of software and the equipment, making sure that all the devices we used were open source, open architecture type software systems, which no doubt Jarkko might mention later.

I think all of these things are things that we need to understand when we're going back to our organisations and saying, "This is how technology can enable better productivity and therefore lower costs and more revenues." If you can reduce your costs and increase your revenues, that's got to be good for your organisations. No doubt you will all get promoted when you go and do that and have higher pay because they can afford it.

The benefits for patients are they can be more quickly diagnosed. They can be more quickly treated. If you have less patients in the hospital for example, you can see them more quickly, you can send them for diagnostic testing more quickly. Even if they are at home on technology that you've provided, which is connected technology, the software can indicate up to 24 hours in advance of when a nurse or a doctor might notice that there's a deterioration in that patient.

Whether it's giving them additional medicine or whether it's bringing them back into hospital, it can be an early warning. You've all, I'm sure, heard of different early warning systems, better for doctors because they're more efficient patient throughput and enabling them to use the latest, most productive technology, better for operators. A lot of the technology that's around now is safer. You can get better training.

If, when you buy equipment, you indicate that training must be provided by the suppliers, and I'm sure a lot of the suppliers next door do that, then you end up with a safer organisation. Also, you end up with a better use of time because you don't have nurses and doctors fiddling with equipment trying to figure out how to use it. Having connected technology also has some vertical integration. If you've got the same equipment in a general ward that is connected and you want to send a patient home, you can send them home with that equipment if you've got that system set up.

Vertical integration is to make sure that the whole system is able to talk right from the patient side into the intensive care unit. That's a difficult challenge. It's not something that we're going to do next year or within the next five years. It's probably something that we could achieve over the next 15 years but it's something that is strategic that you should be taking to your organisations.

 

 

The slides for this presentation may be downloaded here: http://www.ebme.co.uk/downloads/category/17-2016-seminar

 

 

 

 

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