Imagine what a primary care service might look like if we gave the patients the money and asked them to design it themselves. This was the story I heard recently at a presentation given by the Southcentral Foundation, a citizen-owned health-service provider based in Anchorage, Alaska.
The presentation was at a recent event in Cardiff looking at Southcentral Foundation’s Nuka system of primary care. It’s ‘A customer-owner driven overhaul of a bureaucratic system centrally controlled, to one in which the local people are in control.’ It is the use of this term customer-owner which is one of the most striking features of the Nuka system.
The idea of a patient as a customer might feel wrong in the context of the NHS, but in this case the term represented a shift from a service designed around a medical model to one where the patient’s needs were put first. The provocative question for us is, if we considered patients as customers would that improve the experience of being a patient in NHS Wales?
Under customer ownership, primary care was transformed into a value based system that was both modern and traditional; modern in its multi-disciplinary and integrated approach, but traditional in that it is centred on a patient having a strong and permanent relationship with a named GP, with a guarantee of same day access to see a doctor.
The results are remarkable. The time taken to book a routine appointment with a GP has fallen from four weeks to being seen on the same day. The primary care doctor and Quality Improvement Director, Dr Steve Tierney, said that opening up the doors to same day access did not cause the system to break. If anything the workload reduced.
Partly this is because primary care providers were freed up to manage the needs of the customer-owner, rather than trying to manage the appointments system. Doctors were able to address all the clinical needs of patients and ‘sort out the problem’. What used to take five appointments to sort out was now dealt with in two.
It’s thought-provoking stuff. If we opened up our doors in primary care to same day access, would we be swamped by demand? Or would we find that actually being able to sort out patients in one go would reduce the overall number of appointments?
Dr Tierney also said that all his patients had his mobile phone number and can text or email him with queries. This, again, reduced the demand for appointments. What difference would it make if people in Wales could get in touch with their GP without the need for a face-to-face consultation?
The knock on benefit of better management in primary care has been huge. There has been a 36 per cent reduction in hospital days, a 42 per cent reduction in Emergency Room and urgent care usage, and a 58 per cent reduction in the use of speciality clinics. (Read more here)
Nuka didn’t happen overnight. The health system we were learning about was the result of a 30-year process of revolution and evolution.
It began with a relentless focus on understanding the patient using surveys, listening exercises, meetings, engagement events and more. The speakers implied that they could guess what the answers would be before they asked the questions.
Being honest with ourselves, is it that we already know many of the issues patients might raise? Is it that we don’t quite know how to tackle them? In Nuka, patients and primary care worked together to find the answers.
In Southcentral Foundation there is an equally relentless focus on the use of data to provide knowledge about the care being provided. The speakers gleefully told us “we measure everything –we love data!” This became clear when we learned that there are currently 230 metrics used to measure the quality of primary care.
It challenged me to ask whether we value data in the same way? Do we know how we are doing? How are we measuring quality in primary care? All of South Central’s data points are outcome focussed, and centred on the patient rather than the organisation. There was a focus on developing coaching and behavioural management, and care began to focus on the person rather than the disease.
The development of localities and GP clusters is a key moment in the development of primary care in Wales, and gives us an opportunity to put some of these concepts into practice. It’s an opportunity we can’t afford to miss.
The Nuka experience shows us what can be achieved if we listen to patients and act upon what we hear.
So, if we gave the money to patients in Wales and asked them to redesign primary care, what would it look like?
Paul Gimson is the National Primary Care Manager for 1000 Lives Improvement
The Nuka system of care: Lessons for healthcare redesign in Wales was an event in Cardiff and St Asaph organised by 1000 Lives Improvement, Welsh Government and the Patient Safety & Healthcare Quality Registered Research Group at Cardiff University. Resources from the event and workshops are available here.