Health Policy February 13, 2019
Using Learning Health Systems to drive place-based transformation

By News Feature - Accountable Care Journal

The keynote speech delivered by Sir Jim Mackey at the recent Manchester ACJ integrated care conference emphasised the need to fully engage people in building system-wide relationships to deliver integrated care.

A generational cultural change in bottom-up clinical leadership is needed if sustainable healthcare is to become a reality, writes John King and Dr David Paynton of Ethos Partnership.

Decision making is usually linear. A patient presents with a single problem, sees a care professional, a history is taken, an examination made and a diagnosis and treatment plan results. This process may have worked 70 years ago, but no longer.

The rise in people presenting with multiple conditions has added significantly to system complexity. Frailty, mental health problems and social isolation add further complications. Yet, decision making remains linear, top-down and disease or organisation specific.

At a population level, multiple care pathways organically develop as professionals try to navigate a chaotic system leading to siloed behaviour and workforce resistance. Without being organisationally patient-driven, the net effect is poorer outcomes and higher costs. However, cultural shifts are now emerging at the patient and population level.

Driving Change

New thinking and different ways of working are driving change. There is a shift from reactive to proactive care where those most in need are identified and then supported by subsequent care planning. Culture is also changing at a relationship level - in order to build on people’s own strengths to take greater control of their health and wellbeing.

At a population level, patient-centred approaches are becoming embedded in a range of new care models. Building community-wide relationships are a key driver of overall systems improvement.

Highly encouraging primary care driven transformation models are emerging, including the NAPC’s Primary Care Home programme, focused on c50,000 population groups. At the other end of the spectrum, some advanced STPs are now scaling these capabilities to create regionally based Integrated Care. A gap exists for new transformation tools, processes and evidence bases.

With some programmes now covering over 200 sites with regional solutions growing in parallel, these early successes have inevitably begged two questions. How to:

  1. Replicate these new capabilities from community to community - on a repeatable basis?
  2. Spread knowledge, continuous learning and best practice - regionally/nationally?

While major advances have been made in both patient and population intelligence, data analytics alone cannot overcome the inherent ‘human’ barriers to change. Current solutions focus on the organisation not place, activities not outcomes and transactions, not transformation. A backward, not forward-looking view is taken. Most worryingly, knowledge is locked up in individual organisations.

This population intelligence must be harnessed to support a far wider process of continuous planning, shared learning, adaptive behaviour and system improvement. In short, a Learning Health System.

Digital technology

Change is often quoted as 90 per cent culture and 10 per cent technology driven.

We believe a 10 per cent investment in digital technology can unlock the power of shared knowledge and continuous learning. System-wide cultural change can then be facilitated and accelerated through a radically new range of repeatable health community transformation capabilities.

Ethos use simulation to translate population intelligence and system-wide knowledge from multiple sources into digital prototypes of healthcare systems. Conceptually, these prototypes are constructed using generic accountable care principles. This approach supports effective management of health, social care and wellbeing of defined populations within a capitated fee structure. Practically, the underlying algorithms cover epidemiology, deep pathway expertise, clinical ontologies, new service model design, impact assessment and financial structures.

A local (NHS funded) Proof of Concept COPD solution has been developed, tested and substantially de-risked. Effective repeatability and scale up is now the next stage of our development roadmap.

The biggest benefits are at a system-wide behavioural change level.

What really excites clinicians and transformation professionals is the capability to use a risk-free test environment to make collective decisions which reflect the dynamic complexity of modern transformation programmes. Plans can then be based on the best evidence available but tested against ‘what works locally. ' I.e. real-world evidence based on collective experience at a community level.

Two previously unattainable goals become a reality:

  1. Securing community consensus and ownership on system-wide improvement plans.
  2. Continuously learning from each other’s success and changing behaviour over time.

Digital technology can embed these capabilities in easy-to-use, accessible software solutions. Cost-effectiveness directly results from digital scale up - locally, regionally and nationally. However, formal evaluations are required to assess how local communities can use Learning Health Systems to quickly and effectively build system-wide relationships to:

  • understand how dynamic system complexities can impact anticipated outcomes 
  • overcome cultural, organisational and incentivisation barriers 
  • manage system-wide costs and deliver required savings
  • manage risk and governance across traditional boundaries
  • scale-up capabilities and share knowledge more effectively 
  • build integrated and accountable care solutions at a regional level.

About the Authors 

Dr David Paynton- is a GP and the National Clinical Commissioning Lead for the Royal College of General Practitioners. He champions patient centred care - a change of approach that challenges some of the profession’s current focus on the biomedical model.

John King- is CEO of Ethos Partnership, who co-develop digital Learning Health Systems to enable place-based transformation. John has had a varied career in industry, consulting and academia. Latterly, he has worked exclusively in commercialising new knowledge-based businesses.

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