Don't let the glut of pilot projects distract from patient safety

Commenting on Simon Stevens’ speech at the NHS Confederation conference, Nigel Edwards, chief executive of the Nuffield Trust, says: “His call for a systematic approach to evaluating new models of care was welcome in a system that relies too heavily on small, fragmented and one-off pilots.”

‘Reflexively individuals resort to protecting professional interests under cost, performance and regulatory pressures’

I couldn’t agree more. I have visited dozens of acute hospitals and health economies to advise or to learn.

Everywhere I meet committed collaborative individuals striving to improve care for their local population – though reflexively resorting to protecting organisational or professional interests under cost, performance and regulatory pressures.

Spread like wildfire

As a physician, I have also noticed an epidemic of a disease I call “serial pilotitis”. This syndrome has a secondary complication leading to long term disability: “parallel projectitis”.

At my work – high volume services in adult emergency care and services for frail older people across whole systems – pilotitis has spread like wildfire and is doing a great deal of damage.

Everyone understands that there are some existential crises facing our health systems; an exponential growth in the number of people living with multiple long term conditions, frailty, disability or dementia, often compounded by poor mental health, social vulnerability and repeated episodes of acute illness.

‘Once in hospital, frail older people are the hardest to get back home again’

Even if we do engineer a radical shift towards prevention and self-care, they will still be there in big numbers. It is these folk who account for high spend and activity across primary care, intermediate care, acute and social care.

And once in hospital, they are also the hardest to get back home again. This in a country that already has a very low acute bed base compared to most of organisation for economic co-operation and development nations and hospitals running so close to full capacity that their efficiency is compromised.

In turn, service leaders are pursuing the holy grail of “admission prevention” to generate “savings” – for whom? – and are making projections to deliver this at scarcely credible pace and magnitude.

The more enlightened ones have realised there are bigger and quicker gains to be made by focusing on what happens when people do present to hospital. Early front door assessment, early supported discharge, patient flow and enhanced capacity and responsiveness at the back door into step-down services can deliver rapid reductions in length of stay and bed occupancy, despite the obsession with admission prevention as the only game in town.

Still, cashable savings across a whole system are hard to realise unless bed closures follow and community alternatives are actually cheaper.

The desperate quick fix

In desperation, we far too often set up quick fix pilots – with support from external consultants, non-recurring monies and often driven by winter pressures. Such pilots can be set up too fail.

When they don’t deliver benefits of scale and speed or bother to look at the evidence base, pilots are canned before heading onto the next venture, often with another consultancy firm. 

‘How can we stop the NHS having more pilots than Heathrow?’

Worse still, when the pilots do seem to deliver – I have seen elderly care short stay assessment units or community health/social care “in reach” working really well and fairly quickly to reduce length of stay, delays or readmissions – only to be terminated anyway because “the money has run out”.

Damned if you do deliver. Damned if you don’t.

As for “parallel projectitis”, in the wake of the pilots, much debris, some toxic, is left behind. This often goes into the “too difficult file” as building something new can be easier. So we end up with numerous teams all with different names, acronyms, access and accountabilities, all focusing on the same group of service users and aims around case and disease management, care coordination, admission prevention, rehabilitation, early supported discharge or delayed transfers. This is grossly inefficient and bewildering for professionals to navigate, let alone service users.

More pilots than Heathrow

So how can we stop the contagion before the epidemic becomes a pandemic and the NHS has more pilots than Heathrow?

Here’s my prescription:

• There is already lots of evidence out there about what works in peer-reviewed papers, systematic reviews and well described service models within UK systems. No need to keep reinventing wheels locally; just adopt and implement rather than “innovate”.
• There is lots of evidence about what can’t be delivered. Realistic expectation management is needed. Stop promising reductions in activity at a pace and magnitude dictated by how much tariff income you need to save and then be disappointed when the interventions “don’t work”.
• Wean yourselves off the addiction of external consultants with no real accountability for the impact of their advice before moving on. The NHS spends enough each year on consultancy to keep three medium sized district general hospitals going.
• The solutions already lie with existing healthcare staff delivering service transformation. The public sector needs to get better at helping public sector colleagues in other places. But whose job is it to oversee dissemination, adoption and implementation?
• Plan for the medium term. Sustainable service changes will take 3-5 years to deliver.
• All ministers should cease immediately the practice of eye catching gimmicky allocations of short term funded initiatives that provide the conditions for the pilotitis bug to thrive in.

To reduce the long term complications focus on integration. Every organisation in the locality needs to sign up to an overarching vision of how care should be delivered.

‘MPs should stop eye catching gimmicky allocations of short term funded initiatives that provide the conditions for the pilotitis bug to thrive in’

Sweep away duplication and complexity of multiple similar services with similar roles and numerous handoffs, left behind by the serial pilots.

Go for one access point to one set of wrap around services with one set of accountabilities for a population. More efficient, less confusing for everyone and more likely to deliver in the long run.

I have even been into the odd place where people have had the courage to cure the pilotitis and rehabilitate the patient. Lets take the same approach we did for TB: mass inoculation and effective cure for the whole population.

David Oliver is visiting fellow at the King’s Fund