Training for population and personalised healthcare

This is the ninth article in our series on population healthcare

It has been said that the NHS is overeducated and undertrained. What is meant by this is that we spend a very large amount of money educating people at the beginning of their careers but relatively small amounts of money for the next 40 years. But it is more than this. It is not just the balance between initial investment and continuing investment – it is the nature of that investment. There is an important distinction between education and training.

Education helps people learn how to think, how to grow and develop and how to analyse problems, and it is therefore vitally important for everyone working in the most complex business on earth – namely healthcare. Training is a different function: it gives people the skills, concepts and sometimes behaviours needed to carry out a particular task or a policy. The epitome of an organisation that focuses on training as well as education is the military, encompassing all three of the services. They expect people to be well educated, but when a new policy or technology is introduced, everyone has to go for training, and that means everyone. The same applies in industry, and people who have met pharma industry staff will know that when a new drug is introduced everyone must go on the training course to learn about the new drug, not just those who will be directly involved. The importance of this is reinforced by the behaviour of senior management in industry. If someone does not attend the training because they are high up in the leadership team and does not see what a new drug has to do with them, then they will probably be reported to the chief executive; they will possibly have their pay affected and they will certainly be seen as someone who is not ‘one of us’ and therefore would be on their way out of the company.

In the military, new technology as well as new concepts stimulate the need for training. There is no way that the military would have sought to do something like commissioning without a comprehensive plan for training everyone who needed to know, and that means everyone. They would have included every clinician involved in commissioning, even the GPs only working one or two sessions a week, as well as everyone above a certain grade in the commissioning organisation. The training would be accompanied by the introduction of a new doctrine and people would have to learn the new doctrine, namely the meaning of the new concepts and they would probably practise the new skills before returning to their units.

Simulation has been adopted now in the clinical arena, for example as a means of improving patient safety, but we surely have just as great a need in management, policy and commissioning. How else can people learn to apply the skills they have been taught and to find out how their colleagues would operate under pressure. In a typical organisation responsible for commissioning and managing resources, some people are at the utilitarian end of the spectrum; others see themselves as champions of people with uncommon and rare conditions; and yet others might position themselves in the middle of the road, but are these different perspectives every admitted, discussed or harmonised? Very rarely.

In developing population healthcare, we need excellent leadership but we also need training. Set out below are the ten skills and domains that are needed for each of the skills which are required and, a key principle, the actions of people being expected to carry out once they have had their training focused on the three new tasks:

Increasing personal value by ensuring that by providing people with full information about the risks and benefits of the intervention being offered;

Increasing value for the population by shifting resource from budgets where there is evidence of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity;

Increasing value for the population of developing population-based systems that:

address the needs of all the people in need, with the specialist service seeing those who would benefit most;

increase rates of higher value intervention (underuse) funded by reduced spending on lower value intervention (overuse), e.g. shift resources from treatment to prevention or polypharmacy to district nursing;

implement high value innovation (underuse) funded by reduced spending on lower value intervention (overuse).

Sustainability

The term sustainability can be considered a narrow definition focused on environmental sustainability or the carbon footprint of the NHS, although this is not enough to form a major topic for debate. The term sustainability also has implications of the future. The leadership team needs to understand these issues and decide which definitions of sustainability it wishes to use.

The concept of stewardship is related and a shorter definition of stewardship is shown below:

‘Stewardship is to hold something in trust for another.’

Source: Block. ¹

It is not inappropriate to encourage staff to think about sustainability in the environmental sense because many frontline staff are not motivated by the fact that their organisation is in financial difficulty, whereas many are motivated by thinking about waste in an environmental context and taking action to reduce the carbon footprint for the service which will also have financial benefits.

Ten skills

Achieving triple value

It is safe to assume that everyone in a group or a service will have different meanings of the word ‘value’. It is important to emphasise that this is probably also the case for terms that have been in use for a long time, terms such as quality and safety, but in developing the new paradigm at speed it will be essential for everyone in the organisation to understand a basic set of definitions. People at senior management leadership positions need to be able to speak about these concepts with a deeper understanding with the majority of staff being provided with a glossary of key terms.

New skills

New actions

• The difference between the economic and moral meanings of the word value  • The relationship between quality improvement and value improvement  • How those who allocate resources can maximise value, either by the process of allocation or by the way in which they handle innovation and disinvestment  • How allocation decisions can be made not only between programmes but also within programmes and even within the systems budget of resources available for a people with a specific disease  • The meanings of allocative, technical and personal value

• Review the allocation of resources between the different programmes serving your population and identify opportunities for meeting unmet need by switching resources from one programme in which there is evidence of overuse and lower value activity to a programme in which there is unmet need and inequity  • Within each programme, review the allocation of resources to different systems, for example within the respiratory programme, review the allocation of resources, both financially and others, to the system for people with asthma, the system for people with COPD, the system for people with sleep apnoea and the system for people with idiopathic pulmonary fibrosis. Decide upon a scope to meet unmet need by switching resources from a system in which there appears to be overuse of lower value interventions

COPD: chronic obstructive pulmonary disease.

Minimising waste and increasing sustainability

As we have emphasized it is often appropriate to engage staff in discussion about the carbon footprint when an organization is in financial difficulty because it will motivate some staff who are on different about financial problems. Reducing the carbon footprint often reduces financial cost also. The term sustainability is also important to use in both the sense of ensuring the sustainability of the NHS and the sustainability of our life on earth and examples of the broader definition are given below

the integration of environmental, social, political and economic considerations and impacts within decision-making. It also includes notions of social justice and equity. Plans and decisions should meet the needs of the present without compromising the ability of future generations to meet their needs ² .

Source: Griffths J and Stewart L. ²

Living on the earth’s income rather than eroding its capital. It means keeping the consumption of renewable resources within the limits of their replenishment. It means handling down to successive generations not only man-made wealth but also natural wealth, such as clean and adequate water supplies, good arable land, a wealth of wildlife and ample forests.

Source: Brady AKO. ³

There are now many steps that can be taken to reduce the carbon footprint of the NHS developed by the Centre for Sustainable Healthcare in Oxford and the Sustainable Development Unit in Cambridge.

New knowledge and skills

New actions

• The three steps that can be taken in health services to reduce cost  • The difference between technical value, efficiency and productivity  • Identifying the waste of resources from over-diagnosis and over-treatment  • The meaning of the term ‘sustainable development'  • The meaning of the term ‘stewardship’  • The way in which clinical teams can be motivated to take action on sustainability within a health service

• Conduct a review on staff and patient mileage and identify ways in which it can be reduced  • Run a workshop on waste using the checklist provided and identify opportunities for reducing waste  • Produce a sustainability plan for the service for which you are responsible

Designing and delivering population healthcare

It is important to distinguish the skills of population healthcare and the skills of health service management. It is essential that individuals manage services well where the patients are referred or refer themselves, but this is different from a feeling of responsibility for the population and the actions that need to be taken to identify and reduce unmet need. Public health professionals are being given many of the key skills, but the term ‘public health’ does not engage every clinician, so it is probably best not to present these skills as public health skills, but to use the skills of local public health professionals to help people change the way they think. The best focus for this training is to identify someone from every team to have responsibility for leading the work relating to the population.

New knowledge and skills

New actions

• The changing responsibility of the clinician in an era in which healthcare is funded by the whole population and not just by the patients who consult doctors  • The dual responsibility for clinicians who manage services  • The new responsibility of the clinician to and for the whole population and the actions they need to take to discharge that responsibility

• Be clear about which population you are actually serving, probably building up the population from the general practices for primary care teams that refer to a specialist service rather than relying on the boundaries of jurisdictions that are drawn up politically  • Identify similar populations to your own for comparison and shared learning  • Ensure that one clinician clearly has population responsibility in their job description and makes estimates of the numbers of people in the population with the relevant conditions

Developing population-based systems

It is useful to focus on systems and networks together. The simplest definition of a system is that it is a set of activities with a common set of objectives.

New knowledge and skills	New actions
• How the objectives for a system differ from the aim of a system  • The way in which objectives can be set  • The different types of criteria and standards  • How the 20th century was the century of the institution; the 21st century is the century of the system	• Identify three major sub-groups of the population for which a population-based system would be appropriate  • Organise a workshop including the circulation of any relevant national guidelines and set clear objectives for the system  • For each objective agree one or more criteria that can be used to measure progress or the lack of it

Creating and leading networks

A network is a set of organisations that deliver the systems. There is a glowing literature about working in networks, for example a book on connectedness by Nicholas Christakis and James Fowler is helpful and the key text suggests that:

Social networks also have a memory of their own structure (staying intact even if people come and go) and their own function (preserving a culture even when people come and go). For example, if you join a trusting network of people, you benefit from that trust and are shaped by it. In many cases, it is not just that the people in your network are more trusting, or even that their trusting behaviour engenders trust in you; rather, the network facilitates this trust and changes the way individuals behave. ⁴

New knowledge and skills

New actions

• The difference between a network and a hierarchy  • The relative contributions of institutions and systems  • How to build a network  • How to sustain and develop a network  • The contribution that networks make to delivering systems of care

• Identify all the key professional groups and patient and carer organisations that need to be involved  • Identify someone to be the network coordinator, probably the person identified as the individual with time explicit reserved for population healthcare  • Organise a meeting for the network to receive the draft system specification and agree the date of the first annual report to be produced for the network to discuss and compare with the service delivered with other networks serving similar populations

Seeing the right patients and mitigating inequity

Inequity is different from inequality. For example, there is inequality in the allocation of resources because people with severe health problems receive more healthcare and use more resources than people with mild self-limiting health problems. The allocation of resources is unequal, although it uses an example of inequity.

Inequity has concepts of unfairness. The inverse care law was invented by Julian Tudor Hart and he pointed out that often the amount and quality and care provided was inadvertently related to the need in the population served.

It is useful to consider four dimensions of inequity in training:

Inequity related to age: is there under-treatment of older people?

Gender: are there treatments which women are not given, although there is evidence that they benefit just as much as men?

Social class: best identified by relating referral patterns to the deprivation measures of the ward being served;

Ethnic group: are there culture or linguistic problems that mean there are certain ethical groups who are not receiving care in a way that is unfair?

New knowledge and skills

New actions

• How the concepts of equity and social justice are related  • Developing the skills for practise of population medicine and population nursing  • How to explain the term ‘equity' and in what ways it differs from equality  • How to explore the issue of equity, the Inverse Care Law and unmet need in your service

• Conduct a review of the people referred to a specialist service, mapping different rates of referral and parts of the population served  • Conduct an audit of unmet need and prepare low rates of use of specialist services with the social class of the part of the population in which underserved communities live to identify inequity  • Produce clear guidance for referral, including guidance on inappropriate referral and ensure all new professionals to the population receive it within one month of arrival

Engaging people in need

New knowledge and skills	New actions
• The importance of engagement of people in need and carers in service design and delivery  • How engagement can inform the debate about resource allocation and resource constraints  • How individuals can be helped to make decisions that conform with their preferences and values	• Identify key decisions that individuals have to make and ensure that they are helped to understand the risks and benefits of the decision and given the opportunity to reflect on their values by introducing shared decision-making and patient decision aids

Managing knowledge

The key to developing knowledge management skills is to set up a small group comprising a librarian, someone responsible for analysis or a communicator or data and public health professionals. These people all have specialist skills about different types of knowledge and can plan not only training but also a knowledge service that will help them while they work.

New knowledge and skills	New actions
• The difference between tacit and explicit knowledge  • The role and responsibilities of the Chief Knowledge Officer  • How to realise the potential of librarians  • How knowledge from experience can be harnessed  • How to find appraise and act on best current evidence	• Identify a librarian and develop a knowledge management service  • Agree and implement a communication strategy  • Plan and produce and annual report  • Identify one person on the network co-ordinating groups to act as Chief Knowledge Officer

Promoting health and preventing disease

New knowledge and skills

New actions

• Understanding why every health service must play a part in disease prevention  • Understanding how hospital health services can contribute to improving health  • Whether the clinician practising population medicine or population nursing has a responsibility for advocacy on behalf of the population's health

• Make sure there is a smoking cessation service for all people using the health service with reinforcement of the message they attend  • Promote activity and prescribe activity therapy for everyone with a long-term condition including those people who have not been referred to any specialist service by ensuring that all general practitioners, other clinical staff and primary care understand the importance of activity therapy and how to prescribe and dispense it

Leading the transformation and creating the right culture

Many of the writers on leadership agree that the key distinction between leadership and management is that leadership creates the right culture whereas management works within the culture created.

New knowledge and skills

New actions

• How to appraise an organisational culture  • The part that language plays in shaping and changing culture  • How to assess the culture of an organisation

• Agree the key features of the culture that you wish everyone to adopt and write a statement of principles  • Agree which terms need to be used in a standardised way and prepare a Glossary of Key Terms  • Do a review of culture, including an analysis of publicly produced and available websites, an inspection of buildings and facilities to identify artefacts and signs that might indicate what was written was not transformed into reality  • Ask some outsiders from the similar service serving a different population to come and do some interviews and discussions with key staff and service users to see if these informants provide information about the culture that is aligned with the view of the leadership

Public Health professionals’ contribution

It could be argued that many of the skills and principles of population healthcare are simply the application of public health principles to the delivery of health services as opposed to using public health skills to prevent disease, promote health and mitigate inequity. The term ‘population healthcare’ and the related term ‘population medicine’ were, however, chosen because of the resistance of many clinicians to be encouraged to work like public health professionals. There is still a social class hierarchy in medicine with public health, at least until very recently being seen in the lower classes intellectually and socially. However, public health professionals are increasingly playing a part in working with colleagues, paying for and managing health services to get them to think of population healthcare and the needs of the whole population, rather than simply meeting the needs of the patients referred to them.

Thinking digital

Pervading all of this transformation is an appreciation of the principle that healthcare, needs to be transformed from its focus on the institutions that have served us reasonably well in the past to systems and networks that will help as adapt the complex needs of a population and the individuals within it. Digital developments both enable and drive this change, and of course as Manuel Castells emphasises in his trilogy on the Network Society ⁵ in which he describes how the third industrial revolution, after the revolutions of steam and high technology, is being driven by three forces – citizens, knowledge and the Internet.

A network is a set of interconnected nodes. A node is a point where the network intersects itself. A network has no centre, just nodes. Nodes may be of varying relevance to the network. A network is defined by the programme that assign the network its goals and rules of performance. The program is made up of codes that include the valuation of performance and criteria for success or failure. ⁵

His thesis is equally important and relevant to people working in healthcare and it can be argued that the smartphone is more effective than the genome in disrupting healthcare as we know it, from the consultation to the management of resources.

There are skills required for digital healthcare, but it is better to think of the change needed as a cultural change because digital resources can enable any clinical or managerial activity. What is needed as well as a formal training programme is a group of enthusiasts in every population healthcare organisation, the Accountable Care System, for example, that promotes and enables the transformation to population and personalisation by realising the potential offered by the Internet, to use an old-fashioned term.