NHS efficiency savings are unsustainable

LBS expert: shared medical appointments could be part of the answer

Only one in four NHS trust leaders believe they can safely continue to deliver efficiency savings at the same rate, according to a report released today by NHS Providers, the membership organisation and trade association for the NHS hospital, mental health, community and ambulance services.

Could the roll-out of shared medical appointments be the answer?

That’s what the NHS is introducing as part of a 10-year plan announced at the Royal College of GPs conference on Friday. It follows trials at GP surgeries in London, Birmingham, Manchester, Sheffield, Newcastle and Berkshire.

Kamalini Ramdas, Deloitte Chair in Innovation & Entrepreneurship, LBS, is a long-time advocate of shared medical appointments and an international advisory board member of the network which has convinced senior NHS officials to adopt group consultations. The network, Shared Medical Appointments (SMA) UK, founded by now-retired GP Dr Rob Lawson, has championed not only the potential efficiency savings for the NHS, but also big benefits for patients.

Ramdas explains: “I first came across Shared Medical Appointments (SMAs) in the US in 2006. Few would know that the prestigious Cleveland Clinic in the US has used SMAs for over 15 years, for a variety of chronic ailments. This radically different form of care delivery has the potential to unleash tremendous value by simultaneously reducing costs and improving outcomes.

“Key to value creation is the idea that SMAs need not be an add-on; they can be a real substitute for individual consultations. Patients can receive one-to-one clinical attention, just in the presence of others with the same condition from whom they can also learn.”

Ramdas is working with Dr Fraser Birrell, a leading proponent of shared appointments, who runs group clinics in the North East. Birrell, Ramdas and other colleagues are co-authoring a number of influential papers on the potential of shared medical appointments to dramatically improve efficiency, reduce cost and waiting times for all NHS patients, not just those who choose to join shared appointments.

Birrell told the BBC this week: “The big trouble is we don't have enough nurses, we don't have enough doctors and waiting times are worse than we want. So this is one possible solution where if we see people together, we can offer them better care ... and we can see the people with chronic conditions more regularly."

Ramdas is working with healthcare systems in the UK, India and the US, to increase adoption of SMAs.

“In the medical profession, nothing is more convincing than rigorous, scientific evidence,” Ramdas explains.

It’s why she and co-authors Ryan Buell at HBS and LBS PhD student Nazli Sonmez are running a three-year, 1,000 patient trial of SMAs with the Aravind Eye Hospital in India. Preliminary results among glaucoma patients show improved patient knowledge, satisfaction and medical compliance. Seeing the same peers repeatedly makes patients more likely to attend follow-up appointments.

But, as Ramdas and Lord Darzi, former Parliamentary Undersecretary for Health, share in The New England Journal of Medicine, science is not enough. The right architecture is critical if shared medical appointments are to succeed and grow in the UK, as they have in some US hospitals.

“First, the experience has to be tailored to the specific medical setting,” Ramdas explains. “Quick, cheap and safe pilots are needed to figure out the right group size and format.”

The Aravind Eye Hospital first piloted counsellor rather than scarce physician-led shared appointments. When they saw the benefits of peer learning, they did Sunday pilots led by a physician to determine the format and group size. Then they tried out SMAs on their least busy weekday – Friday afternoon.

“After gaining experience through these low cost steps, they finally started a large-scale medical trial to establish scientific evidence,” Ramdas says.

Second, incentivising doctors is as important as incentivising patients, Ramdas explains.

“Some of the value created by SMAs should be shared with physicians. In the US, physician revenues often increase through shared appointments, as patients pay as much as for a one-to-one. Provided there is clear scientific evidence of benefits, health systems can make shared appointments the standard care pathway for certain ailments, giving doctors the ability to override this as needed.”

Third, “education is the cornerstone of changing customer behaviour; it’s no different in the NHS,” says Ramdas. A simple way to educate doctors or patients is to encourage them to observe an SMA.

Weaving SMAs into a hospital or clinic’s patient offerings requires careful planning, and Ramdas believes in starting small, “especially when it’s about people’s lives,” she says.

But if we are to have a healthcare system that can be truly sustainable, and safe, “we do have to make a start” she adds. “The rewards are real and the gains to our National Health Service could be substantial.”