The vital few who need system redesign

Every clinician has a small number of patients who they see very regularly and who account for a significant amount of their workload. Some have an acute episode needing intensive treatment, some have complex conditions, and some have been failed by the system.

Work that we have recently undertaken has shown that just 1% of the population (5% of those attending or admitted to a hospital) are responsible for over 30% of the activity, cost, and performance deficit.
But analysis has shown a few surprises. Half of these patients are under 65 and 10% are under 18. This high user group has a high turnover, with only 20% remaining in the high user group in the subsequent year. Of the superusers of Emergency Department, the mortality is over 30%. The number of individuals accounting for emergency workload has only had a small increase in the last few years; the activity increase is mostly due to more attendances per individual.

There are many examples of high frequency user programs. They mostly use case management to manage the extremely high volume users (the top 0.5% of hospital users). They often claim success because service usage is reduced in the next year, but is this due to the high turnover of the group rather than any intervention?

To address the problems of the top 5%, don’t we need a new approach that detects them earlier, not after they have had a year of high service usage, and looks at how the system has failed these individuals not just manage the system for that individual. Predictive analytics may be able to accurately forecast which individuals will join this vital few next year with sufficient specificity and sensitivity to target interventions at a very early stage of their health deterioration.

System redesign may mean they are cared for more effectively. We still design hospital care around specialties that presume most patients have a single condition. Some patients attend a multidisciplinary clinic and at least have one visit rather than several and have more coordinated care. But they still see multiple consultants, a more radical solution would be to train our future clinicians around cohorts of conditions that commonly occur together rather by organ/body system.

Design the system around the patient not fit the patient to the system.

System redesign could reduce the vital few numbers in to the future, case management solves the problem for one patient.

Hospitals need to analyse their data from an individual patient perspective rather than activity based and work to predict the small group who will become next year’s high volume users.

I’d be sharing more such insightful topics in my upcoming blogs. Meanwhile, do reach out to me for more information or feel free to share your views on this!

Matthew Cooke

Expert in Healthcare

Working at CapgeminUK to develop digitally enhanced healthcare supporting more care in less intensive environments, improved initial clinical assessment systems and improved patient flow through health and social care system.
My background is as an emergency physician who has also been the National Clinical Director for emergency care in the NHS England and is a Professor of clinical systems design.
I am bringing expertise from a clinician perspective to our healthcare projects, as well as an in depth understanding of health policy and how the NHS works.