In health care quality improvement circles, the story of England’s East Lancashire has taken on almost mythical status: working with county and borough councils, local hospital organizations, and medical leaders in primary and secondary care, an executive of the National Health System (NHS) managed to close a substantial number of hospital beds — all the while improving the health status of the community. It seemed that the community had found the holy grail of quality improvement: reducing costs, improving quality, and improving health.
Wanting to learn more about what East Lancashire had achieved, I interviewed two leaders of the endeavor, David Peat, a long-time executive of the NHS, and his colleague, Cath Galaska.
To understand what they achieved, Peat said, you have to understand the East Lancashire story, an area that includes about 500,000 residents. “It’s about cotton and coal, manufacturing, industry. Time had passed it by. There were multiple health needs. People lived short lives, they had high tobacco, alcohol and drug use, and high teen pregnancy rates. These alone are big issues to face,” Peat said. Things were made even more complex by the diversity of the community, which included many immigrants from South Asia and Eastern Europe.
The community recognized that continuing on its current path was not tenable: “They could forecast from the data that they had that they would have even more health problems.” Most telling was a reduction in life expectancy: estimates were that future generations would have a shorter life expectancy than the current generation. All of this was set against the backdrop of a crumbling infrastructure, with 19th century Victorian buildings that served as the hospital and as the community’s primary care centers.
Closing Hospital Beds While Building Up Primary Care
A first step, then, involved closing some hospital beds, a task that cannot be undertaken easily or quickly, Peat said. “You need to build relationships and infrastructure, you need to have evidence for what you want to do. Closing a hospital is very painful to the community and to the people doing it. People worry that it is the beginning of the end for their community.”
Ultimately, in East Lancashire, 120 beds were closed, leaving about 950 beds among the sites. Simultaneously, however, the Trust built better primary care and overtly aimed for better health outcomes. “We closed beds, but we were building new facilities beside them. Things that used to be done on an inpatient basis were converted to outpatient, including dermatology and orthopedics. We found that for diseases such as COPD, we could provide care in homes and in communities, rather than in hospitals.”
To this end, NHS leaders collaborated with “everyone in the community,” said Peat. “We started to build primary care clinics where general practitioners could practice. We built facilities for communities, offering nursing, physical therapy, midwifery, and so on.” At the same time, local government leadership worked toward regenerating the community, focusing resources on improving housing facilities and offering social care services.
Along the way, Peat and his colleagues worked closely with the community they aimed to serve — and learned some remarkable lessons as well. “For example, we found that for residents with sight impairments, it was hard for them to keep track of the stairs as they went up and down. So we put Braille numbers along the handrails so that people could count where they were.”
Stage One of the process, Peat explained, involved “putting something in place.” But it was not enough to just “start with an empty place and a building plaque. People get nervous. So Stage Two, which ran parallel to this process, involved primary community regeneration.” At that time, there were two large hospitals located 15 miles apart, with 4 smaller community hospitals in between. This situation led to issues of financial viability, said Peat, and cost pressures. There were problems recruiting a workforce to adequately and effectively staff the facilities.
Getting Politicians, Physicians, And The Public On Board
Peat and his colleagues worked with the local Members of Parliament and the local city council to “get politicians on board.” They also engaged physicians from all aspects of service, both hospital care and outpatient, working with them to understand the best arrangements that could be made to improve patient care and experience. Peat notes, “Clinicians presented the case in public meetings; the stethoscope trumps the suit or calculator in the public eye.” The team engaged the local university and began to study workforce development issues. Finally, they studied best practices nationally and began to design a service that would achieve similar results.
In the process, the leadership looked at what it had accomplished years earlier in transforming mental health services, a process that involved engaging other elements of the community, beyond traditional health care providers. “You have to enable change in your community. There are precedents for this kind of work, but you need a ringmaster who’s willing to do it. You have to make sure community resources are going to be there for people, and you need to create the bridge that will get people from using inpatient services to the community services they need,” said Peat.
In an endeavor that ultimately took 7 years to complete, Peat and his colleagues looked at East Lancashire community-by-community, assuring people that the new process would get people to care was that better — and get them there more quickly. One small hospital was closed, but outpatient and day services were enhanced on the main sites. Emergency services are now based on one site, and women, children, and maternity on another.
Transportation among sites became a key concern, both for patients and health care providers, in part because the latter sometimes worked at multiple sites. Peat’s team approached this problem on several fronts, providing funding for extra ambulances 24/7 to “maintain service quality with the extra distance involved [in getting to the hospital].” It also worked with local transportation authorities to cover the cost and availability of a bus for visitors, families, and non-emergency patients. “We recognized that our staff would need to travel between sites too, so we provided regular buses for staff to use, and for carers calling at hospital sites,” says Peat.
The leadership convened 18 separate meetings throughout the region and published a special newspaper supplement designed to explain to people what was being done. “The public accepted the clinical need for change,” said Peat. The endeavor, said Peat, “is all about maintaining eye-contact—about maintaining trust, and recognizing that although things might sometimes not go so well, or go your way, in the long run, you and your partners will all win.” As a native of Lancashire, Peat was able to communicate with the community and he made it obvious that the services he was changing were ones that his own family used. “And we communicated that we were doing this because it was the right thing to do.” It is not, he said, primarily about saving money or cutting costs—it is about improving quality and supporting better care.
Early reports indicate that the project achieved its primary goals: providing safer services, quicker treatment, and better coordination of hospital care, primary care, and social care. For some targets, the rates before and after the initiatives clearly improved, including:
- reducing hospital acquired infection rates;
- improving outcomes in cardiology (i.e., from 99 patients dying in a reporting period to 54 in the same period later);
- reducing post-discharge mortality (30 days post episode) from 123 deaths in the year before the program began, to 76 in the year following; and,
- experiencing no increase in complaints about treatment .
The program achieved a net savings of £8.6million (about $13million per year), primarily, Peat explains, “from improved prevention and primary care, higher productivity of clinical staff, and reduction in support facilities.”
None of this has been an easy task. Peat observes, “This was a complex, long-term change requiring stamina and vision to deliver on time and within budget. We established a dedicated program office working across organizations using business program management techniques to focus management attention on delivery and on unblocking or resolving potential crises.”