Its been a while.

If you have followed the various trains of thought on my blog you will know that I'm looking to make a difference to the care of patients in the system we call the NHS. 

I've not given up looking, but now the time has come to make some changes. 

My practice has embarked on a new model of general practice. We had to, we had no choice. General Practice UK has been a model which was once everything that was required by the population. Free access to a resource that was valued by the population and used only when needed. 

Although the NHS is valued as a brand, years of prodding and media bait have reduced value in General Practice to a position of under investment and increasing demand. Average yearly consultation rates have gone from 2.5 to 6 per annum and money has decreased. 

Our partnership has a big ambition, to generate the value and ownership required from the local population in a way that means the relationship shifts from a professional/ customer relationship to a partnership of care. 

Now, I know that such is the way of the NHS that multiple colleagues will now say "but we always engage our patients in decisions"  and "we've been doing it for years" and they may be right, in their own way but our system is changing in ways which are unique to us. 

Do the basics

If you've checked out my linkspage you will know I'm a fan of TED.com, recently listening to a talk by Abraham Verghese on the importance of touch as examination, ritual and therapy I was reminded of another passion of mine which has consumed weekends in the last month- rugby.

The good Doctors call to arms was to treat patients well, to treat them as people, to use touch rather than data as the means to interface with a patient. He gave the case of a woman with breast cancer who had four opportunities go by before someone took the opportunity to do a physical exam and found the tumours.

What has this to do with Rugby?

Well, the English team has left the world cup, only Wales remains of the home nations. How can this be? What was their secret?

In both diagnosis and sport there are certain set pieces, certain formalities which comprise the basis, the essentials of the craft. For both Dr verghese and Wales the secret of success is simple:

Do the basics well

If the basics are all present be it , kick off, line out, ruck, scrum or, introduction, history, examination, explanation and treatment then what follows will be a firm foundation for a successful performance.

It's not a rocket science insight, but given the plethora of discharge letters without a given diagnosis, or the patients perception that they were told nothing about their diagnosis perhaps is is time to make sure we do simply "get the basics right"

Buy, Make or Partner?

One of the issues that seems to be hindering the NHS is the belief that the structures currently in place, both organisational and financial, are preventing the creation of a collaborative, patient centred system which offers the chance to deliver improved quality with improved productivity.
Granted we can argue that every organisation has a responsibility to achieve financial balance. However it is not the only requirement on NHS organisations. The real duty of every organisation is to deliver the best it can for it's customers, be they stakeholders, shareholders, paying clients or non fee paying service users.
The NHS has two blind spots, one is the payors, this Americanism translates to the commissioners, and the other is the service user, in our case the patients. Hospitals, practices, community trusts all forget that they have payors, commissioners who have an expectation of value and performance and instead focus on being the best organisation that they can. Although I don't believe we have a total blind spot for patients we often don't accord them the true status of customers, i.e having choice, power or purchase and a right to expect good service.

Is there a fix for this dichotomy, good organisation and good patient service?

The answer I believe is almost certainly, yes.

Commercial organisations can deliver financial success, efficiency and value. They also deliver customer focus and survive in harsh competitive environments. In that world view it seems obvious that competition is the answer to the NHS.

However if a commercial provider wanted to be the best it could, deliver most value it would also seek to expand it's market, it's influence. Examples such as Facebook, show a service provider who is now partnering with Spotify and other media providers to improve the range of services and value to it's users. Amazon achieved similar benefits when it bought out Audible to enable customers to choose printed, e-book and audio versions of it's products.

So it would seem that acquisition, alliance and collaboration is also the answer.

In the new NHS we now need an understanding of when to choose collaboration, competition or merger as the right blade on the NHS Swiss army knife.

Innovation or Novelty?

It’s a tough call commissioning new care processes.

Do you do the same as usual but faster? Do you do something different, by definition an untried process .

Doing something different is often described as an innovation, but is it really innovative?

A new contract to an existing supplier which is accomplished by the supplier in its current form is not innovation. It may have the novelty of newness, the frissant of freshness, but if the provider is just doing more of what it is set up to do, then there is no innovation. More of the same does not change the landscape and although novelty is amusing for  a while it soon fades and the system returns to normal.

Setting out to commission something which requires existing suppliers to change their processes and structures or which can only be fulfilled by a new provider is innovation. Beware that all existing pressures in our complex adaptive health system will attempt to force the new initiative into a shape that neuters the effect of innovation, so the emergent commissioning decision will need to be protected and steered to produce an innovation solution.

Why bother about innovation?

It is the nature of healthcare systems to be complex and adaptive. These systems want to revert to their current attractor state and the only way to move the system is a significant disruption. If you’re not ready to break it- and we’re not quite there yet with healthcare, the next best thing, possibly the best thing, is to innovate.

Go ahead, give it a try, but not as a novelty item.

Shift your paradigm please, I'm trying to get home.

What would happen if we discharged people from primary care to hospital and readmitted them back to primary care?
Just take a moment to consider what that simple shift in thinking would mean.
Yes the discharging practitioner would need to prepare the patient for their brief exit from the wrap around support of primary care, but also it would not be possible for patients to slip out of primary care and in to the hospital without it being sanctioned by a primary care physician.
Similarly on readmission to primary care the appropriate information would need to flow but the decision about readmission to primary care would again be controlled by the primary care physician.
I know some of us will argue that that's how it already is- but ask yourself honestly- do primary care physicians get consulted or have knowledge a priori of admission?
What would happen if we worked like this? I suspect reassurance that Mabel is always like that, and "yes, I'll see her in the morning" might, in many cases, prevent Mabel entering the hospital walls.

In a similar way when it came to the return of Mabel to primary care, her re-admission as it were, the checks on availability of a primary care bed, the required systems, and of course the information, would ensure that Mabel was not admitted to primary care unnecessarily and that since her readmission would be the default, the Hospital would need to find daily justification to keep the patient.

Perhaps Primary care physicians would like to consider doing the ward rounds in the hospital in order to decide who must stay behind in secondary care and who can leave to be readmitted into primary care.

If we all adopted this simple mind shift I'm sure less people would end up in hospital, they would spend less time in hospital and ultimately remain longer where they wish to be- at home in primary care

Go with the Flow

It's interesting looking at how other professionals work to see if there's something we can adopt in medicine. This last month or so I've been interested in Flow. It all started with the golf, a young player nails the first round, leads the board but next time around he's hopeless- the yips have struck.

Equally in snooker, darts, chess, whatever there are moments when the players are so "in the moment" that for them the game is over in seconds, their performance is faultless, the result dramatic.

This state of "Flow" is something we should be able to promote in medicine. At the very least we should be able to redesign our environments to promote the chances of us being able to deliver an optimal experience.

Here are  a few suggestions to be going on with:

• Prevent interruptions when focus is needed- do not disturb rules.
• Promote an environment which facilitates relaxation
• DO ONE TASK AT A TIME
• Turn off e-mail notification, mobile phones etc.
• Plan the session to reduce breaks in flow- prepare papers, tools etc.

I'm sure there are dozens of other ways we can go with the flow, I'll keep looking and let you know.

Why do we do what we do, when we can be so much more?

I know it sounds like a lyric from Gerry and the Pacemakers but I was thinking about motivation this week.

Daniel Pink in his excellent book "Drive" outlines some of the science behind motivation and draws some lessons for how we manage and motivate. I must admit his work did resonate with some facets of how medicine is currently configured.

No medic starts out with the ambition of being mediocre, avaricious or dangerous, yet some of us become exactly that. Extrapolating the theories outlined in Drive in to the current NHS it would seem that many doctors, regardless of area of practice, are being subjected to rewards based on action which saps their intrinsic drive, their willingness to just be the best they can be, and replaces it with a financial focus on activity.

I would argue that this applies equally to GPs in carrying out QOF and hospital doctors in warning of "destabilisation" if activity levels change in outpatients.

How then can we take the lessons of "Drive" and apply them to the NHS?
Developing a payment mechanism that remunerates fairly without some form of performance measurement is pure fantasy in our current structures.
If however we were able to reward systems that perform well, with all parties in each health economy receiving some benefit for their innovation, economies and creativity, then we might find ourselves in a virtuous circle.

This circle would see patients, primary and secondary care all looking out for each other, offering challenge to unhelpful behaviour and being part of a system that strives for excellence, driven by the intrinsic motivation in each of us.

Simply put-the reward is being the right thing, not doing the right thing.

Transforming the Horse and Cart

Part of the problem in healthcare is that we don’t actively seek transformational change. We focus on being better, being safer and just working darn harder to get results. Unfortunately building a better horse and cart has inherent limitations.

Sport illustrates this quite nicely, the high jump in the early days of the Olympics was a standing jump, which became a scissor jump after a run up. Of course performance increased, and thanks to occasional falls a mat was introduced to prevent injury.

Things went on for a while with slightly better results every four years but then, the straddle jump evolved and results improved dramatically. Now everybody did the straddle jump and things were slightly improving every four years, it seemed that the straddle jump was the best way of doing it, period-until Dick Fosbury came along that is.

Once again a transformation occurred which changed the game with a quantum leap.

Of course now the NHS faces a major pressure to survive, and surprise surprise we’re squeezing efficiency out of the current systems, getting that better horse and cart. Even the potentially transformative shift to Clinical Commissioning Groups looks like it will be focussed on better pathways, again that horse and cart.

So what should the transformation be? Who is the Dick Fosbury of our NHS. I don’t know, it could be you or me. The solution is not going to come to those of us who are equine focussed in mentality. The solution will come from people who are not afraid to question the status quo, and ask the question “why not?”