Inside out, outside in.

Organisational structures are a major barrier to good care.

This is the premise behind integrated care. The organisations do not have to merge or cease to exist, but simply to recognise the barrier exists and deal with the problem.

Simply re defining discharges as transfers to primary care will change attitudes about how a "transfer" to primary care is performed.

However beneath this simplicity lies a complex issue, the knowledge and relationship of the competencies possessed by each of the parties is on both sides limited.

GPs who used to work in hospitals will remember how it used to be, Consultants who have never worked in primary care will imagine the jungle, the savages, the fear that returning the patient to the wild will see it lost forever.

How then to make visible those who provide safe passage and care through the jungle of primary care and the urban landscape of secondary care.

Choose and Book did much to separate individuals from communicating directly. Perhaps now is the time to pervert the Choose and Book directory of services into the tool to put those networked around the patient into a system which allows all participants to recognise each other and communicate.

Time Flies like an arrow, fruit flies like a banana

The delay of a month since my last post is not an indicator of inactivity - far from it. We do live in interesting times, and the changes that the NHS is facing seem to grow daily.
There is a widespread and growing viewpoint that says integration is the answer. However the money is still the question.
Solving this dilemma will require something different, something new and innovative.
It will require the NHS to want to learn from other parts of the NHS and adopt the "industrial scale innovation" which was key to the Nicholson Challenge back in the days of the last government.
Can that element of culture which says it's OK to take somebody else's idea and use it wholesale be moved in the NHS. Only time will tell, but in the meanwhile I'm going to try and find one or two direct learns from neighbouring organisations and see who blinks first in the game of chicken.

Leadership as Renaissance Exploration

Although the literature on leadership often quotes examples of explorers as good/bad/mediocre leaders it is less apparent that good leaders in lots of different organisations are actually explorers.

Granted very few use teams of Huskies to accomplish great feats of physical fortitude, but most are tasked with mapping the unknown, taking on challenges, seeking solutions all in lands which truly qualify for the appellation "Terra Incognita".

Once on the journey to these unknown lands the modern leader must combine a series of skills which are perhaps best related to the development of thought during the renaissance.

Mintzberg in his book Managing 2010, places the practice of management as the centre of a triangle bounded by Science- the analysis of systematic evidence, Art- creative insight and vision and finally Craft- practical learning and experience.  Leaders will recognise a similar trinity in their roles and if they are students of history the ideals of renaissance Italy will resonate strongly. 

So can it be said that leadership is renaissance exploration? Look to your leaders or co-leaders. Do they show that blend of science, art and craft that typifies the renaissance? Are they leading into new lands for the business?

Not every leader will have the style of Renaissance Exploration, few will have the experience and skill set to deliver such a style, but perhaps the odd one or two will thrive on the challenge of the unknown, demonstrate the trinity of skills balancing Art, Science and Craft and deserve the appelation Renaissance Explorers.

The end of an era?

As New Elizabethans we have seen many great things accomplished by our species. A moon landing, supersonic travel and the establishment of a healthcare system, free at the point of care are some of the great things achieved. However, it is unlikely that man ( the species) will set foot on the moon again in my lifetime, equally unlikely that a commercial supersonic airliner will be available in the next twenty years.
Both these two endeavours are of course extremely expensive, idealogically driven and beneficial to some elements of society, but the world has moved on, commercial air travel is moving towards a triumph of mass transit at lower cost instead of speed and luxury. The new Airbus A320 delivers the model required not Concorde. Of course the shift was helped by factors outside the world of aviation, not least the growth of high speed communication -the availability of teleconferencing means that the urgent face to face can happen without a trip on Concorde.
In the case of space travel, the high ambition was a political ideal, designed to secure an unassailable position in world history. Although great science was delivered on the back of the programme the cost and financial restrictions globally mean that the programme is no longer viable.

Apply that same logic to the NHS- the cost, the idealism are all possibly rendered obsolete by changes in society, the only factor missing is a viable alternative model to the current system.

Here's where it goes off the rails. The NHS is a complex system, akin to a living organism. There are certain rules about how such systems work, the current world view is that a bottom up clinically led system will deliver "the right thing" for the population. It is possible that it might work, but such an experiment will, as is the way with experiments, result in some failures before it delivers.

The question is whether the evolution of a politically founded, publicly funded healthcare system is able to be delivered rapidly through evolution or like the shift away from manned space flight and commercial supersonic flight, it may require a hard nosed cessation of one system, so another might flourish. Can we take this giant leap for mankind? Is this one exploration too far for the new Elizabethans? Only time will tell.

Leadership for Commissioning

There is no shortage of literature on leadership. The number of books and the styles of leadership are legion, the range goes from Kotter to Milan (Be The Pack Leader).
Attending a recent Clinical Commissioning Group meeting I was struck by the almost apologetic attitude of the board members, their reluctance to take their places on the table at the front for questions and answers and their non existent answers to the single question from the floor.
In terms of scoring against any indicator of leadership the performance was poor. Did they have a vision? Well, er, no not really. Did they inspire for the challenges ahead? Erm, ahh, no actually.
The big question is whether this "style" is actually appropriate at this time. Given that the changes in the NHS were not sought by many, except those driving PBC, it could be argued that they are reluctant leaders, thrust into the limelight. However the fact that they stood for appointment denies the excuse of reluctance. Perhaps they are awaiting a mandate and their constituents direction as to how they should work? If servant leader model is their modus operandi then they have failed to touch constituents directly, instead relying on practice contacts.

Perhaps we have not appointed leaders at all, perhaps we have appointed managers?

What would the ideal package or style be for a commissioning leader? Of course there is no answer to this question, they should be a balance of credibility, authenticity and vision. Whilst my colleagues are authentic, the lack of vision hampers credibility. There is certainly a long way to go to develop the leaders for commissioning in my locality.

Competition Time?

This weeks BMJ has an expoloration of competition as a means to drive up quality. It turns out that the jury is still out as to the effectiveness.

I think it is pretty clear that competition does improve quality, take motor racing for example. If there was no Ferrari, would there be a Maclaren? Would Red Bull be quicker if there was no one to race? The answer is clearly no, the fact that there is someone to compete against means that the quality indicator of lap time is improved incrementaly year on year.

Stepping back from quality the piste appears less certain. Right now a formula one car costs $7 MILLION. Now I appreciate that this costs is exactly what is required to stay ahead of the competition and that the purpose of the car is to go faster than the competition, but ask yourself this one question- if Vettel and Hamilton were racing in Ford Mondeos then would we find out who was the faster? The answer is of course yes, we would know who was quickest, the competition could be won or lost and the purpose of F1 acheived.

You see competition comes in many dimensions, with many aspects and so when we argue that competition improves things we are correct, when we argue that competion makes some things worse we are also correct.

So is competition good or bad?- the answer is yes.

America is not the answer

"When you go to the doctor feeling sick you spend time cooling your heels, first in the waiting room and then again sitting in a flimsy gown, on an examining table. Finally the doctor rushes in , pausing only long enough to ask a series of questions on a checklist before dashing out again to see the next patent. if the doctor refers you to a specialist, getting an appointment takes weeks. if the doctor prescribes you a drug, your insurer refuses to pay for it."
So wrote Shannon Brownlee in her book "Overtreated" - I was Recommended the book by a colleague who had spent a fair chunk of his career living and working in the states, not as some prized international guest but as a jobbing Doc, who saw the system from the inside, the old, the bad, and the ugly.
So why the fascination with America?
Is it the prospect of visiting a system in which every latest test and treatment is possible? ( insurer permitting). Is it the possibility of seeing what happens when you are in track to spend 20% of your GDP, the equivalent of the total budget of Italy, on healthcare?

I suspect it is because we in the NHS are foolish enough to believe the hype, the media, the spin that says America has it right, is sorted, is the way forward.

Ok, I accept there may be pockets of answers in the states, perhaps accountable care organisations have something to offer, perhaps safety initiatives can be transferred across the big pond. However I would also suggest that we have much more to learn from Europe, where primary care is more like our own, where health issues, financial mechanism and political environment offer more transferable solutions.

If you must look across the pond, why not try the other great nation on the continent of North America? -Canada.

it's networks all the way down.

Network theory offers some insights and structure to the study of systems, whether random or complex. In particular scale free networks "webs without spiders" are particularly resonant when it comes to looking at the NHS.
Scale free networks consist of nodes and links, some links are unidirectional, others work both ways. Some nodes are massively well connected, others have few links.
So far so good, but when it comes to scale free networks there are some caveats, the networks are robust, non random creations, which obey some key principles including a power law for distribution of connections.
Look at the NHS, consider clinicians as the nodes of the network and patients as the links between clinicians, either as direct "please see this patient" or as patient related data, letters results, conversations.
Now sit and visualise your surgery, hospital, patients.
Imagine the lines flowing linking you with the services and clinicians that you refer to and share information with.
Think about how those who work in hospital interact over patients, the discussions, referrals and the vast web of links that is created.
So far so good.

Network theory suggests that the disappearance or failure of some of those nodes will mean that the links reform with other nodes and in many cases the network re-forms, however in some cases removal of a key node results in a cascade of failures, with each subsequent node being subjected to a load with which it cannot cope.

We know this intuitively, as we see this when the clinicians in the local AED are overloaded, the Trust goes "red" and sure enough, the nearest AED takes the load and sometimes fails.

So far the NHS has just about coped with "nodal failures " in general they have been escalating pressures, either seasonal or semi predictable.
Unfortunately there is a property of scale free networks which is unpredictable and undesirable, in that they are vulnerable to attack.

Deliberate removal of a key connector node causes isolation and fragmentation of the network with subsequent failure or isolation of the remaining network.

The NHS has not been subjected to a deliberate attack in terms of removal of nodes, but it is conceivable that change in the infrastructure of hospitals, their service delivery models, and key staff may function as an attack. The consequences cannot be foreseen but could be catastrophic. In some way this could be seen as justifying the maintenance of status quo, no changes to services etc, but in reality Network Theory provides us with a warning, the changes can be done, should be evolutionary and must be thought through.

Baa-ram-ewe! Baa-ram-ewe! To your breed, your fleece, your clan be true

Who earns your loyalty and why?

It's a tough question because we rarely think about who or what gains our loyalty. The sheep in Babe give their hierarchy in the title of this post, but for clinicians the distinctions are not always clear.

Is it your practice or department which comes first? Is it your speciality? Is it your health community?

It is too trite to say that you are loyal to your patients, especially since all too often it is they who remain loyal to the practitioner who has failed them in the past.

This loyalty issue has a nasty inverse consequence. I recently met someone who worked for a specialist trust. She described consultants from that speciality who worked in nearby DGHs as having failed to attain the standards required to work in her organisation, and in effect, not fit to treat her dog.

When loyalties are put in conflict, such as organisational mergers we are likely to see reactions which are unpredictable, possibly aligned to loyalties not apparent to those outside the group. These conflicts will be increasingly common as the commissioning agenda develops.

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"

When conversation is better than commissioning

A hero of mine, Enrico Coiera, once wrote a paper entitled "When conversation is better than computation" you might expect that kind of title from a luddite, with anti technology principles, but at the time Enrico was a Vice President at Hewlett Packard in their special research division.

Enrico argued that despite all the computational power available there were times when developing a relationship and establishing communication was the right thing to do.  I would like to suggest that the same principle might apply to commissioning. We have services that could be improved by stepping back, starting again with a clean sheet of paper and buidling the perfect pathway. Although this risks the God Complex, it will be appropriate at times.

What would happen with conversation?

If there was an outcome which was less than expected it could be talked through and the incremental changes required could be put in place without the need to start again, spend hours redefining and re-procuring the system.

Cynic will argue that talking will just support the status quo, but they miss the point, the incremental change means that the status quo moves whether it wants to or not.

Perhaps the next time you have a letter from a hospital which asks you to look up blood results on the same hospital system the consultant could use, and furthermore to send it to the consultant, rather than moaning about being made to act like  a house officer (F1) you could always initiate a conversation- try it, you'll be surprised.

Losing the God complex

It's often said that doctors act like they're gods. They believe they are right, have the solution, can totally understand the problem. Ok this is a caricature but it has a basis in health systems. We often believe that there is a right answer, that we "know" the right thing to do in any situation. Our science of evidence based medicine simultaneously destroys and supports this view. It destroys the god complex by providing proof of the effectiveness of an intervention in any clearly defined, tightly controlled situation. However, armed with "the evidence" it delivers cast iron certainty that we are right, totally, infallibly correct.
The trouble is that health systems are not simple randomised double blind controlled trials. They are complex adaptive systems which do not respond in linear ways to defined, evidence based interventions. Complex systems require us to let go of the approach which says " I alone have the answer" and further more "this solution is the only one way to succeed".

Considering the NHS in it's current reformation it would appear that our solutions to the Nicholson challenge will emerge not from the top, not even the political direction of the Houses of Parliament, but instead from those near the front line who are able to experiment with the system, take chances on a trial and error basis, tinkering with the system to rapidly follow examples which provide good outcomes, rapidly abandoning features which produce lesser outcomes.

It won't be easy for us to shift from evidence based certainty to evidence based action not because it requires doctors and politicians to admit that they are not correct, but simply because it requires them to admit that they don't have the answer but are willing to learn.

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.

Irreconcilable Differences?

Writing in his book Blink, Malcolm Gladwell tells the story of a marriage guidance counsellor who is able to predict success or failure of a couple after only a few minutes of interview time. The key he believes is contempt, if couples show contempt then all is lost, the relationship is doomed.

This week I have been speaking to people in primary care and secondary care.

In truth there were times when it did feel like being a marriage guidance counsellor.

All the red flags for relationship arguments were being waved in to the debate. The sin of absolute generalisation-"You always (then insert the apparent sin) in primary/secondary care" - really?- We always send out letters late? We always fail to refer appropriately? The sin of dragging in the in-laws "social care doesn't do its job and that's your responsibility to commission" is guaranteed to raise hackles.

Once absolute generalisation is used it tends to suggest that a fight is on the cards and that ignorance of each others feelings and functions is the underlying cause.

The main tragedy this week is that there is starting be be a little hint of contempt. "I never take my child to the GP he's rubbish- I don't know why any parent would."

Really? All GPs are rubbish?

Perhaps we should take a leaf out of the marriage guidance book and concentrate of creating a conversation in every health community which might just avert contempt, otherwise we will really find Irreconcilable Differences

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.

Why start with Why?

Been enjoying a book called "Start with Why?"
In essence the author suggests that customers buy in to services not because of what they do but why they do it.
Although the book majors on Apple, I have been able to think of lots of other companies whose value set and raison d'etre are more attractive than the products they sell. BodyShop, Rohan and the NHS all have value sets that mean their products are treated differently by customers. There is a cachet in having the product because it says something about the user/wearer/ patient. Bodyshop products bestow an environmental and ethical label on their users. But what is it that the NHS label bestows on patients? If asked "Why did you use the NHS?" what answer would you give?
Because it was there?
Because I had no choice?
Because I needed it?

I don't think many of us would say "because I value the core principles of an equitable health service, free at the point of care", which kind of makes me think that there is something missing from the way that we market NHS Services. Not just their marketing but also their usage. Perhaps we should remind patients of the Why afterall.

Costing an arm and a leg

I recently had a conversation with the family of a gentleman in his eighties. Sadly he had undergone surgery, contracted MRSA and suffered significant complications.

The family were concerned that recent swallowing difficlties had required the use of liquid based medicine, his multiple pathologies included various cardiac treatments that were only apparently available as "specials".

In the course of the conversation it transpired that the family were already well aware of the costs of such "specials" and even more surprisingly aware of the perverse incentive that some pharmacists use the most expensive route to obtain the drugs and maximise the profit.

When the son said "bit of a conflict of interest there Doc" I started to tactfully enquire as to their background- were they Lawyers, Teachers or God forbid- Medics?

Oddly no- she worked in IT, he worked in the Council. They were both aware of the cost pressures we all face and willing to consider any option which meant their Dad received good care.

After a while we reached an arrangement involving alternate treatments, delivery mechanisms and some PRN  subcutaneous drugs.

There was no rancour, anger or demanding of "their rights". In effect they were acting as custodians of the NHS purse in much the same way as many GPs do.

Perhaps there is something in sharing care footprints with patients afterall.

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.

We need more variation!

Part of the trouble we face as clinicians is the call to standardisation. There are undoubtedly multiple clinical areas where all clinicians are expected, if not exhorted to do the same things in the same way. Management of AF for example.
Sadly this does not always happen and I would like to suggest a theory why not.
In every given population there is a distribution, the classic bell shaped curve, or asymmetric curve will undoubtedly be present.
By definition 50% will be above the mean, 50% will be below, and two standard deviations will see 95% of the population covered.
When it comes to adopting the standardised behaviour we're all given the same map, guideline, instructions and expected to follow them.
Now we can all see that the instructions I need to get to New York, will be different from the instructions required by a resident of the Broncs.
So why is it that we are helped to achieve best practice by instructions written by those engaged in best practice and no understanding of how far away some of us live?
Would we not achieve greater success in reaching our destination by recognising the various places from which we start?
I would suggest that NICE and other guideline generating organisations would do well to produce various guidelines all designed to work from various starting places, approximating to success and useable by those who live in different clinical lands.