The NHS revolution

We need a revolution. Right now the NHS is at a turning point, as commentators have pointed out post Francis report we a now forced to look with fresh eyes. The emperor has no clothes, performance measures alone do not guarantee great care, they may indicate it, but they do not guarantee it. The friends and family test is a way of "outing" the patient experience beyond metrics, a soft measure which, according to experts, correlates with great care.
But what happens when the FFT shows things are not as good as they could or should be?
Will our staff be required to go the extra mile? Will we mandate smiles, greetings, corporate mantras to give the impression of enhanced service?
Probably, but that won't be revolutionary enough.
Neil Bacon, a champion of FFT has a web site which uses patient feedback to hold the mirror to hospitals and soon, primary care.
Useful though this resource may be, it ignores the voice of staff, frontline, support, engaged, disengaged, who have joined the NHS and are part of the equation which delivers great care.
The Mid Staffs lessons tell us that whistleblowers do badly in the NHS, that we need a duty of candour when things go wrong. Whilst that is laudable and right, it again misses the fact that the NHS should be able to use the staff experience before things go wrong to prevent errors, to raise issues before problems arise.
Outside of the corporate COMMs activities, the "listening into action" and staff brief we need to make the drive, commitment, concerns and solutions which all NHS staff handle on a daily basis , transparent. Transparent to the NHS as a whole, their management, the population.
How could we do this?
Let's set up it's not compulsory, but if you work for the NHS, have a problem, a solution, something to say then let's hear it.
I recall a staff intranet which had "peoplepages" for all the staff, on their page they could put practical details such as past jobs etc, but also space for a photo and statement. One HCA who worked on the cancer unit had her photo with the caption, "I love my job so much- I'd do it even if I wasn't paid". I know now that if I ended up on her unit I would get great care, but I also know that she would be able to suggest ways it could be better and alert us all if things were not right.
I know people will say we can't, that belly achers, disaffected, troublemakers will populate the pages. Maybe, but those people are caring for your friends and family right now. Unheard, unseen, needing a voice.
It's a revolution but we need it now.

When is offal awful?

Undoubtedly board rooms across the land will be full of cathartic conversation, heads shaken in disbelief that a tragedy of this magnitude could be allowed to happen. Some leaders will disembowel themselves with admissions of "we can do better".
The public outcry is stoked by a media aware that the industry has been caught putting profit first, that economic drivers have prevailed over quality and service.
Other nations will wonder what the fuss is about. Their cultural norms are not as ours, they will marvel at our dismay. What to them seems perfectly natural and normal has been "outed" as unacceptable.

Given our context as members of the NHS you will of course recognise that the issue in question is Mid Staffs, but step back and out of the NHS for a moment. The actual topic being described is the horse meet scandal.
In parts of Europe horse meat is an every day product, just as relatives providing basic care is a routine hospital activity. Families eating together at the patients bedside, sharing, supporting, caring is the norm in Eastern Europe just as horse is on the shelf in most french supermarkets.

Now don't get me wrong, there is no excuse for neglect, no apology deep enough for the loss of life and suffering caused by that neglect. I am simply pointing out that expectations, cultural norms and values set the context for any judgement.

In the UK we do not expect to be given horse when we ask for beef, we do not expect to be given neglect when we ask for care.

In both cases businesses under pressure to perform financially have compromised on quality in an effort to reduce costs. At some point in the processes individuals lost contact with the very nature of their key business. Many individuals in Findus, Tescos, Asda were totally unaware of the flawed nature of their product, others who knew of the issue felt it was acceptable and in economic terms sensible to work in such a way.
The real learning emerging from comparing these two very public standards is that legislation is not the answer.
Food standards have some very strict legislation, an army of inspectors, a host of quality metrics and legal powers enough to make your eyes water. There can't be an establishment across the country that hasn't has visits, inspections, ratings and awards, all backed up by inspectors with statutory powers.
Every supermarket and store will have been displaying a rating of their food and hygiene standards, more scores won't fix the NHS.
Our only hope rests in the hearts of every staff member, that they can find the passion to care for people, to do the right thing first time, every time, that they can care for patients as they would wish to be cared for.
The challenge for the boards will be to appease the system and inevitable knee jerk regulation whilst concentrating on the real prize, developing a culture in which great care delivers financial frugality as a by product, and not one in which financial frugality wastes the chance to care.

Mr Francis - too late, too little?

There's loads in the Francis report. 290 recommendations to be exact.
The report is critical but from a medical perspective it looks like a list of symptoms rather than a definitive diagnosis.
Occam's razor suggests that multiple answers to a problem are probably wrong, event root cause analysis gets down to the first thing that went wrong eventually. In the case of Francis it's still not diagnostic.
Neither is it really therapeutic either.
The recommendations are all worthy, sensible and predictable.
However the fundamental failure is not named clearly.
Drucker said "management is doing things right - leadership is doing the right things".
Francis names the management failures, there are loads, and in part the leadership failures, but for me misses the critical point.
Everyone in mid Staffs ceased caring.
The leadership challenge we face is how to introduce "discrete love" into our cynical safeguarded world. How to allow staff to care for patients like family, with compassion and empathy.
Sadly that's one element of care that can not be managed and must be lead. Leadership in the style of Shackleton and not Nicholson is what we require in the NHS.

'Tis the season to be Jolly.

Christmas is one of those times when the cynics seem to take to the streets.

"There's no santa"

"It's all about the money"

"its marketing for churches"

They go on and on.  In a way its good because they leave healthcare alone for a little while. The "overpaid medics" and "lazy nurses" become NHS Heroes, with the NHS becoming a cherished institution. The regular sight of carol singers busting in on ward rounds, reeking of over zealous application of hand gel and grateful relatives dropping off Grannie who's suddenly become unsafe to leave at home alone over the season.

The rest of the year those cynics denegrate , deride and thoroughly disrespect the NHS.

The worst part is that many of those cynics inhabit the NHS, some in senior positions.

 They might not recognise themselves, but they are the one who say-

"We tried that it didn't work"

"What's the point there's no money in it"

 "Its more complex than that"

"what you've got to understand is.."

"what's in it for me/us/the patient?"

These sad individuals live trapped in cages of their own making, believing that the NHS is doomed, a belief reinforced by their very actions.

Perhaps they might try and take something of the festive season into the new year with them. Perhaps the belief and optimisim of Christianity, the love for fellow mankind, the care for those in need and the understanding that every day our actions, however small, count in the lives of others.

It's a small world.

Half way through a study tour of the Boston Healthcare system there are a few key points bubbling around the group.
Before I move to that it would be remiss not to mention the very warm welcome expressed by all the people we have spoken to, from "ward to board" in every Hospital or care setting we have visited.
So what are they saying?
Like the UK American healthcare is not broken but needs fixing. It is in the foothills of a politically instigated reorganisation which will also be visible from space.
I took the decision to view the trip through the lens of sustainability, i.e. Value, Toxicity, Waste and Evolution.
US healthcare does set out to deliver value and is working out what that means, we met a surgeon who is collaborating with Michael Porter, the father of Value Stream Analysis, we heard from providers keen to demonstrate quality through adoption of external standards such as Magnet Accreditation, we met providers who recognise that cost reduction is sine qua non for survival, so the equation value= quality/cost was visible as a thread.
Avoidance of Toxicity shone through at Mass Generals modestly named "the future of ambulatory care practice". This Physicians office based service has completely stripped out the old processes and assumptions which could shackle us to practices of the past. Direct access by e-mail triage, proactive management by a multi disciplinary team, patient rooms not doctors rooms, virtually all toxic habits and accumulations abandoned. Whether it could be delivered in a system that is set in its ways is unsure. The lead physician describes it as a "start up" and it most certainly is.
The reduction of Waste was a main driver behind one provider units use of Magnet Accreditation, in a Hospital where the senior team has been in place for over a decade, the concept that nurses could leave after being trained and developed seemed like a waste, so they undertook an onerous project to achieve a standard which makes them attractive to nurses and reduces absenteeism, turnover and unhappiness with career path.
Evolution is not something you see directly, it deals with timespans greater than our visit allowed, but even so the evidence of natural selection was everywhere, new buildings and developments in some sites, integrated or hybrid theatre suites in others. Reduction in length of stay to two days after a hip replacement and then returning home is impressive.
Will this make the US system sustainable? Is the "big bird" of American healthcare an Auk (extinct) an Ostrich (struggling) or a Turkey (seasonally overpriced) ?
It's impossible to say, but there are certainly signs of sustainability that can be taken back across the pond. it is a small world.

A religious experience?

This week has seen the launch of a new nursing strategy which involves six words starting with C. It's a brave attempt to sum up the values that make a person a good nurse. My dad and one of my brothers are nurses, so I've got a reasonable insight, especially since the Nursing Times was significant in my ending up with sufficient grades to enter medical school.
The trouble is I'm not sure a 6cs list addresses the issue. Here's how my thinking goes.
Many of the caring professions are a "calling" - something not religious in nature but a heartfelt belief that those that have the drive can follow.
If you have that inner motivation, intrinsic drive, yearning, then pretty well regardless of conditions you will exercise your right to choose the freedom how to behave ( See Victor Frankl for details). In Frankls case selfless acts of charity in concentration camps proved that we can choose to follow our callings regardless of circumstance.
I met a nurse who always wanted to join the profession, but in his culture it was a womans job, so he became a mechanic, joined the military and then, having established his credentials, he became a nurse, and a bloody good one.
Would the 6Cs have made him that good?
If the 6Cs turn out to not be the answer can I suggest we take a leaf out of the Derren Brown play book?
Mr Brown used a mix of psychological techniques to expose an atheist to a "religious conversion" - in effect a moment of insight/ joy/ karma that could, if followed up, have resulted in the atheist developing a belief in God.
Perhaps we ought to address the psychology of our staff and seek to promote and reinforce the feeling of a devotion or calling to the nursing profession.
I'm not advocating brainwashing or NLP, simply the idea that we should recognise our nursing sisters and brothers as having a calling, treat them with the respect due to one who puts others before themselves and maybe they will respond by putting others before themselves.


I don't know how familiar you are with Brian Eno.
On one level he's a composer, creator of some seriously interesting music.
On another level he's a thinker, a challenger of ideas.
His Oblique Strategies are an iconic set of inspirational cards designed to help you approach challenges in new ways, with ideas freed from context, hence oblique.
For a while I have been toying with the idea of creating a set of "oblique strategies" for clinical care.
Based on the premise that good clinical care is a triad of science, art and craft, clinical oblique strategies, or MedObliques would act as a knowledge base to support the art of medicine.
After all we have huge knowledge bases to support the science of care, but little to stimulate the art of care.
I would suggest it is the loss of the art of care, an art which invokes passion, emotion and interaction, which contributes to the failure of systems in which knowledge is applied without passion, without care, without feeling. A failing perhaps best illustrated by Mid Staffs.
So the challenge arises what would a MedOblique look like? What would it mean?
I don't know the answer, but that's ok, it's an art not a science.

Of course in the 21st century the cards will be an App, for android or iPhone and in spirit with Web 2.0 users can submit and share their own MedObliques - co-creation is also part of the art.

Towards Equity and Sustainability

In the growth years of health much emphasis has been placed on equity in all it's guises. However as need rises and resource falls the challenge of sustainability grows.
Recognising that healthcare is a complex system, and further an ecosystem, offers the chance to use principles of ecological sustainability to guide changes required in delivery and philosophy.
Enrich Coiera in 2007 borrowed the work of Natural Step to suggest system principles. We can take these principles and clean them up, fit them closer to the NHS.

Principle Of Recycling.
Healthcare must use resources at a rate which equals or is less than the economic benefit it delivers.

Principle of Accumulation.
By products of a system should not accumulate. Waiting lists, outpatient attendances should become static or decline.

Principle of Wastage.
Resources must not be wasted. Staff trained in NHS should be retained, theatres should be "sweated" etc.

Principle of Evolution.
The system must change to fit the societal and economic drivers in the environment.

Although there are similarities with the QIPP agenda, I believe that national, regional and sub-regional systems will be better served by considering the sustainable nature of our system, rather than the QIPP focus, which has, to date, been organisationally driven rather than system led.

As CCGs take system reins the sustainability principles should be written on the back of the hand of every commissioner. System success depends on it.

What's your tribe?

A colleague of mine has always been keen to describe fellow clinicians as tribes. The "ortho tribe", the "respiratory tribe" etc.
Aside from the usual comedy routine of "what's the collective noun for a tribe of urologists" the tribal thinking is a shorthand for shared values and beliefs.
There is a suggestion that the institute in which those tribes work should become "the home team".
I'm not so sure I want to be cared for by a surgeon who feels an alliance to either the clinical tribe or the organisation which employs them.
I would like someone who cares about my tribe to care for me.
So here's the dilemma, if I want to care for a patient as part of their tribe I need to know in which tribe they consider themselves to belong- this could be tricky.
Perhaps geography could be a good proxy? The Kirkby Urologist, the Anfield gynaecologist are equally as plausible as the Liverpool Football Club doctor.
Who knows? Maybe clinicians concerns for the tribe might improve health and reduce costs?
Of course it means the exclusion of secondary care clinicians from CCGs and Health and Wellbeing boards is clearly a flawed plan which only makes sense if you belong to the political tribe.
The answer to the collective noun conundrum? - a bladder of urologists of course.

Dragons Den

Imagine the scene, a young entrepreneur has a plan which will make millions, he goes to the dragons den.
The pitch is good, solid, his idea has been tested out on colleagues and friends, he knows it's good.
He finishes the pitch, silence descends and Theo speaks..
"That's nice, but we're the dragons and we decide what happens"
Our hero is confused.
Peter Jones clears his throat.
"Theo is right, you have to realise we are the new dragons, we decide what happens and we also come up with the ideas"
An uncomfortable pause, before Duncan moves on his chair.
"let me tell you where I am on this- I'm a dragon, we have the money" he says patting a large pile of notes, "and we will decide who gets the money, we also have the ideas"
This isn't working out as expected our heros idea seems to have missed its mark, the dragons seem intent only in enforcing the mantra of their power.
There is only one dragon left to take an interest in the idea.
She looks up from her papers.
"I'm sorry I'm far too busy ticking boxes proving I'm a dragon, have the money and ideas to take an interest in your scheme, come back to me in a few months."

Although this distorted den is clearly a fantasy, the reality is that across the country CCGs are playing those difficult dragons, whilst a diverse group of clinicians, managers and organisations are seeking support, not necessarily investment, for new ideas. Once our CCG dragons relax, secure in their positions things might improve for the entrepreneurs. Until then it's likes to be a frustrating experience in the dragons den.

a Quote we need to hear

If Kennedy did the NHS: "we choose to reform healthcare in this decade not because it is easy, but because it is hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win"

Jenga Commissioning

I have always been slightly concerned by the shroud wavers who say that any change in commissioning will result in the destabilisation of their organisation. Their premise appears to be based on a belief that maintaining the status quo is a desirable outcome.
Put 100 clinicians in a room and I suspect you won't find anyone prepared to state that the current system is incapable of improvement. So what is the reason for their predictions of doom and gloom as CCGs develop.
The literature on change management is clear as to how these refuseniks should be dealt with, but what if they have seen something that others have not? What if they are the Cassandras of current day NHS?
Complexity and chaos predict that in order to change a system from one attractor state to another it must be disrupted. The work of Clayton Christensen suggests this disruptive innovation is sine qua non for health service reform.
The worry eating at my cortex is that we cannot afford to break healthcare in order to re-make it.
Perhaps there is a different way to play this game. Think of the children's game Jenga. The tower of wooden blocks is gradually removed one block at a time, the aim being to ensure your opponent takes out the last block which causes the tower to fall. Suppose for a moment that your local NHS economy is that tower and one by one the various services which are re-commissioned are taken out and placed elsewhere, for example ultrasound services provided out of hospital. If CCGs play a competitive strategy, or even just a non strategic current best move strategy, the tower will fall.
Now step out side the game as we currently play it.
Imagine a system in which commissioners and providers agree the old tower needs to change, be smaller, be redistributed. Imagine a system in which the players agree that once the blocks come out of the tower they are assembled in a coherent new model, closer to home, redesigned and cheaper through efficiency. At the same time the old tower is steadily made smaller, but without the collapse into chaos.

Is it possible to play the game in this way?
I believe it's a yes, but only if the players agree the principles and trust each other.

Striking is not a game- or is it?

Game theory has been back in my thoughts this week.
Principally I've been looking at whether models of ultimatum and dictator games have a role in decisions take around clinical commissioning shifts.
At a tangent the medical profession has voted to undertake a day of action, which will see many Doctors dealing with only urgent or emergency activities.
In theory they are striking to show that they care about their pensions being changed by the government to give a poorer deal.
However that response is not just a response in the ultimatum game played by the politicians, the one that says "here's our offer, like it or not that's the offer -take it or leave it- your choice". It will be perceived as the first move in a new game played with patients. In the patient game the profession plays the role of dictator, "this is our offer- one day no routine care - no choice,tough luck pal".
There is a reasonable body of research behind game theory and the strategic choices made in the simple Dictator and Ultimatum games. In ultimatum games the offer is usually less "unfair" and more altruistic than when the dictator game is played, most offers see both sides achieve significant benefits. The dictator games are different. When the dictator is protected by anonymity the choices work out to be more extreme.
Almost unwittingly the UKs medics are being manoeuvred into a game they do not want to play, the damage will be significant, the belief that "my GP" has "my best interests" at heart will be demonstrated to be patently untrue, not just for the loss of routine care for that one day, but for the way in which the game has been played with patients.

The Unsinkable Titanic

Expectations are an individual viewpoint. They are a synthesis of past, present and future models which govern our actions in the present. They are animal in origin. An example of animal origin would be a badly treated dog,whether it cowers, bark or bites is not purely a function of your actions, but on its past experiences and therefore expectations.
Dogs are not amenable to reason, you can't say "but that was then, and I'm different".
Are humans any different?
In some respects yes, they can be reasoned with, their expectations can, sometimes, be explored. In all cases our expectations can be managed.
It matters not whether the staff on a budget airline are always smiling, we've paid for coach and we're getting it. If a flagship company such as British Airways, or Cathay Pacific deliver less than perfection their expectation raising advertising causes a tsunami of complaint.
Perhaps the Titanic would have been a far less tragic event if the appellation of"unsinkable" had not been applied. It would probably have faded in memory, alongside similar tragic incidents.
So what does this have to do with healthcare?
As we move to a patient centered care system we are likely to aim for and promise better outcomes. This promise might well be a justification for unpopular changes in service, a means of selling a different model. "Closer to home", "nearer the patient", "patient centered" all raise an expectation of service, of something different and better than our current systems.
Expectations raised so high, service delivery inevitably likely to fail on occasion, it seems inevitable that individual and possibly community ire will be heaped upon those who fail to deliver.
Perhaps we need to think carefully and honestly about how we change the system, perhaps are slogan should be "The NHS, doing it's best to please everyone and failing in places".

Run that past me again

Here's an interesting thought.
If your brightest creative mind comes up with an idea what do you do?
The chances are is you would put the idea through some sort of technical assessment.
Ask the numbers guy, the operations girl, the team who "sense check" for a practical solution.

So what happens if the numbers man comes up with a way to slash the costs?
I'm willing to bet that most organisations in healthcare say "Ok let's do it!"

Maybe if you have a clinically led organisation you might run it past the Docs.

But would you run it past the out of the box thinkers?

Why do we subject the creative solution to technical scrutiny, but not subject technical solutions to creative scrutiny?

I would suggest that our society has developed a trust of the "real" the empirical, the concrete.
However transformation and evolution are the outputs of the creative, abstract and "wrong".

I'm not suggesting that every hospital or practice needs to employ a team to "think out of the box" or that the finance department is wrong to point out that a proposed solution is not cost effective.
I am suggesting that any one and every one should take a moment to check out the the latest idea, mandate or proposal twice.
The first time work in your preferred mode, creative or technical, reach a decision then stop.
Run that same idea again but think in your best attempt at your non preferred mode.
Does it make practical, financial cost effective sense? Does it make creative, innovative, developmental sense?

Ideas, initiatives, solutions or projects that deliver in both modes will be the ones that really deliver in new ways.

How you act now will decide your legacy.

Services are changing. Commissioners are changing. Organisations are fighting their corner.
Much of how the system develops and transforms will depend on the actions of the leaders within the organisations.
Leaders at all levels are faced with choices, however the nature of the choices is not labelled or rational. The actors within subsequent decision frameworks also find themselves coping with world changing outcomes.
An example of things to come include consolidation of specialist surgery such as vascular surgery. Right now across the country various hospitals are vying to become vascular centres, treating complex cases, making a difference to patients lives.
Unfortunately the various organisations who have a stake in the dealings don't always act rationally.
On the face of it shifts in service which should be clear, based on good data, good analysis and good procurement/ commissioning of the service appear to be being made slowly.
Unfortunately that apparent clear process masks some aberrant behaviours which are not professional, organo-centric and motivated by values other than patient care.
There is no easy solution to address these behaviours, they must be recognised, identified, and possibly named. Individuals need to be engaged, their damage and apprehension recognised and they must be engaged in a vision and journey to the future.
Easier to write than to do.

Innovation or Procrastination?

One of the challenges facing all clinicians is how to stay up to date when new treatments emerge.

Inevitable much research has been carried out looking at early adopters, late adopters, laggards and luddites. Usually the research focus shifts to the "barriers" of innovation.

It is often the dissemination and adoption phases of innovation which pose the highest challenges. Much focus is placed on "removing" the barriers.

Despite this research, mountains of evidence and guidance, adoption is slow, patchy and possibly dangerous for many of the newest treatments.

Perhaps we should look at the other end of the problem.

As clinicians we all intend to do the right thing, but somehow it just never seems the right time/ option/ circumstance for us to use the drug or treatment.

Our slowness to adopt is not necessarily a negative act. It could actually be a positive, but subconscious, choice to procrastinate.

Peers Steel, in the Procrastination Equation proposes a theory which describes the complex organic choices which result in many of us not accomplishing those tasks we should do or even those we choose to do.

My contention is that Innovation or procrastination are reciprocal in nature. Over time we live with choices, the world changes, we either do or do not change with it. When it comes to professional practice there are things we "should" do, because evidence, guidelines, dictat, all say we should.

Steel proposes that Value, Expectations and Time are all related to how badly we procrastinate. Do we value the change? What's in it for us? Can we physically accomplish it now, given all the competing distractions which are prioritised in our routines.

Already it would appear that a reward system, with time and financial consequences are sine qua non for innovation.

So perhaps Innovation: Health and Wealth will remove the incentives to procrastinate.

The National Scorecard?

Although the NHS looks like a single organisation to those on the outside, once you enter a "pathway" of care you realise that your journey takes you through a series of gardens, sometimes using gates, sometimes jumping fences I order to access the next stage.
Measuring and improving performance across this system is a matter of luck.
Luck in that if you can find a metric that is agreeable across the gardens you will be lucky to find it being measured in the same style in any garden, if at all in some. Taking the metric back to basics is a hope, did this event happen to this patient?- yes or no, means that data finite ones become less troublesome.
So looking around in healthcare why do we have so few National metrics?
Sweden, arguably one of the best performing healthcare systems has a series of national registers, which drive a metric based system.
The NHS has an excellent QOF system, but only in primary care. This system takes a cohort of patients and measures the outcomes of treatment. If QOF extended through the garden of primary care into secondary care we would know now whether all patients receive the right treatment, at the right time in the right place.

At present the best we can do is stitch together a series of indicators and cross our fingers.

Deregulation: the land of opportunity

It is possible to sit back and mourn the disappearance of the old ways of working in the NHS.
The loss of system control, the inherent waste of confusion and chaos, lost functionality that accompanies every structural reorganisation in any industry are real, but despite this downside the current impact of the "not yet enacted" Health and Social Care Bill means that there are opportunities around every bend. The bill effectively opens the market place for competition in a number of areas, verging on a deregulation of healthcare.
Some players sense this, others fear it, for they know it to be true, and some, a smaller number embrace it.
History tells us that the smaller, hungry, driven start up will win out in such arenas.
So what then for the existing players, the big trusts, the large providers, the incumbent practices, what is their future?

Doing nothing is an option, being herded by policy and victim to competition may actually feel like business as usual. However it is not a successful option.
Consolidation of the old ways is also an option, actively perusing a policy which seeks to ensure that all of a particular disease comes our way, "because we're good at it" is also comforting and attractive.
Unfortunately the really successful solution is the most challenging to pull off. The transformation of a big player, to new ways of working, new patterns of care, is almost impossible. Riding the changes of policy, finance and technological innovation is tricky.
New models of care will require considerable effort and disinvestment in older ways of working.
Is it possible for most clinicians and managers to buy in to this vision? Is it possible that a declining status quo will be so attractive to those whose institutions have institutionalised the minds of their key clinicians and managers, that the alternative routes to diversity, transformation and success in a new world will look far too risky?
The next two years will be critical times for the NHS, innovate or die- you decide.

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.