Why is it so hard to make soft changes?

carrotAs Robert Francis is a lawyer, he understands British legal culture, in which rules are deliberately kept as explicit as possible. Nuance cannot be the basis on which legal judgments are made, and so all the factors needed to reach a verdict have to be transparent and ‘hard’. But his final report on the mid-Staffordshire hospital crisis was wise enough to acknowledge the need for complex cultural change, and the challenge of making such ‘soft’ changes happen.

However, the actions that have emerged following the publication of his report in February seem to reflect his views less than the need of politicians to be seen to be doing something. The report may refer to the ‘softer’ less quantifiable aspects of healthcare such as ‘caring’ and ‘culture’, but the remedial steps announced so far seem to be based mainly on regulatory systems predicated on punishment and duty, not on motivation or positive intent.

Thus, the Secretary of State for Health announced ‘a new regulatory model under a strong, independent Chief Inspector of Hospitals’ and introduced ‘a new statutory duty of candour for providers, to ensure that honesty and transparency are the norm in every organisation’. Even the stipulation that nurses should spend a year as health care assistants before they take on ‘proper’ nursing seems a fairly mechanical way of changing values (as well as saying a lot about how we distinguish caring from curing, and the ‘proper’ role for nurses).

I may overuse the aphorism that ‘the floggings will continue until morale improves’, but if ever there was an illustration of its paradoxical ridiculousness, then this must be it. Concepts such as honesty, candour and openness patently cannot be forced onto staff, and so even at face value, such statements will only increase the cynicism that besets so much of the NHS.

The announcements are in themselves an important indicator of the deeper malaise in NHS leadership, where there seems to be no insight either into the manner in which the workforce functions, or into the importance of coherence between rhetoric and behaviour.

Let’s start with the workforce. Vocational occupations, such as medicine, nursing, teaching, policing, and even parenting, all depend for success on their practitioners’ professionalism. My personal definition of what professionals do, is to fill the gaps left by reductive methodologies. Once the rules have been applied, the spreadsheets completed, and the safety checks carried out, it is professional judgment that assesses the nuances and shades of uncertainty that highlight the impending disaster, the malingering patient, the struggling pupil.

The detective’s hunch and the doctor’s gut feeling are key skills, and without such professional behaviours, all the activities described above (even parenting – or NHS management for that matter) tend to lead to worse, and more expensive, outcomes.

Professionalism is the mortar between the bricks of the formal tools, holding them together, yet by definition it cannot be pinned down (or it would have been formalised into mechanical tools long ago). The systems depend on their professionals applying their nebulous skills effectively, but enforcement is nigh on impossible as the ephemeral nature of these skills means that we can’t easily identify deficiency as if wewere checking the accuracy of a temperature or the frequency of a bowel movement.

The motivated detective, keen for approval and promotion, will use his inspired hunches to brilliant effect, whereas his demotivated, burnt-out partner will stick to the rules and hide from disapproval and discipline behind an impenetrable ‘jobsworth’ shell, without actually doing anything wrong. The more we reinforce these respective behaviours, the more each detective will stick to them.

The key to successful change is to understand the factors that actually drive professional behaviour. Approval and promotion work better than disapproval and discipline. For professionals of any kind, the way to motivate them is to tempt them with increases in status, peer approval, patient benefit, pet projects, better income, and more fun in their work.

Of course, carrots need their obverse sticks, and the implicit threat of reduction in status, peer disapproval, patient disbenefit, lower income, and boring, difficult work probably all have a place in the successful management of professionals.

However, carrots work better than sticks – once a culture is perceived as punitive rather than encouraging, then motivation becomes logarithmically harder to achieve.

Jeremy Hunt’s edicts about firmer regulation and harder floggings are likely to be counterproductive, in the same way that thirty years of bullying clinicians to behave more corporately has had so little impact. Until they can understand and feel the benefit of a new behaviour personally, doctors, nurses, teachers and policemen will at best ignore or at worst sabotage each new exhortation, and feel less and less inclined to change.

The NHS is supposed to be a single state-controlled system, so there probably are important elements of corporacy that need to be developed, such as more consistent treatments, communications, and outcomes. But if corporate behaviour is important, then the way to implement these targets is by relating the desired behaviours to professionals’ own agendas. Include the clinicians in problems, involve them in their solution, ensure that the personal benefits and dis-benefits are clear, and so on – there’s a lot more to be said about this on another occasion.

However, the final point to be made is the most important. The incongruity of trying to bully professionals into less bullying behaviour will not be lost on any of the professionals working in the NHS, and the mixed message it gives them about the system in which they work means that their behaviours are unlikely to change.

This blog is based on an article published in Pulse in the UK on 22 April 2013.

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England swings like a pendulum do

MT1Nearly a week has passed since the death of Margaret Thatcher, but I have found it difficult to sort out my overall reaction whilst the river of Thatcherabilia has been in full spate.

I was a hospital houseman when Mrs T came into power in 1979 and like many people, I have gone through different phases in my attitude towards the woman; I never voted for her, but in retrospect, I have little doubt in my mind that the country, beset as it was by industrial conflict and traditional left/right tensions, needed strong autocratic leadership to get it back onto an even keel. Prime Minister Jim Callaghan’s ‘winter of discontent’ meant that the UK was running at half speed, and even as a junior doctor, I was affected by mortuaries being closed, operations cancelled, and a sense of the country being held to ransom.

However her early success in rebooting the country, combined with the serendipity of the successful war in the Falkland Islands, began to affect her in the way that power often affects political leaders: self-confidence turned to arrogance, her certainties felt increasingly patronising, and her self-reliance excluded almost anyone else  from her thinking.

Perhaps though, her impact was less about the person and more about the zeitgeist, and we should gauge her legacy against the spectrum that runs between society and the individual. When she came to power, the country seemed to be stuck at the collectivism end of this scale, with the state, the trades unions, and the whole sense of ‘other’ taking precedence over individuals, their freedoms, and the sense of ‘self.’ This position represented the apogee of the State as Big Brother, and whatever one’s political background, hindsight makes that situation look archaic and almost quaint.

With the pendulum at one extreme of its swing, it was inevitable that it would begin to move in the opposite direction, and it is perhaps moot to speculate whether Mrs Thatcher was cause or effect of this change. As it was, she was the right person in the right place at the right time, and influenced by her charisma and strong sense of direction, the country very quickly away from its collective extreme and towards the individualist one. Famously (if quoted in a slightly flawed context) she claimed that ‘there is no such thing as society,’ meaning that individuals had to look after themselves rather than relying on the Nanny State; she was probably right in suggesting that the balance between ‘self’ and ‘other’ was wrong, but the momentum that was created under her guidance drove the country so firmly towards individualism and consumerism that most of the benefits of collectivism, altruism, and overall human decency risked being lost.

Thus, the mid-1980s marked the start of the worst excesses of Western capitalism, with short-term benefit and self-aggrandisement appearing to subsume any sense of a broader society. It was the start of the ‘me me me’ generation, where ‘I want it, I want it all, and I want it now’ became the clarion call; greed and the lust for instant gratification became acceptable (nay, laudable) emotions, the credit bubble began to expand, Gordon Gecko took over Wall Street, and this country’s attitude to welfare and the more disadvantaged members of society reached their nadir.

It is no accident that when she was toppled from power in 1990 her autocratic style was replaced by the relatively meek and mild democracy of John Major, who tried to reintroduce the notion of consensus in decision-making. As is our wont in Britain, the counter-swing was too fast and too far, and the search for consensus led to political paralysis, with the endless debate over Europe hanging over the country for the best part of half a decade.

So for me, Thatcher represented a societal phenomenon, and showed how it is not just frozen food that needs ‘best before’ dates: three years of her abrasive style might have kickstarted our economy; eleven years meant that it ended at the other extreme, and left us with a legacy so toxic that we may never be able to rid ourselves of its selfish taint.

And in principle terms, she made me realise that the essence of leadership is to understand and use the changing balance between autocracy and democracy: rapid radical change needs autocracy, but smothers inclusivity and creativity. A more democratic approach allows ownership and ‘buy in’ but is too slow to be much help in a crisis. Having the skills to use both, in the appropriate ratios, is what really marks the successful leader.

On conducting orchestras and resisting magic bullets

t_WilkinsConductingThe underlying currents that have been sweeping through the NHS for the last thirty years have been remarkably simple and consistent.

Activity and costs in the acute sector had been growing too quickly for the economy to support and without enough impact on the health of the population, so two main actions were introduced.

The first was the separation of the commissioning of care (procurement, purchasing, call it what you will) from its provision, which was intended to introduce appropriate tension and ‘contestability’ and so remove any cozy collusion in the system.

The second was the strengthening of primary care (and specifically the GPs) at the front end of the system, as generalists able to treat the vast majority of illnesses themselves, ‘case manage’ the rest through their ability to control referrals to the acute sector, and co-ordinate all care, acting as the conductors of the NHS orchestra.

Mechanisms supporting these principles have developed over time, but the direction of travel seemed well established. The population quantum changed, financial levers held by primary care evolved, and the acute sector has been through its own iterations with the private and voluntary sectors beginning to become involved as providers.

The potential ‘magic bullet’ in the changes was the intention to move patients and their services out of expensive institutions. Community-based care was assumed to be more user friendly, more appropriate, more easily accessible, and cheaper, so the philosophy seemed like a ‘no brainer’.

Moreover, the drivers were strong enough to keep the GP community (more or less) on board despite repeated disappointments as the aspirational rhetoric of each round of reforms was diluted by real world politics.

What has emerged as the Kevlar vest against the magic bullet however, has been the difficulty of getting resources to follow the patients. The machinations here have been a perpetual problem that may now derail things once again.

With the reforms of the early 1990s, traditional hospital-based activity did begin to migrate to the community. Patients with diabetes, hypertension, angina, and a host of other medical conditions were treated in their GPs’ surgeries. Even some technical procedures began to move, as GP practices (or surgeons employed by them) started carrying out endoscopies, vasectomies, even more complex procedures such as hernia repairs.

However, what became quickly apparent was that the cash that could be taken out of the acute sector as it lost this activity was minimal. Individual diabetic patients only incur a few prescriptions, a modicum of staff time, and their ‘hotel’ costs. Unless one could close entire wards, real costs could apparently not be taken out, only costs at the margins. Without that incentive, the moves to make radical service changes fizzled out, leaving the established status quo more or less intact.

With the establishment of clinical commissioning (originally GP-led commissioning), the phoenix of real service change looked as if it could emerge from the ashes of previously stalled political initiative. Once again, it was proposed that GPs (or the wider primary care clinical groupings) would ‘control the majority of spending in the NHS’ and thus be able to make step changes to the dynamic of service delivery by moving resources out of the acute sector into community-based facilities.

But lo and behold, another issue has emerged to stymie these moves, based on a political ideology aimed at increasing competition, and the fear that GPs will use the new arrangements to line their own pockets. Formal competitive tendering has been introduced, whose practicalities have yet to be tested. Thus for example (according to guidance issued from the NHS Commissioning Board (NHSCB) last summer) CCGs ‘will need to decide whether services could be delivered by a number of potential providers (which may include general practice) or whether they could only be provided by general practice’. However, it is unclear how they will be held to account for their decisions, and by whom.

Although the NHSCB (through its area teams/regional offices) is not intended in principle to interfere, experience over the last two years has shown that at every stage the need to get the process right has trumped concerns about outcome. To misquote an old aphorism, we are focusing on doing things right rather than doing the right things, and this seems unlikely to change while the CB itself is learning how to function.

But there is a larger concern. The last thirty years have shown that we need to consider the structure and function of the NHS as two distinct issues. The system is evolving so that function is better and more seamlessly integrated, whilst the organizational structures that support these functions are often better kept separate. What must flow freely however, are the lubricants of success, which are money and information.

There is more discussion to be had here, but the immediate point is that as long as the funding streams of hospital and community care are handled separately, and the incentives for the preferred outcomes are not carefully and precisely aligned, no system will ever function properly. The dog’s dinner that has been the politicized process of the last three years has resulted in a confused, opaque structure that will never produce the culture that we need if we want efficient, user-friendly services as our outcome.

(This piece was first published in Pulse magazine on 9 April 2013)