Health policy

The NHS in Lewisham: a victory for natural justice?

Vox PopuliLewisham Healthcare NHS Trust is a mid-sized organisation (turnover in 2010/11 was about £220m) that includes acute hospital and local community services.  It produced a surplus of about £1m in that year, having overcome recurrent deficits to achieve sustained surpluses over a relatively short time http://tinyurl.com/p9yvq93. It epitomizes the successful integrated NHS organization: financially stable, well liked by its users, and expecting to achieve Foundation Trust status until external events overtook it.

Its misfortune was to be sited close to the vast, failing South London Trust, which was put into administration in July 2012, with losses predicted to exceed £60m annually. In early 2013, the Secretary of State for Health Jeremy Hunt agreed with the administrator (Matthew Kershaw, from McKinsey) that the Lewisham Trust should merge with part of the dissolved South London Trust, with the downgrading of its University Hospital and the closure of its A&E Department http://tinyurl.com/oqn57lu.

This decision was challenged legally, and a judgement has overturned it http://tinyurl.com/pn27366 , although the Government is considering an appeal.

The judgment is important, not only for the Trust, but for the messages it sends out about the NHS, its drivers, controls, and self determination. There are at least three main points:

1  Externally driven NHS Trusts may as well be directly managed units

Over the past few years, the Lewisham Trust has shown the value and impact of self determination.  It successfully overcame its financial problems, absorbed community services, and built up a reputation as a thriving, effective organization, a significant ‘player’ in its local health economy. If these achievements are discounted, and its future determined by Whitehall, then staff (clinical and otherwise), users, and local organisations such as the Council, will all see themselves as entirely disenfranchised; how that perception is incorporated into a political agenda of ‘localism’ poses an interesting challenge.

2  Expectations raised and dashed are worse than no expectations at all

The current NHS reforms in England are based on a few simple foundations. The first acknowledges clinicians’ impact on the processes and outcomes of health care by involving them in driving these; doing so produces a degree of ‘buy in’ and responsibility amongst clinicians, and develops a new and appropriate line of clinical accountability. The second is an extension of this: as general practitioners instigate most NHS spending through their prescribing and their referrals, they should be involved in the strategic spending decisions as well as the operational ones. This allows more rational and coherent planning, with the ‘ownership’ needed for responsible, accountable working.

The Clinical Commissioning Groups (CCGs) currently finding their feet are the organisational embodiment of these simple foundations, with responsibility for around two thirds of the entire NHS budget of £108 billion, and some influence over the rest. The key tasks they face in their first year are not only to learn to walk (by getting themselves established, and their members engaged), but also to run (by producing considerable savings, and starting to plan their future, more strategic activities).

These tasks would be hard enough, but if the application of their new found skills were to be immediately overturned by Governmental dictat, then all the efforts that have been applied in overcoming GPs’ natural cynicism about involvement in commissioning will have been wasted; the noise of the ensuing disenchantment is likely to drown out for many years any attempts to achieve the same aims.

3  ‘Vox populi’ is not democracy

If the lay press is to be believed http://tinyurl.com/qx2xvve , the recent judgement seems to have been driven entirely by local activists trying to save their hospital. Whilst local support is helpful, it would be bad for any part of the welfare state if national policy was only the result of local pressure.

The NHS was designed to be both egalitarian and utilitarian, and as such, ‘broad brush’ strategy needs to be driven in a systematic, rigorous fashion. The recent Health and Social Care Act http://tinyurl.com/pj3j4v3 suggests that decisions about service configuration should be made by CCGs working together, with appropriate input from NHS England, under the aegis of overarching Government policy. Whilst patients and the public are obviously important protagonists, it would be a dangerous precedent if major reconfigurations were seen to be driven by public demonstrations.

Finally, it is worth considering how the reconfiguration exercise might have been handled better. Once the South London Trust had been disbanded, it should have been the CCGs working with NHS England who made the strategic ‘macro’ decisions about the overall shape of service delivery; the operational details, the ‘micro’ decisions, should (in theory at least) been left to the new delivery organisations to define themselves, in response to an outline brief (‘what is required’) rather than any overprescriptive, micromanaged approach (‘this is how we want you to do it’). Broad brush strategic management needs the high level players to be involved, but preferably not the politicians; operational delivery is best left to those who know how to do it.

This piece is based on an article published in The Conversation on 1 August 2013, which can be read at http://tinyurl.com/p6wom8j

Referrals by numbers: consultant league tables

table - June1What are the criteria you apply when you refer a patient for a surgical opinion and possible operation? How much of your decision is based on evidence, and how much on ‘gut feeling’?

The likelihood is that, as an informed professional, you base your consultant referral decisions on judgments that include a bit of both: some quantifiable data (e.g. waiting times, lengths of stay, readmission rates etc) with a number of ‘softer’ measures about the consultants concerned (such as how nice they are to patients, whether you get on with them, your kids go to the same school, and so on) and about the patients being referred (will they get on with the surgeon, how far will the relatives need to drive to visit, whom do patients actually want to see, and suchlike).

What you are unlikely to do is base your decision on any one of these factors on their own; the social skills of a doctor are important in diagnosing and treating patients effectively, but are not enough to predict good results. Similarly, any single technical measure is too reductive to be of much use; it is too linear in the same way that the price of a computer is too linear. In the case of the latter, I need to know more about the size, computing power, display, operating system, and software (to mention but five factors) before I can make any kind of informed decision.

Thus, I would suggest that new ‘league tables’ such as the National Vascular Registry are just as unhelpful on their own, because missing out on most of those other markers of complexity makes them impossible to interpret on their own: their bald figures give little if any sense of context. If Prof X in London has a higher mortality rate in his surgery than Miss Y in Leeds, is that because he is a worse surgeon, takes on more risky patients, works with less able junior doctors, or has recently had a messy divorce? Is she a better surgeon, or does she only do a few simpler procedures that are intrinsically less dangerous? On their own, the figures don’t tell us any of this.

And even if the figures do reflect the quality of the surgery itself, it is worth remembering that surgical statistics, like all statistics, deal in probabilities, not in certainties; using Miss Y’s figures tells us what happened in the past, but her future results can only be inferred from them. For that reason, one needs to challenge how much weight to give them against issues such as distance of treatment from home, hospital ‘hotel’ facilities, and other extrinsic factors that may influence the whole patient experience, to say nothing of the intrinsic factors such as age, gender, social situation and co-morbidities.

As professionals who spend their whole working careers dealing in ‘soft’ variables like these, GPs are better placed than most to make the appropriate interpretations; patients, whose experience is limited to events in their individual lives, and perhaps those of a few family and friends, are less well prepared. That being the case, how useful is it to publish such information in the public domain, politically incorrect as it may be to suggest such a thing? Publishing the surgeons’ ratings in the Daily Mail is probably the least desirable outcome of all.

In other areas of consumption where consumers are not experts, there are often guides produced to help them make more informed choices; thus for example, the Consumer Association will list the criteria they use in assessing the quality of any particular product, and even make explicit the weightings they give each one; they will (to mixed effect, it has to be said) try to contextualise their findings, so that any reasonably bright but uninformed reader can gain a more ‘three dimensional’ view of the product, and make reasonable, logical, and effective choices. Alternatively, shoppers can follow the ‘Apple Store’ route and go to a reputable shop, where the assistants are trained to offer advice and informed guidance to the customers (although this is usually biased towards making a sale….).

Whatever the ‘purchase’, the messages are the same; in areas of complexity, simplistic measures are not helpful, and may indeed be perverse. Expert knowledge is required, which may be learned by the dedicated consumer, or offered by a guide, that may be written, or embodied in a good sales rep, or an objective, informed ‘care manager’. In health terms, that person is (or should be) the GP, with a good working knowledge of the medicine, the local NHS Trusts and their consultants, and an ongoing understanding of patients’ context and needs (preferably both physical and social/psychological). It is the GPs who should be the main customers for the ratings, not the red top daily papers.

This piece is based on one published in Pulse Magazine on 17 July 2013

CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013

Kissing it better: beliefs in modern medicine

ImageI’m trying out a new medium today, using the University of Birmingham’s Ideas Lab, on which they’ve just posted a podcast from me about health beliefs. You can find it at:

http://tinyurl.com/nd5wql8

I think the issues are as pertinent to health care professionals as they are to patients and the public, and it’d be really helpful to start a proper discussion about ways of harnessing and influencing people’s health beliefs, rather than always trying to discount them.  Even the term ‘placebo’ now has negative connotations, rather than being seen as a useful tool in the clinician’s bag.

What do you think? Should we be sticking to the narrow and reductive route of evidence based medicine to the exclusion of all else, or is there benefit in looking at a more holistic view of healthcare that uses all the levers it can find, even (perhaps especially) the ones that reside inside our own heads?

The issues obviously matter in the determination and implementation of ‘best care’, but it may also be relevant when we consider professional knowledge transfer; how and why do professionals change their practice, and how can we influence that? Can it be done scientifically, by assuming that this week’s articles in the Lancet will translate into next week’s clinics, or is there something deeper that influences how clinicians think, how their beliefs affect their behaviour? If the latter is true, we may need to augment those scientific journals with ‘softer’, more fuzzy approaches, the kind of tools used in social marketing.

I’d be very interested in your views…

If you go down to the A&E, there shouldn’t be any surprise….

Teddy bearsOur increasing use of hospital services is out of control and unsustainable, and is contributing to the current crisis in accident and emergency (A&E). But the problem isn’t new and 30 years of NHS reforms have tried – and failed – to control it.

We now have figures that show a million more people went to A&E in England between February 2012 and January 2013 than had done the previous year – although changes in reporting may explain some of the increases we’ve seen in the past 25 years. There are also reports that trolley times are routinely reaching 12 hours in some parts of the country.

Now that GPs have been given control of some £80bn to plan and pay for NHS services (it’s what Clinical Commissioning Groups are for…),  many believe they should also be able to treat as many as 30% of people who come to A&E, more appropriately, and in a way that eases the burden.

The 1990s saw the creation of the ‘purchaser/provider split’, which separated those who planned and bought services from those who provided them – i.e mainly the health authorities and hospital trusts. With this came the half-hearted introduction of some elements of competition.

But only if we properly understand the underlying issues can we develop a coherent strategy to deal with them. And these issues can be encapsulated in three words: poorly aligned incentives.

A question of supply and demand

The dynamic between supply and demand drives many aspects of the human condition, and this applies to the NHS too. It has always been demand led, as it was created to respond to and meet our health needs.

There are elements of preventative care, but they’ve never been as prominent as ‘sexy’ acute services such as saving babies or heart transplants.

However, demand for any service is based on knowledge of that service, and in healthcare (as elsewhere), this kind of intelligence lies mainly with those who provide them, who use it to drum up business. Until we knew that 3D televisions existed, we didn’t realise how much we needed one. Similarly, in the NHS, until we know that treatments are available for heart disease/depression/impotence, we don’t ask for them.

As in every other industry, the supply of health services tends to drive demand. Hospital funding has moved away from opaque ‘block contracts’ – crudely, an annual allocated amount – to a system based on ‘payments by results’. As this is actually payment for activity, it tempts hospitals to increase supply to drive up demand.

In commercial industry, demand is largely regulated by price: “I’d love that 3D telly, but I can’t afford it right now”. But NHS services are largely free for us to use.

They are also free to GPs, who control most of our access to hospitals through patient referrals – except A&E of course, where we decide whether or not to visit.

Traditionally, GPs referred cases to their hospital consultant colleagues that were complex, or needed high-tech interventions. It’s always been assumed that referrals are driven purely by clinical criteria (what patients need) and specific skills (of a particular hospital specialist), not serendipity or whimsy. Patients’ needs and clinicians’ expertise are supposed to matter – not consumer choice or doctors’ golfing schedules.

However, if the balance between supply and demand has depended on these assumptions, they have been eroded over the years; it’s been assumed that patients seek help when they need it (though the tension between ‘need’ and ‘want’ increases as we’re encouraged to become consumers of a ‘free good’ like the NHS); we’ve also assumed that hospitals respond to demand (and are not incentivised to increase it) and that GPs are professionally driven only to refer patients when there is an absolute need.

But with GPs’  contracts now based largely on listed activities,  they are less prepared to absorb the grey areas where no explicit activities or payments are described – for example a home visit to a bereaved widow.

Apply these criteria to the A&E situation and the results are obvious:

  • Patients, now consumers used to instantaneous service in other aspects of their lives, are bound to prefer going to A&E than waiting for an appointment with their GP. Not only is A&E open 24/7 but tests that would take weeks to arrange through normal channels are instantly available. Sure, the care is neither continuous or holistic in A&E, but these concepts have been increasingly devalued because they are so hard to measure.
  • Hospitals receive payment for every attendance at A&E, and get addiitonal sums if patients are then admitted to the wards. They are also punished for keeping patients in A&E for more than four hours, so admitting patients becomes a no-brainer. It’s only now, when demand for hospital services is starting to outstrip supply – and the cash to feed it – that the cracks in the system are beginning to show.
  • If there are no disincentives for GPs to refer patients into hospital then why wouldn’t they do it, when they feel disenfranchised and de-professionalised by the reforms that have been churning round them for three decades?

This is all easy to analyse, but harder to repair. The basic precept underpinning the NHS has been that it’s free at the point of delivery, so the mismatch between consumerism and the welfare state is bound to expand, unless the notion of corporate responsibility in health can be re-introduced or until services cease to be free.

One mooted idea has been to increase public awareness of NHS costs, on the basis that this might make them think twice before (ab)using the ‘free’ service.

Activity-based hospital funding isn’t sustainable, and a return to some kind of risk sharing between service providers and those who commission services (the GPs) is a prerequisite to managing demand at an institutional level.

GPs’ incentives must be better aligned so that it becomes truly in their interest (professionally and morally, as well as financially) to restrict referrals to those that are really necessary.

The biggest issue is that of managing service availability; as long as we increase the supply of hospital services (particularly in A&E departments) this will feed demand. We have responded to the supply side constraints in clinics and investigation facilities by increasing that supply, so it is hardly surprising that this has in its turn encouraged higher demand.

The obvious corollary would be to deliberately restrict services, but that would be very hard to sell politically to an already disillusioned electorate. However, if GPs and the CCGs were allowed to do what they were first intended to do, their core purpose would be to extract the optimum health benefit from the public funds allocated to NHS Trusts.

Managing demand would be high on their list, and most of them would tell you that given the right tools, they would manage to do this in a much more coherent fashion, albeit at the cost of reduced health consumerism. The challenge is to loosen the stranglehold from central government sufficiently to allow this to happen before all the breath of enthusiasm for doing anything is completely cut off. And that really is a Political decision.

This is a modified version of an article published in ‘The Conversation’ under the title of ‘A&E is in crisis because we all take it for granted.’ That piece is available to view at http://tinyurl.com/mp8esp6

A snack that you can eat between blogs without ruining your appetite

I’ve been very busy this week, and haven’t had the time to do a full length entry.

However, I was involved in an interview with The Consultant magazine, part of a feature that they were running on commissioning.

The link to the magazine is: http://tinyurl.com/o25jxmo, and it may be worth a look.

Hopefully, I’ll be back on track in the next few days with a full blown article here.

Making CCGs work: three cardinal rules

jigsawClinical commissioning has arrived, but it will take a while before it becomes clear whether it is creating order or chaos. Now may be an appropriate time to revisit the underlying principles to see how it is likely to pan out.

Commissioning is not a simple notion, but an inclusive concept that covers a number of different functions. At the ‘micro’ level, there is the direct procurement of individual services, a process that has been called contracting: the customer pays the supplier for a service on which they agree.

Let’s say the customer is a home-owner, who wants a new kitchen; he has a rough idea of what he wants (the ‘output specification’, if you like) but as he doesn’t know much about building kitchens, he will need to capitalize on the supplier’s expertise and trust him to do the job well. Success will be measured in terms of overall quality and satisfaction, timeliness, and costs, and if these aren’t met, the buyer may have to use the contract to hold the supplier to account, and gain redress for any failure.

In NHS terms, such micro-commissioning is based on GPs’ referral decisions: GPs know roughly what they want, and they have a knowledge of the local expertise; their role is to organize specific procedures with the appropriate experts, and then check that they been carried out to the agreed specification.

They have the advantage over the home-owner that their knowledge of specialist provision, whilst not encyclopedic, is detailed enough to let them make realistic assessments of quality and perception, timeliness, and costs.

At this level, one would not expect the home-owner or the GP to make decisions based on strategic impact or links to a European Directive; it would be for the specialist expert in each case to keep their customers apprised of any legal issues, and it would be the experts who would be held responsible for any non-compliance.

At the ‘macro’ level, the parallel relationship may be that between the town planners and a major home-builder; as with the individual kitchen, there needs to be agreement based on a mutual understanding of the outcome of the job, and any necessary markers of its progress.

Thus, the planners may want the new estate to be carbon neutral, to fit into the existing architectural ‘mood’, and to be completed within a certain time, to a specified quality, at an agreed cost; if they are sensible, they will leave it to the technical experts to decide the precise manner in which they respond to these specifications. Not only does that involve the builders in the decision-making and so keep them engaged and enthusiastic, it also maximizes the benefits of their expertise and promotes a degree of risk-sharing that divides up the responsibility (legal, financial, perceptual) for the project, and ensures that both parties need to attain the same positive outcome to be satisfied.

Back in the NHS, this relationship mirrors that between strategic commissioners (the CCGs, Area Teams, and the regional offices of NHS England: do we really need all three???) and the acute sector pretty well. Like the town planners, the strategic commissioners will need to incorporate national policies and regulations into their strategies. They will need enough knowledge to ensure that their providers are not pulling the wool over their eyes, without getting bogged down in the level of operational detail that boomerangs the risks back to them whilst raising the transaction costs of the whole process.

At this level, the quantum being procured is much larger, and so it is harder to ‘contest;’ a local authority, having agreed for a contractor to build them a whole new housing estate, would find it much more complex to withdraw from their contract than if they were contracting for a single kitchen. However, a competent authority should have levers to pull, should the builders not fulfill their side of the agreement.

And it is here that we come to the nub of whether or not commissioning in the NHS will succeed.

While developing and monitoring contracts (like any other performance management system) should be based on the carrots of success, it should be backed up by sanctions that are appropriate and viable.

Such levers should ultimately be based on the ability and feasibility of withdrawing the contract, something that itself depends on the availability of alternative provision and the consequences of such action (be they financial, legal, and perceptual, with the added complexity of how they affect the health of the population involved).

When the notion of commissioning first appeared the NHS in 1990 in the guise of the ‘purchaser/provider split’, its main purpose was to steer the acute sector away from fuelling ‘supply-led demand’ in health services and towards a new responsiveness to the needs of the population.

In fact, several iterations of change have not really had major impact on the acute sector, which still seems to be relatively unaffected by the current organizational changes, although it is facing some highly challenging financial pressures.

As long as it remains impractical to offer real challenge to the acute sector, commissioning will be largely irrelevant, offering no more than minor political irritation to the vast and politically-aware acute sector.

The three key challenges for the new commissioners may be summarised as follows:

– At the micro-level, the development of more widespread alternatives for GP referrals needs to be encouraged; merely shifting referrals between different hospitals won’t be enough, as the ensuing Brownian motion is unlikely to promote any real change, just random movement.

What is required is the threat of removing activity from the sector entirely, which will depend either on practices being allowed to develop viable alternatives themselves, or other providers (private or otherwise) being given access to such provision.

– At the macro-level, the systems being developed (whether through contracts or other less tangible ‘currencies’) must not be allowed to become ‘too big to fail’. Keeping the quantum of exchange small enough to allow real contestability is going to be key if commissioning is to become an effective management philosophy.

Thus for example, it is much easier to challenge the provision of a single service (Physiotherapy? Pathology? Plastic surgery?) where real service delivery changes may be seen, than in trying to shut down an entire hospital, or even parachuting a new management team into a failing Trust, where direct patient care is unlikely to be affected (at least in the short term).

– And at the ‘meso’ level that spans micro and macro, it will be vital that the consequences of any actions be seen quickly and directly. If the GPs in a CCG want to repatriate a service out of the acute sector and into the community and it takes three years and a warehouse-full of bureaucracy to do it, then the GPs will simply give up trying. The links between input and effect need to be obvious and the accountability for both needs to be transparent and appropriate.

If commissioning becomes an ineffectual brake on demand, then we may as well abandon the whole concept now; however, if we manage these cultural changes, then the introduction of the new commissioning arrangements have the potential to be the ‘pivot point’ for changing the entire dynamic of the NHS.

A version of this article was published in Pulse magazine in the UK on 8 May 2013

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.

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)

The birth of CCGs: so much to do, so little time

ImageThis blog was first published in Practical Commissioning on 19 March 2013.

Although Donald Rumsfeld was a US Secretary of Defence, he will probably be remembered for a statement he made in 2002 about the Iraq war, though we’ll ignore that symbolism. Anyway, this is what he said:

‘There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.’

As CCGs prepare for their formal birth, Rumsfeld’s aphorism is a useful guide to thinking about their developmental needs, as long as one adds the one missing category, the ‘unknown knowns’  – the things we don’t know that we know.

CCGs are designed to combine two important elements of healthcare into a single, seamless function. Although their stakeholders are intended to be clinicians generally, their focus is on GPs, whose key purpose is to integrate healthcare delivery with referral decisions to ensure that the services in the specialist (hospital) sector effectively and efficiently fill any gaps in primary care provision.

For jobbing GPs, there will probably be little difference in their routines; they will still see patients, and refer those who cannot be adequately treated in the consulting room. In their referral decisions, they may be expected to conform to CCG rules as to where and when patients should be sent, but other than that, the transition to CCGs may – and it’s not such a bad thing – have little impact for the ‘grassroots’ GP.

It is at the organisational level that Rumsfeld’s aphorism may have more relevance, for CCGs will need to consider the strategic and operational aspects of commissioning, and indeed make sense of the term itself. Thus for example, at an operational level they will quickly need to understand the business models of their local trusts, link service availability with local population needs, identify and fill any gaps, and develop referral policies for which their member GPs will need to become accountable.

At a more strategic level, they will need to understand how the needs of their population may be compared and combined with those of neighbouring CCGs, grapple with medical and societal trends and juggle these issues with the political pressures that will constantly intrude.

They will also need to wrestle with the issues of probity that bedevil the whole of the British welfare state, but are probably worst in the NHS, where life and death issues overlay rational decision making, whether financial, legal, or clinical.

These are just a few examples of the tasks facing CCGs; the questions they raise concern the skills needed to succeed in them, how well equipped are they in these skills, and what help will they need to develop the ones they lack?

Which brings us back to Donald and his various permutations of known and unknown. There are skills in the CCGs that are so well established that their clinicians don’t even have to think about them: good general practices are so effective at understanding the interweaving complexity of patients’ physical and psychological problems and handling the uncertainties and probabilities underpinning good care care that they do these almost unconsciously. These are the skills that Rumsfeld missed out: the unknown knowns. We are so good at what we do that we forget how hard it is to do. Like experienced cyclists who give no thought to balancing their precarious machines whilst ducking and weaving through the traffic, good primary care clinicians are unconsciously competent at what they do. We should celebrate the dedication and training needed to achieve such effortless effectiveness.

However, there are many tasks for which CCG leaders will need new skills. They (generally..) realize that they need more financial and political skills to cope with their Local Area Team, the NHS Commissioning Board and the rules and regulations that could explode around them like land mines. These are ‘known unknowns’ where they are consciously incompetent, and where training is already under way. I have slight misgivings about the nature of such training, as the need to produce programmes ‘at scale’ for so many CCG leaders and senior staff feels at odds with the highly individual developmental needs of each person; it’s important to understand accounting systems, and the latest version of the NHS Operating Framework, but it needs a defter, more crafted approach to discuss how to cope with personal and organizational politics, or how to manage the care of too many people with too little money.

Finally, there are the ‘unknown unknowns,’ those problems that only become apparent when they become apparent. For instance, it’s likely that much work will be required to manage autonomous clinicians without losing their enthusiasm and dedication, or in re-invigorating the caring culture that has been so deficient in recent years, especially when the NHS (like every other vast bureaucracy) will continue to be reductive and punitive.

But even an external dispassionate view cannot predict unknown unknowns (or they’d be known unknowns…). The challenge is to have mechanisms in place in anticipation of the new, difficult issues, less to help in solving them than to support CCG leaders as they cope with their implications: for it is when blissful unconscious incompetence (‘commissioning is just an extension of what GPs do’) turns into conscious incompetence (‘OMG, what do we do now?’) that the risks are highest of the wheels coming off the wagon. And in this case, the wagon may be CCG leadership itself as much as the mechanics of CCG function.

Having high level, developmental support in place working with CCGs leaders will be crucial in allowing them to grow and mature in ability, confidence, and effectiveness.