Alcoholism: heartsink or microcosm?

ImageFew GPs get excited by seeing known alcoholics walk into their surgery; they are the classic ‘heartsink’ patients, with a host of problems, often insoluble. They range from the physical (you really do destroy your body with long term drinking), through the underlying psychology (there are often personality disorders and depression), to the day to day consequences, such as social isolation, unemployment, and homelessness.

Dealing with all these issues is difficult, as it entails the interaction of many different people, each with their own rules, cultures, and bureaucracies: alcoholism is perceived in very different ways by say, policemen, social workers, and nurses. Moreover, the patients themselves are often unwilling or unable to take control of their own destinies, and this makes the oversight and management of alcoholism all the more difficult.

However, with patience, experience, and the ability to work across many professions and disciplines, progress can usually be made. It may not be possible to overcome the problem completely, but at least one may be able to reach some form of stable balance between alcohol and the external world, a modus vivendi that allows life to continue in a relatively sustainable way.

In that sense, there may be lessons to be learned from alcoholism as an example of modern medicine’s new Big Issue: the treatment of all long term conditions.

The first half century of the British NHS were dedicated to the creation of super-specialists, able to diagnose and treat ever more precise conditions, thus defining their patients not as people, but by their illnesses (‘the leg in Bed 4’, ‘the appendicitis in A&E’). This approach may be useful when everything is running smoothly apart from one small problem, but such a ‘Kwik Fit’ approach to medicine fails utterly when there are several major issues to be addressed at the same time, especially when they include social and psychological determinants as well as physical ones.

Increasingly, health services around the developed world are finding that it is these complex cases that are exercising their services (and increasing their expenditure) rather than simple mechanical failures. Managing a sixty year old lady who has diabetes, breast cancer, and has recently been widowed is very different from mending a broken leg, or even treating a straightforward heart attack, and it is here that there may be useful lessons from the enlightened management of alcoholism. The key messages in both instances are:

  • Take an holistic, person based approach to the problem, don’t try to fragment it into reductive components to be treated in separate silos.
  • Be prepared to work with other teams, disciplines, professions, and organisations, without assuming that only you have the answers
  • Care is at least as important as cure: many of these conditions will last a lifetime, so we have to move away from the idea that absence of cure is failure.
  • Work with the patient, and not at them; in the end, it is their illness, and their involvement and expertise are key to its management.

I wrote this piece for the blog site of the Health Services Management Centre (HSMC), where it was posted last week.

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CCGs need to evolve and mature, NOW!

I have writEvolutionten before about the difference between ‘unconscious incompetence’ and ‘conscious incompetence’, and how one has to recognise a deficiency before one can address it, but I have rarely seen such an acute example as the one that currently exists in the CCG world.

As new organisations, often incorporating senior GPs with little if any experience of strategic leadership, it is perhaps not surprising that CCGs have taken time to grasp the breadth and the depth of the issues that face them; not only are they notionally responsible for an annual budget of over £60 billion of public money, they have to ensure that their own primary care house is in order, and deliver a degree of corporacy amongst their members that has never even been envisaged, never mind achieved.

However, now that they are nine months into their first ‘live’ year, one might have hoped to see more recognition of these issues, and a wealth of initiatives both locally and nationally to try to jolt the young groups into a maturity that admittedly needs to be well beyond their years. It is disappointing therefore to note that (certainly in my universe), there appears to be little if anything happening at a systemic level. The Leadership Academy seems intent on setting up a production line to manufacture senior leaders (an oxymoronic concept if ever there was one), and attracting mainly managers from provider organisations.

Others that might be expected to be compiling effective, accessible programmes to fast track CCG development (NHS Confed? BMA? RCGP? NHS Clinical Commissioners?) seem at best merely to be considering setting up such initiatives. They appear to be more concerned with meeting DH/NHS England operational edicts and maximising contractual benefits, beginning to replicate what CCGs were intended to end once and for all: doing things right at the expense of doing the right things.

In the meantime, NHS England, in its unreconstructed macho fashion, is starting to exert more direct pressure in the only language that its political masters seem able to understand: reductive operational targets. The whole notion of culture change and clinically led progress is rapidly being diluted, to be replaced by structures that will look more and more like PCTs, or the even older Health Authorities.

So what is required? The first thing is for CCGs themselves to recognise the need for internal development; even in my own small way, I have been trying to encourage the development of locally focused leadership programmes, learning sets, even stand alone workshops for CCG staff and their members to start to get to grips with the agenda, but it is proving to be a steeply uphill task. CCG chairs and accountable officers should think about resourcing such work themselves, as large scale mass produced products can never achieve the kind of cultural and organizational ‘fit’ change that a ‘bespoke’ programme can. The larger players (see above) should support and facilitate these local processes, and some central resourcing would be very helpful to oil the wheels and get the show on the road.

Do it now, applying a bit of welly to the process, and progress will be satisfyingly fast; leave it much longer, and those in the rank and file of the CCGs, the GPs who really need to ‘think differently’ to achieve systemic change, will have lost interest and gone back to the day job. Without them, not only will CCGs not succeed, the ‘supply side’ drivers (hospital crises, by and large) that have steered the NHS for so long will come to dominate even more strongly, with the only levers available to control them being the traditional blunt, insensitive, centrally controlled levers that have never really worked.

As the adage has it: ‘if you always do what you’ve always done, you’ll always get what you’ve always got.’ Isn’t it time that CCGs started taking control of their own destinies?

A&E departments and the M25 effect

I’ve just done a shorImaget slot on the local radio, talking about the ‘crisis in A&E’. It was based on the new report by the Health Select Committee that highlights the issues, but says very little that is new about their solution. We know that A&E is the ‘safety valve’ for the system, we know that the patients are confused about its role, and we know that fewer and fewer doctors choose to work there.

However, the solutions mentioned by the Committee are almost entirely structural and unimaginative: beefing up the Urgent Care Boards from small talking shops into larger talking shops really isn’t the answer; neither is a vague exhortation that Ambulance Trusts should become ‘care providers in their own right’.

Perhaps it would be helpful to reframe the issues, and consider them in a slightly different way. If we look at A&E from the perspectives of hospitals providers, of those working in the community, and of patients themselves, we might get a more rounded view of the problems and maybe their solutions.

Hospitals are under tremendous pressure; they have to see patients referred to them within eighteen weeks, admit acutely ill patients from Casualty in under four hours, and do it all within ever tighter financial and quality constraints. To deal with the front door issues posed by A&E, they have introduced more and more services there, so that for many patients, turning up at the emergency department offers a ‘one stop shop’ solution to their problems. The paradox is that the more that is provided at A&E, the more the service will be used.

Clearly, the corollary of reducing services at the front door is probably not a viable option in political or practical terms, but at least we should be aware of the dynamics of supply and demand in this setting, and think twice before we get seduced by more manifestations of the M25 effect.

From a community services perspective, it’s worth asking what the incentives and disincentives are to sending people to A&E: in the middle of the night, at an ill patient’s bedside, when relatives are panicking, no other care facilities are available, and the hospital light is on (to use Stephen Dorrell’s image), why shouldn’t the ‘on call’ clinician send the patient into hospital?

The presence in NHS111 of a telehealth service that seems to do no more than signpost the road to A&E doesn’t really help either; one of the reasons we have trained professionals is to cope with risk and uncertainty in a way that an algorithmic system simply cannot do, and offering a cut price alternative was predicted by everyone but the party politicians not to work.

From the poor benighted patients’ point of view, they are faced with the emotive issues of ill health, with little or no information, often on their own, fed by a media diet of Holby City on the telly, and instant gratification in all other aspects of their lives; they also know that if they call their GP they will have a battle to be seen promptly, and if they ring NHS 111, they will probably be told to go to A&E; so once again, what’s the disincentive for them?

Complex issues cannot usually be solved with simplistic sticking plasters, so whatever single concrete suggestions are made will not be enough; indeed, given our track record, playing around with the system (any system) in a ‘quick fix’ sort of way often compounds the problems, and puts different parts of the system under strain.

However, applying a deliberately opaque and undefined solution, whilst harder to quantify and assess, does allow the system (and particularly individual professionals within the system) to use such a solution constructively and effectively, and to feel more involved in that solution; ownership is a recurring theme in all the current manipulations of the public sector.

Thus, giving Acute Trusts a new process measure to meet, such as a new Trolley time target would merely stimulate a new ‘gaming’ solution (what is the real purpose of medical assessment units, for example, if not to take the strain off the A&E four hour target?).  However, contracting with the CCGs for an outcome measure of reduced admissions (and giving them control of the resources currently involved) would allow them to be inventive and innovative in their approach, involving their own professionals, and letting them see the direct benefit to patients, to hospitals, and yes, to their bank balances too.

The GPs who are involved in running CCGs aren’t bad at understanding health and illness, and the ways in which patients are involved (or not) in their care; they are also infinitely practical and pragmatic, so if given the tools to create a solution to a problem with which they empathized, then we might begin to see some progress.

Without their ‘buy in’, no single prescription can ever work, even for Bruce Keogh and Stephen Dorrell.

 

This piece is based on one first published in Pulse Managazine on 24 July 2013, entitled ‘Another sticking plaster for the A&E compound fracture’

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.

Links to two recent papers

Here are links to two papers that may be of interest; the first is useful, not just because my wife Sarah is the first author, but because the finding that the NHS Health Check could be easily and cost effectively be improved. The link to that one is

http://tinyurl.com/c9zjuye

The other paper is based on work in which I was involved that looked at the process and impact of staff engagement in four NHS Trusts. It showed how leadership, genuine ‘buy in,’ and a dynamic programme all help to develop and maintain effective staff engagement. The link to that is at

http://tinyurl.com/dybudgj

Raising and dashing GPs’ expectations

Charlie BrownMichael Dixon was on the radio again on Friday; this is such a normal part of life that it’s not usually worthy of comment, but this  interview raised issues for me that went far beyond the vagaries of ‘any willing provider’ (important though that may be), and went into the broader areas of how human nature responds to external stimuli.

Ever since 1989, GPs have had the carrots of increased prominence and influence in the NHS held in front of them; whether it was the creation of the purchaser/provider split, the introduction of GP fundholding, the appearance of PCGs and PCTs, or the publication of White Papers with enticing titles like ‘A Primary Care Led NHS,’ the GP community was repeatedly promised that each round of reforms would increase their profile and improve the lot of their patients.

But like Charlie Brown having the football he longed to kick always removed by Lucy at the last moment, the promises made to the primary care community have never been properly kept; unlike Charlie Brown, there is now a real risk that GPs will finally recognise the pattern, and refuse to play.

As has been drummed into us for so many years, GPs are generally independent contractors, and their obligation (and the reason why most of them came into practice) is to deliver personalised care to individual patients, ‘doing what they can, and buying in the rest’. Additional wrinkles such as revalidation and QOF points have been added over the years to strengthen this central plank of their existence, but it would be nigh on impossible to compel them to consider the broader issues of commissioning (with its implication of dealing with populations rather than individuals) as part of their ‘day job’.

The only way of engaging the general GP workforce in this work is by ‘selling it’ rather than ‘telling it’, but when deals are promised and not kept, potential buyers move from disappointment to cynicism, and eventually walk away completely.

Fundholding was never allowed to realise its potential; Primary Care Groups lost the centrality of clinicians in the main decision making processes as soon as they became PCTs; the ‘primary care led NHS’ was distorted by the behaviour of large acute provider Trusts, and the move towards clinical commissioning groups (itself a dilution of the original GP commissioning groups) looked as if it was the last chance to add significant primary care common sense to the commissioning of NHS services.

And now, even that promise is being eroded: the introduction of senior managers into CCGs is not the problem per se, because CCGs will need very senior managers to turn GPs’ decisions (whether strategic policy decisions or operational referrals of individual patients) into action; it’s just that the ones being hired are generally bringing with them the culture and bureaucracy of PCTs, and are not the innovators and influencers that are really needed to make change happen. And whilst we do need accountability in the CCGs that will be spending enormous amounts of public money, are the mechanical competency hoops through which aspiring CCG Chairs and Accountable Officers are being required to jump the most appropriate ways of developing that accountability?

And whilst we clearly need to prevent unethical ‘gaming’ in procurement, are the slow, ponderous processes that favour only the largest and most conservative providers the best way of controlling the potential conflicts of interest?

Finally, despite the obvious need to control spending in the mega-industry of the NHS, is the repatriation of so many of the ‘high end’ commissioning issues into central bodies the best way to engender the localism and ‘buy in’ needed to ensure the success of this round of reforms?

My questions are deliberately framed in a one sided way, as there are few people who would argue that the mechanisms currently being developed are anything other than reductive sops to the political pressures being exerted; for any chance of success, I would suggest only a few key principles are required, and that the Great and the Good should be expounding on these, rather than responding to individual operational ‘symptoms’ being raised in the media on a daily basis. These are:

  • The Centre should be determining what is required, and letting the CCGs work with their providers to establish how this is going to be done. This works to everyone’s strengths, empowers local professionals, and means that there would be considerably less micromanagement than at present.
  • CCGs should be considered as the health maintenance organisations responsible for the healthcare of their populations, making the allocation of specific roles and funds for provision more like sub-contracting than strategic commissioning. This would simplify the perceived conflicts of interest, and reduce the stranglehold on progress being exerted by the artificial bureaucracies of the current tendering process.
  • Finally (and probably the most difficult to enact), professional clinicians (doctors and nurses) need to be treated as professionals, and encouraged to make individual decisions within a corporate framework. In that way, one can overcome the paradox that it is only when professionals feel that their autonomy is being respected that they are prepared to act more corporately.