You can take GPs to water, but can you make them drink?

This article was first published in Practical Commissioning on 12 December 2011, and shows the origins of some of the ideas cited in my blog about managing expectations (1 March 2013).

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What makes doctors choose general practice? When I made that choice, I was attracted by the idea of holistic whole person care, and of developing long term relationships with patients, their families and even their communities. There was also the appeal of ‘divergent thinking’, rather than the reductive mechanical approach that was followed in hospitals. But there was something stronger too, a pull towards the community as much as a push away from hospitals, something about self determination and control; doctors in general, and GPs in particular, are individualists who don’t think corporately. Is this down to nature or nurture?

As far as nature is concerned, medical schools select bright students with scientific backgrounds, and enough ‘open’ thinking to allow them to develop good clinical judgment. On the nurturing side, the emphasis throughout medical training and postgraduate development is on autonomy and the importance of personal accountability to back the primacy of the doctor/patient relationship, based as it is almost entirely on individuals.

We take this approach because society values the ‘sanctity’ of the consultation, and the fact that what happens between doctor and patient remains entirely between them. This mutual trust depends on this axis of confidentiality, and so anything that threatens the primacy of this relationship would be extremely hard to sell to GPs.

These thoughts came to mind when I was at the NHS Alliance conference recently, talking about the future of the NHS. I was thinking about what it takes to persuade the autonomous, self-determining, (generally) self-employed individuals who are GPs to change at all, never mind acting in a corporate fashion and taking on a externally imposed agenda, with a budget deficit and bureaucratic rules that would make even a seasoned civil servant blanche…

There isn’t a simple answer, but generally, if you want people to take on a new and risky role in a meaningful manner, you need to follow the dictum of ‘sell it, don’t tell it’. Those taking on the role need to believe in its value, see some benefit from doing it, and be exposed to as few surprises in its implementation as is possible.

Does this work if we consider the moves towards genuine clinical commissioning? Although the jury is still out about its effectiveness, most GPs like the notion of having more control over what happens to their patients in the secondary care arena. They are however highly suspicious and extremely cynical about the motives of the Government in setting out this agenda, many believing that any benefits will be in terms of money saved for the Government, rather than for improving services for patients or (dare one say it) benefitting GPs themselves.

Increasing the bureaucracy of the system (as already seems to be happening), making the approach ever more parental, and limiting the scope for innovation and diversity would all be excellent ways of smothering the changes before they even start; just look at what happened to practice-based commissioning, which ground to a halt even before it was fully established.

Moreover, in the words of the aphorism, ‘an expectation raised and dashed is worse than no expectation at all’, and over the past 20 years, GPs have had their expectations raised and dashed many times; whether we are talking about fundholding, ‘a primary care led NHS’, PCGs, PCTs, or PBC. In each instance, much effort was put into persuading the GP community that this was their breakthrough moment, only for each initiative to become diluted and eventually scrapped. For the evangelical GP, each step along this Via Dolorosa may be seen as inevitable on the path to salvation, but for the jobbing GP, perhaps vaguely interested but certainly not prepared to subsume her mortgage payments for the sake of eventual paradise, each dashed hope merely increases their sense of disengagement and cynicism.

If the current round of reforms isn’t fully implemented (and the current tussle between the centralising clusters and the nascent CCGs doesn’t look promising), Dr Average may well take his or her ball away for a very long time, and simply get on with the day job; and given that the day job includes indirect control of most of the resources of the NHS (wisely or otherwise), this scenario may be one that the Government wishes to avoid..

What Francis should, but probably won’t, say (first published 5/2/13)

This article was first published in Clinical Commissioning on 5 February 2013

The Francis report, due to be published tomorrow (6 February), is Robert Francis’ final report on events at the Mid-Staffordshire NHS Foundation Trust, and is expected to make far reaching recommendations to prevent such failures from happening again.

Whilst there is no doubt that events in mid-Staffs reflected cultural and operational problems unique to that Trust, I would suggest that there are a number of more deeply seated issues that affect the entire NHS, that could no more be solved by tighter regulation than could the seven deadly sins.

Paul Batalden’s famous aphorism that ‘every system is perfectly designed to get the results it gets’ has become something of a cliché, but the NHS illustrates this truism over and over again. If Francis is to have any impact, it would do well to acknowledge some of the design issues that have led to the system delivering the services it currently does; perhaps by addressing just some of these, the cultural issues that drive any large iconic institution may begin to change. What is certain is that new regulations, however draconian, will only reinforce the current culture, and do nothing in the longer term to prevent further mid-Staffs type crises from happening.

Let me highlight just a few of these design issues:

 

Clinical/managerial dissonance

The Griffiths report of 1983 was an important milestone in the history of the NHS in that it introduced the notion of general management, by which the running of the health care system was effectively separated from its clinical function. To paraphrase the reason, it was to liberate clinical staff from the onerous administration of the NHS, and allow them to get on with treating patients.

There were two main consequence of this separation, both of which were, in hindsight, entirely predictable: the first was that clinical drivers and financial pressures effectively became polar opposites, with the call for better treatment inevitably countered by the political and economic need to squeeze more out of every health care pound.

This dichotomy led to the inevitable result that managers became the champions of the financial end of the tug-of-war, whilst clinicians fought for clinical improvement; the traditional tensions between practitioners and ‘the system’ had become formally entrenched.

In the case of mid-Staffs (and perhaps in many other financially challenged Trusts?), this tension was played out in ever poorer levels of staffing, and in money-saving clinical shortcuts that adversely affected the standards of care, sometimes terminally. In system terms, the only way to overcome this tension is by developing some congruence between the different champions, giving them common purpose rather than creating artificial rifts.

Organisational welfare, which encompasses financial health, reputation, clinical outcomes, and even the ‘friends and family’ test, would make a better (if necessarily more vague) target for all staff than separate, often conflicting, aims for each professional tribe. A utopian ideal? Only insofar as it pre-supposes a solution to the next design issue:

 

Lack of ownership and disempowerment

The NHS is large; it’s HUGE; it employs a significant percentage of the entire population, and moreover, it’s nationalised, belonging to the country. Like anything else that belongs to us all, it actually belongs to none of us; it is ‘they’ who run it, ‘they’ who tell us what to do, and ‘they’ who carry the responsibility for it, not us, who are just trying to get on with our jobs under difficult circumstances.

You get the idea; the NHS is so large, that it is hard to feel any real sense of personal involvement and pride beyond the specifics of one’s own particular tasks. There is an overwhelming lack of ownership, and the current culture in the service only increases this. As long as the rhetoric of ‘localism’ and ‘involvement’ is matched by the reality of central command and control, cynicism can only grow, and disenfranchisement flourish.

Creating stronger, more locally based organisations (as Foundation Trusts were perhaps intended to be) might have been one way forward, but the pressures for transparency and value for money in our nationalised system mean that even they are now driven more by external pressures than by any internal sense of pride or aspiration. If you and I were to set up a business together, just the two of us, with our own money, then we would have total ownership of it, and it would be clear that we would succeed or fail entirely by our own efforts. Once there are several thousand of us, that sense of pride becomes harder to sustain, but not impossible, especially when many of those thousands are autonomous, self driven professionals. However, once those thousands are not only told precisely what to do but exactly how to do it too, then it becomes virtually impossible.

For people in general, and autonomous professionals in particular (managers as well as clinicians), to retain their enthusiasm and drive, they must perceive the problem as theirs, and see the direct benefit of its solution; if the problem is perceived as artificial or irrelevant (as was the case with many of the procedural targets such as trolley waits), then solutions emerge that owe more to gaming theory than to good clinical practice, and the downward spiral of rules leading to malaise leading to regulations continues inexorably to tighten. The system is perfectly designed…

As with any cultural issues, their solution is not simple, but the principle set out when the purchaser/provider split was first set up may be helpful here: the purchasers defines ‘what’ needs to be done, and the providers determines ‘how’ they will do it. In that way, those working in the provider Trusts may feel that they are included, enfranchised, and with good leadership, can happily accept the mantle of responsibility that is part of the pleasure of working in a professional capacity.

If purchasers prescribe the ‘how’ as well as the ‘what’, then not only will the disempowerment worsen, but any benefit of the separation will also be largely lost, as the system is intended to capitalise on the expertise of the providers on provision, not expect purchasers to know everything about provision as well as commissioning.

A third design element within the NHS that Francis would do well to address is that of the role of the Board.

The reforms of the last thirty years or so have emphasised the notion of giving NHS provider organisations a degree of independence, perhaps in an attempt to pre-empt some of the issues raised above; and as quasi-independent bodies, they have been obliged to have rigorous governance in place, overseen by a Board comprising non-executive as well as executive Directors.

If you were creating good governance in an organisation providing health services, what roles might you ask the Board to fulfil? Yes, it would need to ensure legality of process by having some legal expertise, and sure, it would need to be financially sound, but we’d be sure to include some non-executive governance of its core function, wouldn’t we? We’d give at least the same priority to the clinical aspects of care as to the procedural issues of money and law, and we’d make sure that the Board membership encompassed all these roles.

And yet, I have never seen advertisements for Trust non-executive Directors or Chairs that mention clinical oversight as a core part of the job description; indeed, I left the Trust I had chaired for over five years when it became apparent that Monitor expected the Chair of an aspiring FT to be an accountant first and foremost. In my view, borne out by events at mid-Staffs, governance needs to comprise four aspects of organisational life: core content (in this case governance of the clinical function), financial and legal surety, and workforce governance. The Board needs to juggle all four to be successful, and once again, Batalden’s aphorism rings true: if the system is designed to provide only financial surety, that is what it will do.

So Francis would do well to cover at least these three design flaws; how the system deals with them is a further and genuinely ‘wicked issue’, as true cultural change is generational in its timescales, and can’t easily be condensed into eighteen months to meet the needs of the political cycle. I have one radical suggestion to offer, as my starter for ten:

If you let me open my own hospital, and recruit all the staff from scratch, using criteria that correct the design issues I have described, I think I could give you a healthy, functioning, successful organisation. Let that organisation define the skills and expertise of its staff, and let it determine ‘how’ it will deliver the commissioners’ ‘what’, and we might have the basis of an exciting and vibrant health service.

Do any of us expect Francis to deliver such vague recommendations? Of course we don’t; government sponsored reports are almost always based on numbers and rules; but if the report makes no reference to the ‘soft’ elements that are so hard to deliver, then it will have solved nothing, and indeed, may be seen in the fullness of time to have compounded the problem.