What is success?

This might seem to be a silly question, but in the current climate, when most stories are reported with a mix of suspicion and negativity, will we recognise success if it hits us in the face? Those twinges of doubt have started to crowd out some of my own optimism.

Let’s ask some hypothetical questions and play a gedanken experiment.

Let’s start with a typical frail elderly population receiving a mix of services across the health and care spectrum. Now let us suppose that we can allocate each individual to one of three groups.

The first group of stalwarts grew up to be very grateful for whatever services they have received. Their biggest fear is to be seen to be a burden on those around them, and they will soldier on through thick and thin. They are proud of the way they have managed to struggle through adversity and have to be on the verge of death’s door before they will seek out care. As they have aged and become more frail, their resolute spirit still drives them to put off that call for help, even when in their heart of hearts, they know they should.

Our second group are the worriers. Their fear is of being struck down so that they become dependent on others. They worry that each croak and ache might be the first step along a slippery road. In their heyday, they may have been the “worried well”. Seeking reassurance from the experts. Not necessarily hypochondriacs, but still watching out for unexpected signs. As this group becomes more frail, their anxiety levels may be rising. They will be in and out of the GP’s surgery walking out with something more important than a prescription – they will have a sense of ease, at least for a while. As the loneliness of age bites, they may find that the health system becomes a gateway to basic human contact, not just provision of care.

Then we have a third group who are neither the worriers, nor the stoics. Those with good, strong family and neighbour networks will often come in this camp. They have a sense of when to get reassurance from within their own networks and when to seek professional help. When they need to consult a professional, help is often at hand to smooth over the difficulties of navigation. As they become more frail, their frequency of turning to professionals increases, but only proportionate to their frailty.

Now, we experts in the strengths and shortcomings of the care system, observe how our fragmentary care system could be improved through a more unified, seamless approach to services, with a bit of help on navigation, more sharing of information and all the clever stuff we build in to oil the wheels from our perspective as professionals. So we decide to run a new model of joined-up care. But, being the intelligent folk we are, we decide that we need to control for variability where we can. We choose to divide our trial population into our three respective groups, so that we can compare the results between them.

I just know you’ve already made the mental leap, but, please, stay with me!

In our wonderful. integrated care pilot, group 1 makes more use of the services because the new model we have put in place does precisely what it is meant to do – it captures the need at the right time, rather than late. For this group, integrated care should reduce risk, improve both mortality and morbidity. By capturing the need early, it should reduce length of stay, but might very well increase admissions. Rightly! So integration increases demand!

But group number 2 receives reassurance in a more appropriate way, reducing the demand that we experts think is inappropriate. They probably make less use of the service, but with a better level of targeting. By providing more appropriate reassurance, they reach the front doors only when there is a higher risk. Integration reduces overall demand, but leads to a higher conversion rate of admission per attendance!

Quelle surprise? Demand from group 3 is relatively unaffected by our carefully developed improved service, though the better joining up will reduce levels of frustration.

So, which of our three trials succeeds in giving us a definitive picture of the effectiveness of integrated care? Group 1 makes more use, and is likely to be happy. Group 2 makes less use – equally happy. Group 3’s demand unaffected, but still happy.

Now let’s leave this hypothetical construct behind and return to reality. What can we really learn from the evaluation of integrated care pilots which is widely trumpeted as showing that integration doesn’t work? Has it helped us to define success? Nick Goodwin, in commenting for the King’s Fund, has gone a long way to putting the work more carefully into context, avoiding the simplistic solutions which have been too prevalent in other headlines. Now can we move this debate along to a more productive consideration of just what we should be doing to design care around the patient, and therefore what we need to know to evaluate whether we have achieved success or not?

There is one single, unequivocal message. The effects of integration are unpredictable and unmeasurable, UNLESS defined by the effect on the individual. Success is defined by the patient or service user, not by the service provider.

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Desperately seeking sanity

As an independent advisor to Matrix Informatics, I am delighted to be reaching out with opinion pieces on topical stories through the Matrix blog, as well as the Centre’s blog.  My views of the world of health informatics will be shared through their pages, complementing my work at Cass.  Please do visit…. 

My first blog on their pages looks at the opportunity presented by HC2012 – just 12 days to go to the first major health informatics conference & exhibition in the UK since the formal demise of Connecting for Health.  Will the NHS seize this opportunity by a “more of the same” strategy, or by openly seeking to learn from the history in other sectors?

Here we are, at one of the most critical times for the whole global healthcare industry.  Needing breakthrough solutions that will simultaneously enable people to achieve greater fulfilment despite living with chronic conditions, and achieve better and safer outcomes across an increasingly complex range of life-threatening acute conditions.

Now is the time for sound judgement from courageous leaders who won’t be shackled to past ideologies and mistakes.  Instead we see insanity replayed….

Read more…..

So! The golden bullet appears to have gone rusty.

So many hopes have been built on the expectation that integration is a silver bullet for the woes of the health system, that we really should see it as a golden bullet – far more than a mere silver one.

Well!  The reporting of the evaluation of the DH funded integrated care pilots would have you believe that we are doomed!  The headlines suggest that patients did not experience greater continuity of care, reduction in emergency admission has not materialised, and there is little, if any, overall financial benefit. 

More of a rusty bullet than a golden one! 

But the only gold items that rust are fakes – still built of base metal but painted over to make it look like gold.

And we should surely conclude that there is an element of dressing up and pretence about the integrated care pilots.  If only we had looked for the evidence before clasping the pyrites to our bosoms.

We know from most industry sectors, that all the case study reviews of transformation teach us that success needs to begin with transformation of the business model.  Which of the pilots did this?

We know from our own studies (which will be published in May) that what marks out good leadership of whole systems, demands new characteristics of our leaders: that are currently in short supply amongst the NHS top leaders.  Were the leaders of our pilots selected for their fit to these new styles?

We know from the very basics of engineering, that failures occur at boundaries, so our integration design should do three very specific things: reduce the number of boundaries; reduce the risk of failure at boundaries; and, reduce the impact of those failures which do occur at the boundaries.  Which of our pilots have used these as design criteria?

We know that for any system to work smoothly and efficiently, we must align the driving forces – i.e. incentives – to make sure that each part of the system is acting in harmony with every other.  What dispensations have our pilots been given to devise a new locally fit-for-purpose system of incentives, rather than the conflicting set currently in play?

We know that at times of disruption, attention naturally and easily focuses inwardly to deal with the consequences of change, diverting away from the attention which should be on the relationship with the cared-for.  What investments have the pilots made into genuine engagement with and involvement of patients in the redesign, or better still in co-design?

We know that sharing the right, high quality information across the whole system is the only way to reduce some of the risks, build a common purpose and enable all players to feel part of a single solution.  Which of the pilots has moved beyond temporary lash-ups between data sets?

Let’s hope that we can now read the small print of the evaluation report, not just the headlines.  The small print suggests we’ve got to work harder to get it right.  I suggest we just need to work smarter!  Integration is not the right answer, especially if most of what we do puts fixes around the current system weaknesses and boundaries.  The smart answer lies in understanding how to use the principles of integration to achieve a clear vision of patient centred, seamless care, and then to use that to drive investment in a purpose designed business model, that has all the characteristics to make it work. 

Just because we have a pot of gold paint doesn’t turn us into successful alchemists.

How many figs make a right arm?

I was recently introduced to the following quotation:

“I wouldn’t give a fig for simplicity, this side of complexity, but I would give my right arm for simplicity the other side of complexity.”

For a long time I have been conscious that if we are to achieve the necessary transformation of the care system, then we need to stop pretending that it is a simple system, instead recognising that it is truly complex, in the meaning used in complexity science.  A blog is not the place to introduce readers to complexity science – there is plenty to be read elsewehere, but suffice it to say, that one of the neatest ways of thinking about a complex system, is that it contains so many variables that even if we know everything there is to know about the system, we can never predict exactly how that system will behave.  But, if we treat it properly as a complex system, then we can describe the state it is most likely to be in.  It is not unlike a poor man’s quantum physics, but applied to everyday life.

Put simply, this means that we can never control a complex system, but we can influence it.  Control is the stuff of centralised management, and influence is the stuff of shared leadership.  Get my drift? 

Back to that fabulous quotation.  Pretending that a complex system can be simplified, before we have got a good understanding is worse than useless.  Making sure that we understand the system, getting to grips with what is important, and then simplifying it for a given context is priceless.  Facing down the complexity, allows us to simplify the system, AND know when those simplifying assumptions run out of steam, and we have to go back to the complexity to understand the new context.

So who made that profound statement?  It was Oliver Wendell Holmes Senior, more than a century ago, long before anyone had conceived any of the sciences which contribute to Systems Thinking.  As I read more, I got to like the man who challenged the established clinical practices with his observations about infection control before Pasteur.  Amidst more controversy, he sought to admit the first black medical students and the first woman medical student to Harvard.

It seems to me that he was a man before his time – in so many ways rocking the established thought and practice.  His work eventually reflected new norms in diversity and infection control.  As a man of letters, he coined the new term Anaesthesia to describe the emerging practice. 

Are we, even now, on the dawn of responding to his plea to stop pretending and grapple with that kind of simplicity which only emerges on the other side of complexity?

From forlorn despair to hope in one day

Those of us involved in any way with the care ecosystem need to keep our mums and grannies and kids in mind.  Whether we are commentating or deeply involved in delivery, commissioning or education.  Yesterday provided one such opportunity – a hospital appointment for my mum.  It was always going to be difficult! 

I had mentally taken that extra beta blocker as preparation, but I hadn’t reckoned on the real cause of the stress.  There is no better word than primitive!  Mum’s record was only about 3 cm of paper in a tattered and torn green folder with an elastic band round it and containing her previous two addresses, but not the current one.  The scheduling system was determined by where this folder rested in a large pile of similar folders, few less than 2 cm and some up to 8 or 9 cm thick.

The first check with the nurse took 5 or 10 minutes longer than it needed, because the part of the record she needed had only been added as a comment at the foot of one page somewhere in this stack of inaccessible information.  She kept overlooking it in the search for a more substantial and carefully constructed account of a previous treatment cycle.

For the next half an hour, I watched as this teetering pile of information was shuffled and inspected each time another patient completed the pre-assessment to begin their wait for one of the three doctors in that clinic.  Goodness knows what the glancing look proved, but it was a ritual which clearly provided some satisfaction to the nurses amidst this forlorn process.  Perhaps I dreamed the papyrus scroll sitting there next to the ink-well and the neatly clipped feather!  At least one patient appeared to be missing that vital folder, but maybe it turned up.  I couldn’t keep up my excitment levels to notice!

I’ve been working with IT systems for so long, I had forgotten that life can still be so primitive and processes inexcusably mismanaged!  

And this is the point to ask: “how could we get the National Programme for IT so badly wrong?”  The potential for improvement in safety, quality, efficiency and outcomes is just so obvious.  Any engineer will tell you that weaknesses, failures and poor quality happen at boundaries between systems and processes and organisations.  And here, in these fat, green, scruffy folders are a series of broken boundaries on show for everyone to see!  This is not a technology issue.  This is a basic fact that, following the command to do no harm, the next most important rule for every clinician must be to keep an accurate, reliable record of every aspect of the intervention, which is communicated effectively to anyone else involved in delivering care.

And then later that afternoon, as I sat in recovery mode with steaming towel round the forehead to dissipate the stress, in through my inbox came the report from the working party of clinicians seeking to establish a basic standard of clinical record keeping.  As I mused on the way this was reported, it read just like a repeat attempt to reinvent the technology mistakes of NPfIT.  But I had been privileged to engage with one of the leaders of this work at the beginning of the month.  

This is different! 

It has the potential to be revolutionary!  

It is the work of each Royal College and other luminaries, stating that the solution to better outcomes, greater efficiency and more inclusive working with patients and carers must begin with these clinicians focusing on transforming the way clinical records are defined and kept.  Defining and adopting structure and standards which will later lend themselves to better use of technology, intelligent mining, and ease of sharing! 

This is the first real sign I have seen that the kind of monumental change we need to see right across care, must begin with the experts in the care processes powering it forwards by driving the development of appropriate tools.  This is real clinical leadership in action!  Don’t be confused by the way it is reported!  This is good stuff!  

I continue to be fascinated by the juxtaposition of apparently different streams of intelligence and observations.  Sometimes the light bulb moments are genuine and uplifting.

Folks!  There is hope!

Too many buses?

With a spate of bad publicity about the apparently rapid vanishing sense of caring from the world of care it was bound to happen.  The kind of fight back reminiscent of the queue of buses clogging up the roads just after it has stopped raining!

With the anticipation of a white paper on social care in the Spring: first in the queue was the minister himself.  Paul Burstow speaks about the importance of care with a degree of sincerity and authenticity that is compelling.  He has established a series of working groups under the title Caring for our Future with the specific aim of consulting with key groups before the white paper is published in Spring.  Whether he has seen the value of the Future Forum process led by Steve Field for the Health bill is open to speculation, but if this consultation process can get in touch with the real issues, rather than rely too heavily on the rather less connected view from Richmond House than it has my vote.

Then, this morning, a press release crossed my desk from the Care Provider Alliance – a body setup to represent the vast majority of social care provision inEngland.  They have just published a vision document to stimulate debate about the nature of regulation and inspection.  In it they suggest an approach to the co-production of the regulation regime, encouraging CQC to tap into the knowledge and experience of the members, most of whom admit they are seeking re-establish credibility and shrug of the tainted image left by Southern Cross.

Lo and behold, this afternoon, I bumped into another press release, this time from Dignity and Care Partnership, an alliance launched in July between the NHS Confederation, the Local Government Association and Age UK.  This worthy group has just launched a Commission, to gather evidence from all interested parties to help improve dignity in the care provided to older people whether that be in hospitals or residential care.

Together this constitutes a chorus saying enough is enough.  I applaud it, but can we have some degree of joining up to avoid dissipation of effort to get this right.  

Now I leave it to you to decide whether the Centre has just allowed another bus to leave the depot, or is offering a suitable interchange station at which those on the buses may meet up for the next leg of their own particular journey.  In responding to Caring the Future, we have already billed one of the Centre’s seminars on 28th November as a forum to support its work and bring academic and practitioners together around the quality and workforce topics.  One of our planned speakers from that working group is also a leading player in CPA, and we will continue our quest to be truly interdisciplinary in our approach as we plan out that seminar.  Do help this important debate – contribute, follow and maybe even join us.  

Hashtag #Futurecare.

What does it take to shock us?

However deplorable the terrorist attacks were a decade ago, and however much the impact has reverberated around the world, it remains a mystery to me how we can be shocked beyond measure by one circumstance, whilst another source of pain to society remains almost unnoticed.

There were just under 3000 awful and premature deaths on September 11th 2001 – devastating terorist strikes, destroying the hopes and plans of 3000 families;  reverberating across New York communities, leaving orphans and widows in its wake.  There have been almost daily incidents around the globe since then, with too many of them causing death tolls above 100.

But in the decade since then, nearly 7000 US citizens (military personnel and contractors) have been killed on the war fronts of Afghanistan and Iraq.  It is difficult to count the deaths on the other side, but estimates vary between 25 and 50 thousand directly killed and maybe 20 times that number of “excess” deaths caused by a combination of sanctions and war conditions.  What an awful term: “excess deaths”!

But where are our thresholds of unacceptability?  The same decade has seen around 150 thousand homicides across American society – 15 Americans killed by local violence for every single one killed either in the twin towers or in the war zones since.  And what of the 360 thousand Americans killed in road traffic accidents – casualties of life.  Are these any less devastating to the friends and relatives?

But here is the real rub!  Nearly 1 million “excess” deaths across the USA because the American health system has so many holes in it!  If the life expectancy in the USA was equal to the average value across the OECD nations, more than 900 thousand lives would have been saved in the last decade.  Investment in UK health reform in the same period has successfully closed the gap from its poor performance, so that in 2009 – the latest full year data, the UK crossed over to better than average life expectancy.  But procrastination about American healthcare reform  has seen its gap continue to widen almost every year, so that the average American can expect to die 4.8 years sooner than his or her Japanese counterpart, and 2.1 years sooner than the average throughout OECD countries.

How does the shockwave of such appalling devastation of life and relationships pass by so unnoticed?