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?

Organisational Elasticity

As a physicist by inclination, I often gain useful insight through metaphors which draw on the science of “stuff”.  The experiment of loading a wire or spring with different weights (a pure physicist would insist on talking about “masses”) is one I am sure most people will recall from school days.  The heavier the load, the more the wire stretches.  Up to a certain point, most simple materials stretch in direct proportion to the load.  This property of stretching is called “elasticity”.  The force acting through the length of the spring when the weight is added is called “tension”.  But a fine wire is weaker than a heavier gauge wire.  This is because the tension acting in the spring is spread across the cross sectional of the wire in the spring.  The impact of this tension in the wire is “stress”: – the force per unit area.  The amount that the spring stretches compared with its original length is called “strain”.

Now, all this was discovered by Robert Hooke, a physicist who was a contemporary of Isaac Newton.  He gave his name to Hooke’s law which states that for a given material (none of the clever composite materials in his day – this was all about metals), the strain is directly proportional to the stress, so that the ratio between them is a constant property of the particular metal – the “coefficient of elasticity”.  If we get right down to detail, other parameters such as temperature play their part and will change this coefficient – the hotter the spring, the bigger the strain for a given stress.

What Hooke’s law means is that when we remove the load, the wire or spring returns to its original length.  Take away the stress and the strain goes back to zero.  But, if we keep on piling on the load, the wire starts to stretch much more than we expect – Hooke’s law has run out of steam!  And now, when we remove the load, the wire no longer returns to its original length – it has a permanent distortion in it.  The stress applied was so great, that we changed the properties of the wire  in a way that cannot be changed back by the simple processes of changing the load.  The point at which permanent distortion starts to happen is called the “elastic limit”.  When we have applied stress greater than the elastic limit, physicists describe the behaviour as “plastic”.  Plastic strain is that change which happens to a material when we have loaded it up so much that its behaviour is no longer predictable according to Hooke’s law. 

In the plastic region, the relationship between the variables (the cross section, the length, the coefficient of elasticity and the total load applied) ceases to be linear, because very small effects (called second order effects) start to become too large to ignore.  In the case of the metal wire, the forces applied are sufficient to change the way the microcrystals relate to each other.  Typically, at one point in the wire, necking will occur where the rearrangement of the crystals in the direction of the force will cause the wire to narrow.  The friction of the crystals rubbing past each other will heat that part of the wire.  The smaller cross section means that the stress is higher, and the temperature increase means that the strain will increase for a given stress.  As more external load is applied now, more damage is done concentrated at this narrowing, until at some point the wire breaks.  We refer to this point as the breaking strain, reflecting the fact that any material can only be distorted so far from its natural state before the strain simply becomes too much, and instead of stretching further, it snaps.

As one final aside, there are some interesting things you can do to change the coefficient of elasticity, to change the elastic limit and the breaking strain.  Metallurgists will be familiar with work hardening (the black-smith hitting the hot metal repeatedly), or case hardening (treating the metal surface to change its composition slightly), or annealing or quenching – heat treatments that also change the surface and the crystalline composition. Interestingly, some of these treatments can strengthen the material so that the strain is reduced, but at the same time might reduce the elastic limit or breaking strain, so that it has a more limited range over which its behaviour remains predictable and elastic.

Now the fact that you are still reading, suggests to me that you are either a physicist, checking out my details, or you have latched onto my analogue.  The language of tension, stress, strain, elasticity, breaking point, all relate to experiences in other parts of your life.  You can see the parallel in mental or physical health, or the working environment – different people exhibit a different relationship between stress and strain, and this relationship can be strengthened by workout, so that the strain arising from a given stress can be reduced.  Some have an elastic limit much lower than others, so they start to behave out of normal character at a much lower threshold level, and others might appear strong for longer but break very quickly after passing their elastic limit. 

But the analogue I want to touch on is that of organisations.  Organisations are elastic – they respond to forces being applied to them, which in turn translates into stress acting within the organisation giving rise to strain – the changed shape arising as the organisation reacts to the stresses.  An organisation is more complex than the simple wire, nevertheless, if the stresses are applied within the elastic limit, the organisation will continue behaving exactly as before – take away the stresses and it will return to its original shape.  Increase the stresses and it will react predictably, until it has been pushed beyond its elastic limit.  The properties of the organisation can be changed by organisational development which can strengthen it against the stresses, to make it more resilient.  But the truth is, when you need to effect major change, it is essential to push it beyond the elastic limit, creating some permanent lasting change because the relationships between the atoms and the forces binding them together have been permanently changed.  And when you push something beyond the elastic limit to avoid it bouncing back unchanged, it is critical to be mindful of the breaking strain which leads to permanent, irrecoverable damage.

Now, everywhere I turn at the moment, people are talking about the need to create disruptive innovation in the health system.  But this is in real danger of becoming another fad, rather than a serious and fundamental approach to management science and understanding.  I even heard it said recently that we want disruptive innovation without the disruption.  And to understand what it is we need to disrupt, it is crucial to look at the “atoms” and “forces” which contribute to the resilience and elasticity.  We talk about these as the silos – the “microcrystals” of our wire.  These include the individual teams and 400 plus organisations within the NHS.  They include the professional silos designed to protect individual professional standards.  The financial forces designed to reward fragments of care.  The education processes that are grounded within current cultures.  The research processes.  The political processes, especially the Kidderminster effect!  The media frenzy which misleads the public into fighting any change!

Disruptive innovation means pushing each of these areas beyond their own elastic limits – some areas will distort plastically, but others will undoubtedly exceed the breaking strain.  If this is not happening, painful though it might be, the organisational elasticity will ensure that the current system lives to fight another day, on precisely the same basis as we are losing the battles today.  Ultimately, it is the business model which needs to be disrupted, because this defines the architecture within which all the ingredients are held and work together.  The need for competition, and innovation, and new forms of professionalism and regulation are all part of the new business model(s).  Disruption, and the painful stresses and strains are essential.  Bring them on!

What of the Bill?

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them? 

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid. 

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

  • that are better at adopting innovation,
  • in which all elements of the system drive together towards best possible outcomes for available resources,
  • that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

  • detail of how Clinical Commissioning Groups (CCG) will be held to account;
  • how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
  • how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards. 

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives. 

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour. 

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.

David & Rob