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.

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.

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!

Report from our annual debate

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition. 

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident. 

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend. 

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough. 

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

  • defines the basis on which professionals make their decisions about treatment;
  • sets a clear expectation for patients and carers to make their choices;
  • defines the benchmark performance against which different providers will be compared;
  • enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed. 

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests. 

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

Can we learn about health reform from the US experience?

Within the NHS, there are always some antibodies to the idea that we might learn something about health from the US system, which costs twice as much and delivers poorer outcomes.  But the reality is more complex.  Almost certainly the poorer US mortality figures are caused by the institutionalised inequity, and when you look to the best of the best, there is clearly much to admire and seek to emulate.

Having spent my early career in engineering and materials science, I understand integration as a necessity to reduce boundary and hand-off effects which in turn are sources of risk and failure.  So the current mounting pressure to achieve meaningful integrated processes for care is a great encouragement.  

One of the most promising approaches is the Accountable Care Organisation model.  It is important to understand that the term “Organisation” refers to the alignment of processes, not a physical entity.  I’m hoping that a paper I have co-authored on ACO will appear soon in the BMJ – there is real potential for breakthrough with ACO, simply because the defining characteristic is that it aligns incentives throughout the system, directed towards the desired outcomes.

Well, the Americans have been putting considerable emphasis on the wonder of ACO, since their reform bill recognised its potential.  An ACO approach is also one of the few hopes that Christensen has for overcoming inertia of health systems and truly disrupting the health system so that it can tap into the order of magnitude improvements which have happened in almost all other industry sectors but healthcare.

So here is the rub!  Some of the thinking about the power of the ACO model comes from looking at the most successful health systems – Mayo clinic, Intermountain, Geisinger, Cleveland Clinic.  Federal policy being made after taking a good look around, finding the best and seeking to stimulate an environment in which the very best can be built on and replicated.  Sound familiar?  Well, it appears that the programme to stimulate such adoption of the best has wrapped the very best in so much centralised bureaucracy, that the best are declining to party.  The federal approach appears to be stifling the very stuff which has made it the best!

Let’s hope this is one lesson that Sir David N will choose to learn from the USA!  The best are best, because they have worked at it, understood it and given a real sense of ownership to the front line people who make it the best.  The very thing which makes it the best, is the very thing which no centralised administration can replicate or, heaven forbid, succeed in imposing.

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