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!

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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

The listening exercise

Welcome to this, my first posting from the Centre for Better Managed Health and Social Care.

David Cameron has announced the addition of Integration as a fourth strand to the continuation of the  listening exercise and the work of the Future Forum.  Much of the Centre’s work to date has focused on the need to reduce the artificial boundaries which exist throughout the care system.

Our emphasis on the Interdisciplinary aspects of care demands that the professional boundaries be peeled away – there is so much evidence that diversity in its widest sense yields better solutions to problems, with stronger engagement and ownership of the solutions when there has been clear consideration of different perspectives.

Our emphasis on treating health and social care, not as different domains, but as different contributors within a whole care ecosystem demands that sectoral boundaries are overcome, so that the process of care is not fragmented, and the journey of care is seamless.

Our emphasis on new styles of leadership and governance demands that there is a renewed sense of clarity of purpose, constructive partnerships and greater transparency.  Only with these in place can incentives be properly aligned throughout the system, instead of pulling in opposite directions and reinforcing individual fiefdoms.  Only when freedoms and accountabilities are held clearly in balance with each other, will appropriately judged risk-taking foster the combination of innovation and quality by which most other industries have been shaped.

Let us now invest serious energies in nurturing meaningful integration, not because it is declared as policy, but because it is owned and understood to be the best way to ensure that each service user is placed at the centre of the entire care ecosystem at their moment of need.  When these social principles of putting the needs of each service user first are partnered with the entrepreneurial spirit which simply won’t accept that today’s solution is good enough, then we might be able to forge ahead, sweeping aside much of the polemic which currently polarises debate and stagnates progress.

David (first published 18th August 2011)