It’s all about leadership. Inspirational leadership.

The horror of the circumstances leading to the Francis enquiry demand urgent action.  We understand the temptation to impose punitive controls on a system that demonstrably failed to understand its core purpose.  But the danger of such populist intervention is that it will exacerbate the very cultural flaws that created the hole into which Mid Staffordshire Hospitals Trust fell.  At its heart, there is only one sure-fire way forwards. 

The solution must lie in reinforcing the statutory duty Board directors already have.  Their duty is first to do no harm, but then to inspire everyone in their organisation to do great things using the resources available to them to maximum effect.  This is hard and difficult stuff.  We need people of courage to step forward and lead the way.  For too long, we have prevented leaders from making the right decisions at the right time, conditioning them to look over their shoulder to the heavy handed interference of the army of regulators, government departments and politicians.

There are three imperatives for anything that flows from the Francis report.  These are messages for all leaders and managers in the NHS, and potentially even wider for all organisations, whether they are public, private or not-for-profit sector:

  • the failings which occurred in Mid Staffordshire hospitals were horrific, unacceptable, inexcusable and must never be allowed to happen again;
  • the friends and relatives of those caught up in these failings were confronted with a system which was completely deaf to their pleading and complaints: a level of arrogance, complacency and closing of ranks which must never be allowed to be repeated;
  • the review has exposed a level of systemic failure of both leadership and governance in which accountability, priority-setting and decision-making are always someone else’s responsibility.

Francis produces 290 recommendations targeted liberally throughout the system.  The report condemns the system for allowing the target culture to supplant the core purpose of the NHS.  Francis rightly demands a new culture which is dominated by patient outcomes, and does not tolerate harm to anyone caused by failure to implement known practice.  It is astonishing that these recommendations then are designed to reinforce that purpose with an unprecedented level of micromanagement and imposition of a regime in which the centrality of that purpose is threatened by total emphasis on compliance.  Evidence points time and again to the fact that cultures built around compliance lose the spirit and passion that constantly strives for improvement.  CHE is proud to be a major partner of EIGA – the European Institute of Governance Awards – a body whose purpose is to encourage and celebrate organisations that have an approach to governance designed to demand more from continuous learning and improvement.  This is liberating, empowering stuff that encourages leaders to inspire and motivate their staff.  It treats clarity of purpose, insatiable curiosity and fearsome courage as bedfellows in leadership.

This report is entirely about leadership.  It is about Boards that have developed a subservient culture of seeking both direction and permission from multiple regulators and government departments: outsourcing their very duties to others.  It is about a system-wide style of management that focuses on centralised control of power rather than leadership capable of inspiring a whole workforce to align behind the great values of service on which the NHS was built.  It is about performance management that focuses irrepressibly on enforcement of process targets, rather than encouraging a relentless drive for improvement and learning at every level and by everyone.

In any and every organisation, it is the single-minded duty of the board of directors to act with integrity and commitment to ensure that they deploy the scarce resources of their organisation to achieve the very best outcomes for the groups of people whom they serve – customers, patients and relatives, staff, suppliers, community, shareholders.  Boards must ensure that they have an unequivocally clear purpose and that they drive towards this purpose working with a clearly exhibited set of values – the ethos they personally live and breath, and which they expect their staff to live and breath at all times.  Boards must put in place the mechanisms of accountability by which the directors personally and collectively know categorically that their teams are doing the best they can.  And they need to encourage the curiosity in leadership that is hungry for new learning, new insight and new experience, which will help them to shape a better future.

None of this can be imposed from outside by fiat or mandate, or strengthened under the watchful gaze of regulation by compliance but nor can it be delivered behind closed doors.  An external view from regulators and those who have direct experience of the services will stimulate the openness, without which hubris and complacency lurk.

Francis demands a populist response of the iron fist and a tightening of control, and even a little bit of vengeance.  But this is just a rewiring of the stuff that got us to this point.  The emasculation of real accountability by those whose job it is to guarantee the quality, safety and effectiveness of services that created the breeding ground within which compassion was replaced by soulless complacency.  We need to rebuild trust in the management and leadership provided by the Boards who understand that their duty is first to do no harm, but then to inspire everyone in their organisation to do great things using the resources available to them to maximum effect.  This is hard and difficult stuff.  We need people of courage to step forward and lead the way.

See how this has been reported in the Huffington Post, and the National Health Executive.

Watch my interview on the subject as part of the Cass Talks series of video recordings by Cass Experts on topical new stories.

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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!

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 perils of squeezing out judgement

Our recent past is littered with large scale systemic failures, each of which has led to probing reviews, a myriad reports and the inevitable rewriting of regulation, each time marking a new dawning of governance and protection for innocent casualties.  Maxwell!  Enron!  Clapham!  Barings!  Baby P! Bristol!  Alder Hey!  MidStafford!

In some ways the review findings are predictable.  Technology has enabled practice to outstrip and outsmart the regulator.  The regulator caught napping!  Regulators essentially caught colluding with the deceit – Enron was the first of these to reach my consciousness. 

When you peel the layers away, every one of these is a failure of risk management process.  Inadequate consideration of, and planning for, the risk that things might not work out as we want them to.  Insufficient integrity in those controls which should have been starting to glow red as the likelihood of impending failure rose.  Insufficient emphasis on assurance – that triangulation process which seeks independent confidence that all is well. 

But then, risk management is too easily relegated to the “process nerds” who interfere with innovation and shun entrepreneurial flair, demand that proper time is allocated to consider complex issues in depth. 

An opportune moment perhaps to rewrite that perception?

In 2009, Sir David Walker’s report on the failure of banking recorded some of the most memorable words from a governance review:

“……improvement in corporate governance will require behavioural change in an array of closely related areas in which prescribed standards and processes play a necessary but insufficient part. Board conformity with laid down procedures such as those for enhanced risk oversight will not alone provide better corporate governance overall if the chairman is weak, if the composition and dynamic of the board is inadequate and if there is unsatisfactory or no engagement with major owners. The behavioural changes that may be needed are unlikely to be fostered by regulatory fiat, which in any event risks provoking unintended consequences. Behavioural improvement is more likely to be achieved through clearer identification of best practice and more effective but, in most areas, non-statutory routes to implementation so that boards and their major owners feel “ownership” of good corporate governance.”

Earlier this year, Professor Eileen Munro reported on the circumstances of the Baby P tragedy, concluding that the child protection system had been built up of layer after layer of so-called assurance, which ultimately diverted attention away from the very purpose for which the processes existed, recommending that energy in safeguarding needed to be brought back to its core aims:

“These forces have come together to create a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children, young people and families”;  and:

“instead of ‘doing things right’ (i.e. following procedures) the system needed to be focused on doing the right thing (i.e. checking whether children and young people are being helped)”

Can the combination of Walker and Munro mark a sea change in thinking about risk management and governance?  Yes, process is an important part of the story, but it can never be seen as more than just a part. 

I have a few simple mantras which, if applied in a few more places could improve effectiveness.  One of these applies here.  Information rarely gives you answers – it simply helps you understand and formulate the important questions to ask! 

Put simply, it is the duty of management to use the best available information and evidence, combine it with experience and professional judgement, and subject it to peer review from as wide a cross section of perspectives as practical.  That for me is a statement of good governance and the duty of both individual managers and whole boards.

So, when we read the litany of misfortune and the apparent disarray within CQC, we have to be worried, even after stripping out the undoubted misreporting, exaggeration and sensationalising of the telling. 

Easy to make a transcription error that puts the wrong number down for the number of inspections carried out last year, but impossible to misjudge your core business by a factor of two!  Valuable for board members to be setting aspirational plans for how they want to see processes becoming more consistent and controls being tightened, but unacceptable to then misjudge the gap between today’s reality and that future goal.  Commendable to see an internal review conducted when staff properly raise concerns about process quality, and easy to understand why sharing such a review publicly would need careful handling, but impossible to see how an organisation whose very raison’d etre is to provide public assurance, could misjudge the importance of transparency and consider disciplinary action as a first resort.

And the biggest question of all!  What can be done to enable the CQC board to achieve Walker’s sense of “ownership of good governance”, to generate an effective balance between process and culture, when the government imposes increasing demands, expands the scope and reduces resources at the drop of a hat?  Where is the meaningful consideration of risks, the integrity of the controls and the confident, independent assurance and exercise of professional judgement.  Surely, at the very heart of this governance minefield, it is ironic indeed to see the Department of Health acting almost in the role of Shadow Directors of CQC, removing the very ownership the board should have in determining how to square this shrinking circle! 

This feels to me to be the very antithesis of the assurance process for which CQC exists.