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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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.

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!

Just how do we define the priorities in health?

I’m not usually slow to understand, but I’ve just been forced to think hard about what I am missing.

I am under the impression that we are deeply in the economic mire, and that everyone is grasping at straws to try and find some savings from their budget simply to break even, let alone contribute to the £20bn savings required to offset the growing pressures of the demographic challenge, most of which comes from increasing demand of more people needing to manage their chronic condition for a longer time.

I am also still of a mind to think that the NHS remains firmly wedded to the aims of improving patient experience, improving quality outcomes, and helping people to enjoy a greater sense of wellbeing – that pithy little adage about years to life and life to years which still does it for me!

I keep seeing policy statements about localism, and devolved responsibility, and nudging closer to our partners in local authorities, and latching into their long-standing skills in commissioning.  I keep reading how desperately we need to engender a spirit which thrives on innovation, and that we absolutely must find and plant the magic beans which will automatically sprout into widespread adoption of proven ideas.  I keep hearing people talk about using technology more effectively.  I keep working with clinicians who are regularly patted on the shoulder and told how important it is that they take a stronger lead in decision making, because, after all, they are the experts.  I talk to experts on corporate governance and leadership, observing the profound wisdom that leaders need to balance effective processes, with good judgement and a dose of personal accountability.

But then, I read the topic headlines from the Department of Health, and I am confused.  The last week or so, has seen 41 pages of detail preparing the transfer of public health to local authorities, 86 pages of command to Aspirant Foundation Trusts to demonstrate that they are sufficiently on the ball to look after themselves, plus goodness knows how many memoranda instructing doctors precisely how to configure their CCGs.  Rank this alongside a staggering 4 pages of passing comment on the Whole System Demonstrator evidence of just what telecare and telehealth can achieve.  Evidence from 6000 patients, supported by 240 GP practices, showing a 45% reduction in mortality, a 15% reduction in visits to A&E, a 20% reduction in emergency admissions and an 8% reduction in bed days.  

These findings merely put substance behind the intuitively obvious: that technology is just as capable of changing our business models in healthcare as it has been for every other service industry.  They suggest that we don’t need to wait another three years, for any more studying.  We don’t need to have another document from the DH micromanaging innovation, or bemoaning lack of adoption.

I am sure I must have my priorities wrong somewhere.  I still can’t reconcile why policy is measured in kilograms of report, when some of the best evidence for policy change appears to be defined by improved outcomes, more stable health and some pretty impressive efficiency numbers.  Ah well!

Too many buses?

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

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

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

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

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

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

Hashtag #Futurecare.

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.