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.

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.

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!

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!

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!