My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Overwhelming NHS Problems #3. Technology.

Filed Under (Health Improvement, Patient involvement, Reform of the NHS, Technology) by Paul on 26-03-2014

All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to look at the nature of technology.

In our everyday lives technology enables. Sometimes it frustrates but mostly it makes our lives a lot easier. Modern communication is rarely a burden and mainly a boon. In our world it doesn’t feel like an overwhelming challenge.

The challenge of new technology for the NHS lies in the enormous and recognised gap between what the NHS knows it is achieving through technology – and what it knows it could. Most people, whether they be a district nurse in a patients’ home, a GP trying to find out which drugs were prescribed to their patient in hospital, or a patient just trying to find out what is going on, know that their experience of the NHS is not as “technology enabled” as it could be.

Each of them, and others beside, recognise that simple and cheap elements of new technology could transform the ways in which things work – and how they are looked after.

Indeed some of this is not new technology at all, but is old technology used to its full potential. A GP friend of mine always used to say that if doctors ever recognised that the telephone was a two-way instrument – that could be used to talk to patients as well as having them call you, the consultation process could be transformed.

And within that observation lies an important truth. New technology only really works if it enables something that the NHS already wants to do. Too often the NHS has tried to use technology as a change agent in its own right. When that happens the current way of working – the current culture – maintains its old way of working and the new technology simply bounces off it.

Its lies like a heap of junk in the corner of the room.

So the battle for modernity in the NHS needs to be won by using technology as a small part of change, rather than as its main driver.

One example would be changing the nature of the GP/patient consultation. The technology supporting telephone consultations has been around for a long while. The technology for email consultation for not so long, but few people would still refer to email as new technology.

Yet it is only in the last couple of years that the GP practice with multi-channel forms of consultation has developed with any scale. ‘Getting to see’ the doctor has become less significant than ‘talking to the doctor’. This hasn’t abolished the face to face consultation, but it has placed it in a multi-channel set of contacts.

This has not been caused by the invention of the telephone and email. It is a consequence of some GPs recognising that they have to change their core practices if they are to serve the best interests of their patients and then using ‘new’ technology to facilitate the change. Once the decision to change has been made really new technology can transform this multi-channel relationship with patients.

In the future we will see this as a significant change in one of the core relationships of medicine. Given that we know that the main site of health care is the patient’s own home, interacting with the patient there during consultations will become ever more important.

If we succeed in making the home technologically enabled – so that it can  provide a place of safety for high acuity cases – then the ‘burdens’ of both aging and non-communicable diseases (discussed over the last two days) will be transformed.

The potential here is transformative. It provides us with a real chance to address the disparity between the services that are provided – with their over-emphasis on hospital-based care – and those that are needed – for more care in the community and at home.  The opportunity is to harness technology – from big data, through patient-owned health records, to mobile health applications – to help make that transition.

And before anyone points out that the use of modern forms of communication is differentially spread around the population, this is of course true. But the relationships formed by new forms of communications are surprising and can be developed by the NHS. Many people much older than me have benefited from using Skype as they keep in contact with their family across the world. Grannies rent or buy new TVs so they can have big pictures of their grandchildren beamed in from New Zealand.

What we know about this technology is that the public will only use it if there is a point to using it. Grandchildren provide such a point.

I would suggest that the better management of health – staying out of hospital – will provide a similar powerful motivation.

New technology will be an enabler in developing the public’s motivation for better self-care. But it will not make that happen. That will need a better understanding by the NHS of what motivates people to better self-manage their own lives.

Why do we seem to need to see the pressure on the NHS as being so overwhelming that we can’t do anything about it?

Filed Under (Alan Milburn, Culture of the NHS, Health Improvement, Healthcare delivery, Reform of the NHS) by Paul on 24-03-2014

One of the main purposes of this blog is to question some of the established orthodoxies of the NHS and how we think about it. By definition that means that I raise questions all the time about how the NHS thinks about the main issues it faces.

For the last five posts during this month of my return to the fray I want to develop a different set of arguments. These will question why so many leaders and commentators in the NHS seem to need to passionately portray the organisation as being mired deep in a many faceted crisis.

There is constant talk about ‘the graph of doom’ which has demography rising and resources flat lining.

I want to explore the nature of the psychological need that is being met by this constant return to viewing the world in this way.

Because, from the outside, all this talk of doom seems to make the job of actually achieving anything very hard indeed.

One way of looking at this is that if there are…

  • too many old people
  • too many sick people (who are also apparently the wrong sort of sick),
  • too many changes in technology
  • sky-high rising public expectations and
  • no new money

…then don’t all of these external factors create a set of drivers which argue relentlessly for the necessity of radical change?

One would think so. But then in the real world where these arguments are being made by and large radical changes of scale are not being made.

So I think we need to think of another purpose that this way of looking at things serves. If all of these external factors are coming together to create pressure for change isn’t it also the case that change on this scale can’t be achieved? So, the argument goes, this is all so overwhelming that nothing can be achieved – so let’s carry on much as we are already.

So the paradox of this week’s posts is that what should be powerful arguments leading to change have in fact become OVERWHELMING arguments resulting in people not knowing where to turn.

I am grateful to my old boss Alan Milburn for showing me how these arguments need to be turned on their head. A few weeks ago at the Guy’s and St Thomas’ Charity he gave a lecture on how all of this overpowering doom could be a set of opportunities for the service potentially leading to very different leadership activities.

Because, as with so many things, this is all about leadership. The framing of the argument is a matter for the leadership of the system. And at the moment that argument is being framed to be so overwhelming that everybody is being frightened back to the status quo.

This week I want to spend a day on each of the five areas which have been portrayed as overwhelming challenges and see what possibilities they provide the NHS.

  • Demography
  • The nature of disease
  • The nature of technology
  • Public expectations
  • The money

On demography I need declare an important interest. I am 65 – the same age as the NHS – and therefore part of the age group and generation that are being seen as the burden that will destroy it.

Personally I don’t quite see myself as a burden but I sort of get the point.

However, my generation – colloquially referred to as the “baby boomers” – has, until now, more often been seen as a generation causing problems because of too much activity – not too much passivity.

We were – just – young mods and rockers (in my case a failed rocker as I never mastered riding a motorbike); we developed and sustained several parts of pop culture; we were the first major wave of student unrest; we were an early part of the property boom; we rode a tide of divorces and changed jobs far more often than previous generations.

All of this seems very active. (For our parents, much too active.)

Apparently now that we are entering retirement we are going – for the first time in our lives – to become a passive burden, rack up several co-morbidities and spend the last 30 years of our lives bothering doctors.

Old people are not just often referred to as a ‘burden’ but we also seem to feature in a lot of ‘drowning analogies’. There is, and will be, a flood of demand which will lead to the NHS drowning under it. All of this becomes a tsunami of need.

One of the statistics used to make this case is that by 2030 a third of the population will be elderly. This is assumed to clinch the whole argument since a problem that big must be insuperable. Personally I would be 82 and be part of this flood by being ill, and passive.

I think it’s certain many of us will be ill. My aches and pains will develop into arthritis and I am pretty sure that my blood pressure will be too high. Almost certainly I will also have another morbidity.

So it’s true that there will be more of us and that many of us will be ill in complex ways.

But will we be ill in the same way as today’s 82 year olds?

When I read the Saturday and Sunday supplements many of them treat me as a very active consumer for the rest of my life. I read them as appeals to me and older generations to become ever more active. There are a whole host of organisations that are looking to me to be very active indeed when I am in my 80s.

Private sector organisations assume I will be very active.

The NHS assumes I will be very passive.

Voluntary sector organisations see me as active.

The NHS sees me as passive.

The NHS assumes that its burden (and the problem of their increasing activity) is caused in part by my passivity.

But what will be the characteristics of my activity that the NHS, if it understood me in that way, could work with?

How might my GP be encouraged to view the next 30 years of my life as a set of assets with which the NHS can work?

One of those assets would be my wish for my home to be the established and clear locus of health care. I do not want care closer to home. I want care at home.

Our care will be centred on our experience of our own homes and not designed for the convenience of the organisations that will deliver it. My generation will expect much more high acuity care in the comfort of our own homes.

This will be a challenge to the current way of working. The new generation of the old will not tolerate a system of care that tells us what to do.  We will want to tell it what to do.

But for the NHS this is also a very considerable opportunity. It will require a shift in the way in which the NHS delivers care but that shift would be based upon a recognition of our capacity to play a much bigger and active role in our own health care.

The opportunity is to re-fashion care so that it is aligned with the mind-set of this century rather than the last.

The development of integrated services for patients may be being adversely affected by the passion that many feel for the forces that fragment NHS care.

Filed Under (Health Improvement, Integration) by Paul on 07-01-2013

2012 was the year when every part of the NHS that came under the powers of the new Health and Social Care Act had the duty to integrate services added to their statutory powers. In addition to the deluge of instructions to integrate, November’s mandate from the Secretary of State to the National Commissioning Board made it clear that he wanted the public’s money spent on the development of integrated services for NHS patients. Read the rest of this entry »

Another New Venture

Filed Under (Health Improvement, Healthcare delivery, Integration) by Paul on 22-11-2012

Regular readers of my blog will recall that I have been saying for some time that the NHS is going to need some help from beyond its culture. This is specifically the case when it is developing something that is both as new and as difficult as integrated care for NHS patients.  I have written a few times about the need for organisations to specifically act as integrators bringing very different providers together to create a patient pathway.

From today I, and a few others, are setting up a company called LTC Ltd. as one of these integrators. Our aim is to help develop integrated care for NHS patients. The company, and myself as a part of it, will be bidding for work from NHS commissioners.

I wanted to make my part in this new venture public at the earliest opportunity.

The web site should be up later today at www.longtermconditionsltd.co.uk

How CCGs can stick to their mandate and develop patient-led value for the NHS.

Filed Under (Clinical Commissioning Groups, GP Commissioning, Health Improvement, National Commissioning Board, Patient involvement, Self Management) by Paul on 21-11-2012

This evening, at about 18.15, I am speaking to the NHS Alliance conference in Bournemouth. My theme tonight, as it has been for some time now, is how the NHS can develop better public value by viewing people with long-term conditions as ‘assets’ rather than as ‘costs’. Read the rest of this entry »

What’s wrong with modern health systems – an analogy. Plus an explanation of what I mean by the cost and price of failure in the NHS and the Canadian health system.

Filed Under (Canada, Health Improvement, Resources) by Paul on 15-11-2012

Whilst in Canada I spoke at a conference run by the Ontario Hospital Association (the equivalent of our Confederation but only covering hospitals). The opening speaker was Don Berwick who, whilst being from the US is no stranger to the NHS and its reform. Don helped to set up one of the best health improvement organisations in the world – the Institute of Health Improvement (the IHI, the website is well worth a visit) and it was as the IHI that he spent much of the late 90s and the first decade of this century helping the NHS. Read the rest of this entry »

Understanding how Francis might understand the world of the NHS

Filed Under (Accountability, Francis Report, Health Improvement, Health Policy) by Paul on 17-10-2012

A few weeks ago we learnt that the publication of the Francis Report on Mid Staffs will now be put off until January. In the interim there have been some concerns shared within the NHS about how the report might understand its world.

As Paul Hodgkin from Patient Opinion said at the conference I mentioned in Monday’s post, if the answer that the Francis report comes up with is ‘more regulation’, then they are probably asking the wrong question. Read the rest of this entry »

Developing prices for a ‘year of care’

Filed Under (Health Improvement, Health Policy, Patient Choice, Self Management) by Paul on 29-05-2012

Over the last few weeks I have been outlining the nature of the reforms that NHS commissioners will need to implement if they are to transform NHS health care. Last week I explored two different forms of contractual relationships that are being created and will be necessary if there are to be different relationships with providers. Read the rest of this entry »

More thoughts on new models for creating more value from patients.

Filed Under (Health Improvement, Patient involvement, Public Health, Self Management) by Paul on 14-05-2012

I received some interesting comments on last week’s posts about the necessity for investment in improving self-care to improve value for the NHS. Most of my posts concerned the implications of some recent work on diabetes and also articles in the Lancet from last Friday on co-morbidities in Scotland. Read the rest of this entry »

To realise patient based value will require some investment – So where, in times of austerity, does that come from?

Filed Under (Creating public value, Health Improvement, Patient involvement, Public Health) by Paul on 11-05-2012

Having set out the general case for moving away from the old fashioned idea that value in health care can only be found by buying more medical staff, kit or drugs, I have suggested that investment in patient health literacy would increase the value they contribute to their own care. This would, as a consequence,  add value to the NHS as a whole and help change its resource base at this time of austerity. Read the rest of this entry »