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 #5. The money

Filed Under (Healthcare delivery, Reform of the NHS) by Paul on 28-03-2014

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 discuss the money.

The money is one of the main arguments that feels overwhelming. This is partly because more and more people in the NHS believe that there won’t be more and more money and that’s a bit overwhelming.

For 60 years we have all been working in a service where we have been getting a larger slice of a bigger cake. The GDP has been growing and the proportion of that GDP that has been going into the NHS has also been growing. Even in difficult times, taken over a five year period, the amount of money has gone up and up.

For the last few years it has not been going up. But many people believed that eventually normal service would be resumed and money would start going up again. Only over the last few months have more and more people begun to recognise that if we are very lucky between now and 2020, it won’t go down.

(Of course there are still some whose wishful thinking overcomes their judgment. But I hope for them that the passing of the budget last week – without a few billion extra pounds for the NHS – marked the end of that hope. The moment of maximum political pressure is the budget 14 months before an election. If the money is not found then why would it be found in the first four years of a new Parliament? No. What we have is what we will get)

As more people realise this they begin to talk about the “Graph of Doom”. This shows demand increasing every year while money stays the same. The doom comes from the growing gap – that gets bigger every year.

This gap is based upon the expectation that we will continue to do what we have done before. If demand has gone up by 20% by 2020 the expectation is that, given we will treat these new sick people in the same way as we have treated sick people before, we will need 20% more money to do it.

We heard this logic last week when the RCGP said that to meet the new demand there would need to be 10,000 extra GPs. As reported the story contained the rather odd claim that GPs might become extinct.

(That’s a very strange word to use about the future of a bit of the medical profession. Is there no little bell that goes off in people’s heads when they make these claims?)

It’s true that GPs are under great pressure from rising demand, and what some of them are doing as I discussed on Wednesday in my blog about technology, is changing the nature of their consultations with patients to utilise their time and skills in different ways.

The NHS and social care will not be treating that extra 20% of demand in the same way that we treat them now. If they (and we) are lucky we will be providing a much better service of coordinated care with much less use of emergency beds for fewer exacerbations.

The NHS is not full of people who in five years’ time will have to do what they did five years ago.

It’s not full of people who have to deliver exactly the same service that they did five years ago in five years from now.

But it is full of people, at least those over 30, who have been used to working in a service where the money goes up all the time.

What we need to do is to use the inventiveness that has been there in the past to incorporate new forms of treatment to the service for better value for money.

One of the reasons why people are not doing that is that their leadership has been talking in such gloomy doomy ways about everything – including the money.

What we need from the new leadership of the NHS is some concerted hope for the future which sees all these difficulties that have been described as “overwhelming us” as issues that provide opportunities for development.

With a bit of good leadership we won’t be overwhelmed, but will use these pressures to grow.

My last post of this month long return to the blogosphere will be about the prospects of political leadership facing these changes.

Overwhelming NHS Problems #4. Public Expectations.

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 27-03-2014

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 discuss what is seen as the problem of rising expectations.

I started working in public services, in London local government, in 1984. From the start, and continuously over the last 13 years of working in the NHS, I have heard leading public servants complain about the rising expectations of the public.

The argument is straightforward. If the public expect more, we can’t deliver it and it makes out job harder. So ‘rising public expectations’ over the last 30 years have consistently made our job harder.

In its own terms you know what people mean when they say this. If the public don’t complain and fit in with how we organise ourselves, (for example by not getting sick between Friday afternoon and Monday morning when we aren’t there) then the work of a health service is a lot easier.

If people are prepared to travel a few miles to what we refer to as an “outpatient clinic” (but which is in fact inside the hospital so should be called an “in-patient clinic”) and turn up with a crowd of other people at 0900 to be seen at 1215 then our organisational ability will likely meet their low expectations.

But over the last 30 years more and more people have found that in the rest of their lives they can make an appointment with, say, their hairdresser – near their home, at a set time and will probably receive a text reminder beforehand. And on nearly every occasion there will be someone ready to cut your hair at the appointed place and time.

Given that a hairdresser can organise this, the problem for the NHS is that now they now expect it to do the same.

A coda here about class.

Amongst the top 10% of the population I am not sure that expectations of public services have increased in the last 30 years. In the mid-1980s the top 10% expected to get respect, courtesy and convenience for all the services they used – public and private. And when they didn’t get it from the NHS they made a fuss.

For them expectations have always been high.

No the problem of rising expectations for the NHS is caused by the fact that ordinary people now have greater expectations of it than they had 30 years ago. From amongst a class of people who were once simply grateful more and more people have emerged with higher expectations.

This means that more and more people expect services to be organised around their lives – and not around the needs of the organisation .The main problem is not the rising expectations, the problem is that we now need to confront the way in which many of our organisations work for their own convenience.

And it’s true that people are more informed and inquiring. They are demanding a greater say.  Ordinary people are getting a taste for greater power and control in their lives.  

One of the main political points I want to make is that the very existence of mass public services raises expectations. 

Expectations of what the NHS would be had been raised, from its very creation, by the public’s experience of World War II. That generation expected more from life and from Government.  (It was just as well that that generation also had the courage to hold high expectations about beating the Nazis).

The point of mass secondary schooling was to raise the next couple of generations to want to attend university.     

If people involved in a large scale public service complain that the public want more then they don’t “get” the movement of history of which created their service in the first place.

Now there is apparently a problem because too many people are getting too much information about health and health care.

In the past people would talk to their immediate family before a visit to their GP. Now more and more will consult the internet and walk in to see their GP with printouts. In the past they would come in with bits and pieces of knowledge from their parents and grandparents, now they come in with bits and pieces of knowledge from the World Wide Web.

Of course this knowledge is not ‘correct’ but it’s there – and it’s there to be referred to when the patient has had their consultation. The doctor can’t say “don’t go on the internet” in much the same way as in the past he couldn’t say “don’t talk to your grandmother”.

So rising public expectation is seen as a problem across the whole service, from consulting room to boardroom.

Yet in other industries and services, there are attempts to raise expectations and organise to meet them.

In the hotel industry for example one can imagine that a hotel manager may feel that Trip Advisor makes their life a lot harder. I can imagine them moaning to themselves about the latest complaint on the website. But what I can’t imagine them doing is talking to their staff in their morning meeting and complaining about rising public expectations of the hotel.

Nor can I imagine a similar discussion taking place in the boardroom of the hotel chain.

In the hotel industry, and in most other services, the role of the leader of an organisation is to use those higher expectations to drive improvement. The problem for leaders in other industries is constructing a service when the public doesn’t know or demand what it wants.

The same is true for the NHS. The problem for the health service is caused by people putting up with fragmented services that don’t help their recovery.

To create a really successful health service we need, both in the consulting room and among the public, much more active engagement and we need to use that activity and demand for better health and healthcare as an asset.

This week I gave a talk at a mental health trust about these issues. I just caught the end of a patient’s story when she said that the pivotal moment for her had been when a member of staff had said to her that one day she, the patient, would get a job and go back to work. At that moment it was not imaginable, but slowly that hope of a better outcome raised her own expectation. She was then able to use that raised expectation to recover.

Recovery in mental and physical health is assisted by the raised expectation of recovery. Good medicine works with not against that expectation.

Overwhelming NHS problems #2. People are now so differently ill that the NHS can’t cope.

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 25-03-2014

This is the second of five posts exploring the way in which discussions about pressures on the NHS are being framed by its recent leadership and current commentators.

Yesterday I challenged the widespread assumption that the increase of the proportion of elderly in the population would from now onwards be seen as an overwhelming burden for the NHS whereas other industries see older people as possessing assets – assets that would be much more useful for a health service to work with.

I argued that characterising such problems as overwhelming does not bring about change but makes the NHS ‘hunker down’ under the status quo.

Today the second of my five posts focusses on the way we frame the argument about the fact that, in England, disease in the 21st century is different from that of the 20th.

Commentators, including myself, have said that the radical change in the nature of disease is a very big challenge for the NHS. The diseases that the NHS took on when it was founded in the last century have now been if not conquered certainly tamed and this century’s disease battle is very very different.

Health systems now have to tackle non-communicable or chronic disease.

As with the increase in the number of old people this issue is often presented using drowning metaphors – a wave, a flood or a tsunami of need is being talked of. The same enormous increase in figures used in regard to the numbers of the elderly are deployed again.

The first thing to say about this change in the nature of the diseases that the NHS has to deal with is that it is not a future thing, it is already here. Given that even today about two thirds of the NHS budget is spent on chronic diseases we must recognise that the problem has already arrived.

The fact that statistics for nearly every non-communicable disease point to a dramatic rise over the next few decades seem to ramp up the size of the problem to another one that is overwhelming.

Firstly it’s important to see that some of this is a problem of success. All of these conditions are more prevalent with age. The older the population, the more likely it will suffer with long term conditions. The fact that we are living a lot longer is partly due to the NHS, so the fact there are more people with non-communicable diseases is also partly due to its success.

In the pretty nigh unending battle between disease and human endeavour, notch one up to us in ensuring people are living longer.

Let’s take the specific of heart disease.

When I grew up in the 1950s the expectation was that when someone had a heart attack they either died or they quickly had a second heart attack – and then died. That has changed dramatically. Over the past 20 years survival rates have increased and now many more people survive heart attacks. We are now much much better at stopping the attack from destroying the heart and much better at stopping the second attack. We are also much better at diagnosing a ‘weak heart’ before an attack.

All of this means that there are now many more people with ‘heart problems’ than previously. It’s difficult to see this as anything but success.

The same is true of cancer. Go to the Macmillan’s website now and you will read a lot about survivorship as a major issue for people with cancer. Again in the battle between disease and humankind I can’t but see this as another great success. Much more to do, but so many more people surviving is a good thing.

So why is the changed nature of disease with which the NHS deals with such a problem? The main issue is caused by that word ‘change’. The NHS is shaped to do one thing and it now has to do another. It finds that change hard, but such a change does not have to be overwhelming.

The main reason it is described in this way is that the nature of the change the NHS needs to go through involves how 15 million people with long term conditions need to maintain their health. This, as a task, seems beyond the NHS – and in a literal sense they are right, it is.

The only way this new form of illness can be tackled by a health service is to recognise the importance of the people themselves in managing conditions. On its own the task lies beyond the boundaries of any health service. The service needs to find different ways of working to include and involve those people in much better maintenance of their condition.

What patients do to manage their condition – their lifestyle, diet and exercise – is as important as everything clinicians do.

A successful healthcare service needs to enhance the nation’s capacity to look after itself when it is ill.

Of course a really successful health service needs to enhance the nation’s capacity to look after itself before it is ill.

The danger is that the NHS sees itself as being overwhelmed by non-communicable diseases because it has to change to treat patients differently. They need to be seen not as passive recipients of care in a system that denies them both power and responsibility but instead as an integral part of a system that empowers them to take greater charge and more responsibility for their own health.

A model of health care that is controlling finds the necessity of this change overwhelming.

But in reality it is an opportunity is to bring patients inside the decision-making tent. An opportunity to let go of all that responsibility and let patients share the dilemmas clinicians and managers face – rather than keeping them outside.

This is only overwhelming if the NHS cannot let go of this power. What will be overwhelmed is a particular model of health care – not health care itself.

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.

Commissioning for integrated health and social care (or just because everyone agrees with you, doesn’t mean it’s going to happen)

Filed Under (Clinical Commissioning Groups, Healthcare delivery, Outcome based commissioning) by Paul on 07-03-2014

Over the last year the idea of outcome based commissioning within the NHS has evolved from being a policy to establishing real contracts. In a little while a completely new provision for musculoskeletal (MSK) services will begin in Bedfordshire organised by a partnership of a local Foundation Trust (FT), an existing GP led MSK service, a private sector hospital group and patient charities. This partnership will replace a plethora of very different and fragmented contracts that are currently held by different organisations, each of which was contracted to provide fragmented care inputs.

It’s a big change, and the journey to establish outcome based contracts has been characterised by long periods of universal agreement punctuated by periods of intense conflict. Why has this happened?

Those with experience of working to change policy in the NHS will recognise that dangerous moment when everyone agrees that the new policy you are trying to create is correct.

It is the moment when you prepare… for nothing to happen. All sorts of people agree with a change in policy – because in the end no one cares about changes in NHS policy. What matters are the changes in NHS practice that will take place if a policy is implemented.

Unsurprisingly this has been true of the recent development of outcome based and integrated care contracts in the NHS.  From 2010, with the development of the NHS outcomes framework followed by the Secretary of State’s mandates for NHS England, most policy has argued that the NHS should start judging itself on patient outcomes and not inputs.

At the level of policy few can disagree with that. Intellectually we know that money spent on a hip replacement operation only creates real value if the patient can resume work – or walk to visit their daughter without pain. The policy of paying for outcomes and not inputs must be correct at an individual, social and economic level.

Equally most policy makers are quite rightly concerned about the current fragmented care for the elderly. So it’s interesting that when you ask older people and their organisations what would count as a positive outcome for their care the answer is very simple.

“Since you spend so much money on our health and social care, what we would like is that every time we come into contact with the health or social care system, we are more independent at the end of an intervention than we are at the beginning”.

The individual social and economic outcome of greater independence must be a good thing and, if we could achieve it, surely worth the money that is spent on the service. As a goal it’s difficult to argue against.

But current provider practice is all about fragmented inputs. Moving to new, patient based, outcomes is very disruptive of current practice. The problem is that a great deal of existing practice produces the opposite outcome for older people in that it creates greater dependence. If the long term condition of an older person becomes exacerbated – resulting in a 12 day emergency admission to hospital – this hospitalisation will normally leave the patient with a higher level of dependence. If they move wards several time during their stay, they may even have increased experience of dementia and therefore substantially increased dependence.

A contract based on paying a provider only if they achieve greater independence for this older person would therefore need a very radical shift in practice. And it is here, at the point of implementing a policy of outcome based contracts, that the near universal agreement with the policy disappears. Providers recognise that in order to maintain financial sustainability they will need to radically change the way in which they operate.

It is at this stage that we are told that working to patient outcomes will destabilise the NHS.

And if we take that last sentence literally it is true. The current stability of much of the existing model of care from providers has evolved from the experience of fragmented care that many patients regard as normal. Integrated, outcome based, health and social care will destabilise these existing models of care – and that will be a good thing. .

Because policies really don’t matter if they aren’t implemented, and over this calendar year we will see whether the NHS and social care can bring about the change that comes from working towards outcomes.

In recent weeks Oxfordshire Clinical Commissioning Group (CCG) passed proposals for the CCG to work with existing providers to develop outcome based contracts for older people and mental health services. The CCG have now reached the point where they have to negotiate with existing providers the radical changes that working to outcomes will being.

By deciding to work with existing providers the CCG have demonstrated that the development of outcome based contracts does not have to involve market based procurements. The CCG recognises that existing providers may have the capability to radically reorder their priorities. But they have the option to hold an open market procurement for the roll-out of 2014-15 contracts should dialogue at the point of contract agreement not be successful.

As in Bedfordshire outcomes based contracts will necessitate new ways of working which will need new forms of provider partnership.

Elsewhere the movement is gaining widespread support with CCGs backing prime and alliance models of contracting, to change and challenge the commissioner/provider relationship where existing models simply don’t work. Along with Oxfordshire, other CCGs leading the way include Cambridgeshire, Bedfordshire, Bexley, Northumberland, Croydon, and Staffordshire.

In all of these locations and more, the crunch will come when the idea moves from being a policy to making the necessary changes in the practice of provision.

Take a few steps back to understand what failing hospitals really mean for the NHS – and why we need to do something serious when they do.

Filed Under (Francis Report, Healthcare delivery, Hospital Trusts, Localities) by Paul on 28-01-2013

Last week I drew the analogy between the role of the administrator in the NHS and the fact that someone with the same name – administrator – winds up High Street retail chains like HMV. The point I was trying to make was that the announcement of an administrator for HMV was recognised as being the end of the line for the current organisation of a failed chain of stores. However when an administrator  was announced for South London Healthcare Trust it was seen as another opportunity to develop the trust with the minimal amount of change. Read the rest of this entry »

A manifesto ‘to’ primary care or a manifesto ‘for’ primary care. Small change but a whole world of difference..

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 10-01-2013

Today I am taking part in an interesting conference organised by the NHS Alliance about the future of primary care. They have asked me to develop challenges to an important set of chapters that clinicians and others are writing about the future of primary care.

Let me share some of the challenges that I will be making. Read the rest of this entry »

The NHS Confederation makes its case for a year of change in NHS hospitals

Filed Under (Clinical Commissioning Groups, Health Policy, Healthcare delivery, Hospitals, Independent Reconfiguration Panel, National Commissioning Board, Secretary of State) by Paul on 02-01-2013

The Government’s NHS reforms have done little to prevent the main change that will have to take place to ensure that our health service survives and thrives in any meaningful way in the future. That is the major reorganisation of many of the patient services that are at present delivered from NHS hospitals. In the last few days of 2012, the NHS Confederation has been putting the argument for change.   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

Reform and Healthcare in Canada

Filed Under (Canada, Healthcare delivery, Public Health, Public service reform) by Paul on 12-11-2012

I spent last week in Canada talking to people engaged in health care reform in the provinces of Ontario and Quebec. Canada has a socialised medicine system with a lot of similarities to the UK system. The very existence of a socialised medicine system is very important to most Canadians.  Many would say that it is their socialised medicine system that differentiates them from the USA. Read the rest of this entry »