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 »

People powered health and patient coordinated care

Filed Under (Health Policy, Patient centred coordinated care, Patient Choice, Patient involvement, Self Management) by Paul on 20-03-2014

I know it doesn’t feel like it in 2014, but the dynamics of disease will move the NHS into an era which will either fully utilise patients and their carer’s capacity to better self-manage their conditions – or collapse.

The old model of healthcare will not be able to muster sufficient resources to cope with the new model of disease.

Moving from here to there will be difficult, with many fits and starts, but patients and their organisations will be the main force that will drive this change.

That’s why yesterday I posted that too much of what is at the moment called “integrated care” is simply shuffling existing services around and hoping they will fit.

They don’t.

Given the multiple morbidity of many patients it will take much more than this to create care that is properly coordinated.

Above all it will need investment in the assets that patients, their carers, families and communities have to better manage their conditions.

This process starts with a very difficult set of changes from inside the existing model of care.

At the moment many medical staff, seeing a list of sick people – some of them very sick – fairly inevitably see their patients, carers, family and communities as a set of deficits. Patients are seen as lacking average blood pressure, good breathing, the ability to be active in the world, the ability to manage their condition themselves etc. etc. Patient after patient comes in expecting some external help from the doctors and the nurse.

This experience makes it fairly likely that the tenth person who comes into the clinic will be seen as a set of needs – and not as having any assets.

Which of course becomes a self-fulfilling prophecy. The NHS sees no assets amongst the patients and the patients therefore don’t feel, when they come into contact with the NHS, that they have any.

But if we continue in this way, treating patients as if they are nothing but deficits, the health service collapses under the weight of demand from co-morbidities and an insufficient supply of medical staff kit and drugs.

Finding out what assets people have is not a straightforward process. Different people have very different assets.

Many people have family and friends who can do much more than take a prescription to a chemist. But to do more they need some investment of time and effort from the NHS. Helping people to play a bigger role in helping other people first requires the recognition that there is something there to work with and then some time and effort to help them know how to improve the patient’s capacity to self-manage.

But others – the very old and the vulnerable – may be very isolated and have lost all their organic relationships with family and friends. Here the NHS needs to find ways in which local voluntary and community groups can stand in.

Last autumn the Red Cross fundraising campaign had a picture of an isolated older lady at home in this country. This, not the health outcomes from an earthquake in another country, was ‘the crisis’ that the Red Cross was pledged to help to solve. For some years now the Red Cross have been training volunteers to spend time with isolated patients.

Of course they are not alone in this.

Organising someone to visit an otherwise isolated person is not something that a busy GP can take on board themselves. It may only rarely make sense for a doctor to find out about all the voluntary groups in their area, but it always makes sense for them to have someone who knows to whom they can refer the patient. This practice of social prescribing is gaining recognition within the NHS.

If the increase in the number of people with several long term conditions is the disease burden with which our health and social care service needs to cope, then my point is that the only way that this can be done successfully is with the very active management of patients themselves.

Changing health and social care to achieve this will not be easy.

Last year, before I suspended blogging, I posted about the work that I and others had carried out with NESTA. There are several publications on their website that flesh out how investing in better self-management can work for the NHS.

Creating patient centred coordinated health and social care isn’t just a matter of bringing existing services together.

Filed Under (Health Policy, Patient centred coordinated care, Patient Choice, Patient involvement) by Paul on 19-03-2014

Across various parts of social care and the NHS the last year has seen a great deal of planning to create what the NHS and local Government likes to call ‘integrated care’. (I commented yesterday on how providers of care like to call it this whilst patients like to talk about ‘co-ordination’).

Across the country, there are regular meetings where teams of people are sitting down and looking at their existing services and trying to stitch them together into a different pattern.

Over a year ago I tried to understand why this was so very difficult. Staff wanted to do it; patient’s carers and the public wanted to do it; resources were demanding it. But, meeting after meeting, it kept on not happening.

My answer to this conundrum is that we underestimate the passion with which staff and services have developed their fragmented bit of the whole. More and more people come to work in health and social care with greater and greater specialisation in their work. Most careers have been developed not around better coordinated whole person care but around greater specialisation.

Two weeks ago, tucked away in John Oldham’s report on Whole Person Care was the recognition that the way in which merit awards were granted to the medical profession not only encouraged but practically enforced body part care rather than whole person care.

In the field of social work, despite several decades of argument for generic social work, specialisation is how you get ahead.

Of course staff don’t come to work with the aim of fragmenting a person’s care. They come to work with the experience of working only with diabetes; only with residential homes for residents with dementia, or only with depression. The constant in their work is the specific illness – the variable is the human being.

And it is not wrong to describe staff as ‘passionate’ about their specialisation. Hearing specialist consultants, nurses, or residential social care staff talk about their specialism is a moving experience. They really want to improve their skills but talk about more and more specialist activity.

This process has created passionate fragmentation.

And there are very many who believe that coordinated or integrated care will be created if we bring these fragmented services together. Rather like a jigsaw puzzle. So the job of the coordinated care officer is in some way to find the picture on the top of the box and fit all the pieces together.

It’s a compelling analogy – but it doesn’t work.

The jigsaw takes an existing picture – let’s call it “Whole Person Care in the Home”, cuts it into bits, and then jumbles those bits up. The coordinated care person a) knows that somewhere in all the bits there is a real coherent picture and b) that whilst it will take time and effort their job is to fit the bits together to make that picture – and given time and skill that is what they will achieve…

The problem for real coordinated care is that the fragmented services have NOT been created as a single picture and then fragmented. They have been created to only deal with bits. They have been created as fragmentations.

The big problem is that the part of the jigsaw for an 85 year old woman called “diabetes care” has not been created to fit  neatly with the part called “dementia home care”, which in turn has not been created to fit with the part called “COPD care”.

They have not been created in a way that they will fit together.

The organisations that create them have made these services as “bits” in their own right.

So a really clever coordinated care worker can shake all the pieces out of the box for Mrs Patel’s whole person care and then find that the problem is that when they try and fit them together – they won’t. They were not made that way.

At best they might get a few that look a bit similar to form a line, but they will not form a picture of whole person care. And when you look at that line, there are holes in between through which patients fall, and duplications where they have to do the same thing over and over again.

To build a picture of whole person care you have to fundamentally change these fragmented services so that they might just fit together.

To achieve that coordinated care staff will need much much more power to transform existing service than they are normally granted.

It won’t surprise blog readers that I think that this greater power comes from patients and tomorrow I will describe how I think that might work.

Patient-centred coordinated care

Filed Under (Integration, Patient Choice, Patient involvement) by Paul on 18-03-2014

Over the last year I have read more about integrated care than about any other health and social care topic, and even though I don’t read much more than 5% of what is published on the topic we are talking about what, in hard copy days, would have been called “forests of paper”. I am sure that in the digital world, there are several terabytes of disks filled with the stuff.

Over the next few days I want to make some comments about what has and has not been achieved in this area of health and social care in the past year, but first some comments about language.

Because so much has been written about integrated care, I want to say a few words about the language we use to describe the changes we want to bring about.

Quite rightly much is made in making the case for change for integrated care, of the bad patient experience created by the current model of fragmented care. Different specialists feeling they are the only doctor the patient sees; different nurses asking for the same back story to be outlined by the patient; different social care staff coming at different times to carry out un-coordinated care. At best it’s merely bewildering, at worse it has a bad effect on patient well-being.

Nearly every local case for change in integrated care talks about patient experience as a reason for change before resources are ever mentioned.

Given the recognised saliency of patient need in this set of changes, it’s a great pity that the language we use to describe what we are doing is still a language dominated by our task and not by language that patients can understand.

About a year ago NHS England commissioned National Voices to carry out a discussion with patients to find out how they and their carers describe the changes that we call “integrated care”.

The very fact that NHS England asked for this to be carried out was a recognition that the current method of description and explanation needed change. Commissioning the work was a good thing. But if you trawl through NHS England’s web site you will see that the changes are still referred to as “integrated care”. They paid for a patient centred piece of work to be carried out and then ignored it in their own practice.

What did National Voices actually come up with? (Here’s the link to a presentation)

After extensive discussion they found that the phrase that made sense to the public was “person-centred coordinated care”.

Integration is what the system needs to do.

Coordination is what the public need to experience.

The key wish for patients is that,

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”

Contained in this sentence is the reason why language is so very important and why who is in charge of the language is such an issue of power over practice.

This sentence is reasonable. But it’s pretty obvious that it describes a way of developing care which puts patients in charge.

It starts off with I can plan my own care. Whilst this is ideologically what the NHS and social care claim to want, it fairly obviously implies that organisations that currently plan patient care around their needs would no longer be in charge.

With people who work together to understand me and my carer. Again ideologically it’s what everyone says they want – of course we work together to understand the patient and their carer! (Well no, that’s the problem isn’t it?)

Allow me control… Again the wish is that patients should have control, but the reality is that services are not organised around that concept.

…and bring together services to achieve the outcomes important to me. The clinching argument here is that the services would have to be organised around outcomes that are “important to me”.

So what National Voices have wisely done is to ask patients how services would be different if they were organised in their interests.

Unsurprisingly that resulted in not only a shift in language but a shift in the power that language describes.

And that’s the reason, a year later, we all go on talking about “integrated care” and not using the language that patients want to use to describe that change.

This is the rather sad conclusion. Even when the NHS genuinely wants to do something that is in the interests of patients and even when we explicitly find out how patients want to describe these changes we still can’t bring ourselves to put it into practice.

Our own language, our ability to talk to ourselves internally is much more important to us than our ability to communicate with patients.

And the reason for that is that we know once we start using the language of patients to describe what we should be doing, we will cede a lot of the power that we have over their lives to them.

“Unless you bring the consumer into the heart of these changes you won’t get the change.”

Filed Under (Ed Miliband, Health Policy, Patient Choice, Private Sector, Public service reform) by Paul on 10-03-2014

 (Ed Miliband on the Marr programme)

When Ed Miliband said this in January he was talking about the energy industry. One of the major planks of his policy for developing a new economy is to encourage and enable much more active consumers.

Active consumers challenge provider bad practice in two ways.

First they make a fuss about their existing supplier. Increasingly they may join a range of campaigns about how badly they are treated – and social media is making those campaigns more powerful every day.  The political scientists (and Ed Miliband) call this ‘voice’. Increasingly consumers let the world know when they get bad treatment and they say it ever more loudly and in greater numbers. The reputational costs for providers of services that have campaigns run against them can be immense. So providers worry about consumer voice.

Second, where there is competition consumers have the right to take their business somewhere else. Political scientists call this ‘choice’. In the energy industry Ed Miliband makes the important point that exercising choice is difficult. He is committed to making it a lot easier for consumers to move their business. And where there are monopolies he will develop policies to break them up and provide the consumer with more choice.

Whilst voice can raise problems of reputation for businesses, it is the loss of customers through choice that is the direct driver for companies to improve service. If there is no choice the impact of putting consumers at the heart of change is diminished.  Thousands of active consumers combining voice and choice will have an impact on bad providers – or they will lose a lot of business.

The important political point for Ed Miliband here is that given his committtment to stand up for consumers against monopolistic power in the private economy where does he stand on the issue for consumers of public services.?

On February 10 he made a speech addressing the problem for consumers of public services. In this speech he clearly said that he was as committed to tackling the abuses of power of public services as he was of private services. This is a new dimension to the recent post-2010 politics of the Labour Party and of course will have a big impact on the politics of the NHS.

If you are to win votes from voters outside your tribe then good politics is all about developing positions that are a bit different from those that the tribe expected. A traditional Labour position attacks the power of private companies over consumers but has not attacked the power of public organisations over citizens.

So when his Feb 10 speech talks about understanding that that there are people feeling powerless because of state institutions and not only private sector companies, he is making an important and not completely expected point.

The speech went on to talk about enhancing the power of the citizen in developing their voice in gaining more power in public services. There were important promises for parents (and in the future patients) on developing their public voice to have a greater say. In particular a part of the speech that could have a big impact on the NHS was the promise of helping individual patients organise themselves with similar patients. This blog has often spoken about the importance of patient organisations developing a more powerful collective voice for individual patients. This is potentially an important and practical policy.

He was talking about people powered public services.

But when it came to choice he said that this was different for public services because parents don’t choose a school in the same way that they choose a café. That’s true. A café choice is made every day, and a school choice once every few years. That makes them very different choices – but they are still choices.

And parent choice of schools informed by information from Ofsted has had and is having a big impact on driving up standards. Just as for a private company if you don’t listen to the voice of parents about your school then parent choice will have a direct impact on your bottom line. Head teachers who don’t care how parents use their ability to choose schools don’t last long.

To allow consumers in private industry to use the power of choice is a vital way of empowering consumers.

Not to allow citizens who use public services to use the power of choice will limit their empowerment.

If you want to improve public services people need all the power they can get, choice as well as voice.

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 »

With elective care in the NHS how is patient choice faring?

Filed Under (GP Commissioning, Patient Choice) by Paul on 12-09-2011

Over the next few weeks the Bill will be going through a quiet period, so it’s a worthwhile opportunity to take a different look at some of the highly politicised issues that we discussed last week. Today I thought it would be useful to run through a review that was published in July this year by the Cooperation and Competition Panel concerning how patient choice for any willing provider was actually working. Read the rest of this entry »

The big show down. The BMA and its fight with patient choice

Filed Under (BMA, Patient Choice) by Paul on 09-09-2011

Last week’s BMA briefing on the Health and Social Care Bill not only argued their continuing opposition to the Government reform, but demonstrated how much they wanted to move the NHS away from modern society.

In June readers will remember that the Government’s reform of its reforms argued that they would amend their Bill to make it clear that they would outlaw any Health Minister that argued for a change in the proportion of NHS services that were provided by the public sector, the private sector or the voluntary sector. They did this because they had been stung by the accusation that they had a policy of increasing the share of NHS services to be provided by the private sector.

So, true to their principles, they reversed the policy from being one in favour of increasing the size of the private sector to one where you were not legally allowed to have a view on it at all.

This new law would outlaw a policy where a Minister, or Monitor, argued – for example – for a higher proportion of third sector organisation hospices providing services for end of life care.  The outlawing of this statement was meant to prevent the accusation that the Government was in some way against NHS public service provision.

If the current state of provision was, say, 30% private, 30% third sector, and 40% public sector then freezing proportions may in some way make sense. But given that for most parts the NHS provides well over 90% of provision, this policy freezes provision in very unequal proportions.

The aim of this new law was to argue that Government could not have a policy of increasing the proportion of care from a sector. However the Government was NOT saying that they would stop individual patients from choosing whatever provision they wanted. So if a large number of patients chose, for example, to move their end of life care from an NHS hospital to a voluntary sector hospice, the government would say this was up to them and not caused by Government policy.

It was not having a policy which would tell patients what to do that has made them fall foul of the BMA. .

At the time I suggested that whilst the BMA and other public sector trades unions would welcome the fact that the Government no longer wanted to have a policy of increasing competition in the NHS, the policy of Government neutrality would not appease them.

They would not rest until the Government had a policy of outlawing the private sector from providing any more services for NHS patients.

Last week’s BMA briefing made it clear that this was now their position.

“ In relation to the increased use of the private sector in providing care, the changes in the Bill put a duty on the Secretary of State, Monitor and the NHSCB not to ‘exercise  <their> functions for the purpose of causing a variation in the proportion of services provided  by any sector. This does not prevent such a variation taking place as a result of market forces < e.g. patients choosing more providers from a particular sector through AQP- any qualified provider>

The BMA believes that

  • Although the Government has attempted to address concerns about the increased use of the private sector, there is still too much emphasis on using ‘market forces’ to shape health services. The Bill still allows for there to be an increase in the use of private sector providers”

BMA briefing page 2

This is a really important explanation of the BMA’s position and it gives us a view of the kind of society that they want to create. It demonstrates how far they are prepared to change the nature of an open society in order to appease their own fear of the private sector.

Since they argue that the Bill is flawed because it “allows for there to be an increase in the use of private sector providers”, presumably a good Bill would in some way outlaw any such increase.

Since the Bill does not ‘prevent such a variation taking place as a result of market forces – for example patients choosing more providers for a particular sector’  presumably a good Bill would in some way outlaw patient choice if that choice was to result in a higher proportion of NHS care being provided by the private sector.

In an open society this is extreme stuff. It is worth a moment’s quiet thought about the sort of society these restrictions would create.

The BMA want a bill that would make it illegal for private sector organisations to provide a higher proportion of NHS health care than they do at the moment. Even more shocking is the fact that the BMA would be satisfied with a Bill that would make it illegal for patients to choose to have their operation carried out by a private sector provider if that movement increased the proportion of provision for NHS patients from the private sector.

In the past there has been much talk by the BMA about their concern that patients are individually not really up to making these choices.

But here it is clear that they are not frightened of the individual capability of patients to make these choices but they are really worried that the overall outcome of making these choices might increase the proportion of private sector providers for NHS patients.

They want to restrict patient choice for directly political reasons.

But what sort of society do they want to create?

Does the answer to the problem of creating integrated care lie entirely within the NHS?

Filed Under (Health Policy, NHS Providers, Patient Choice, Private Sector, Reform of the NHS) by Paul on 16-06-2011

Tagged Under :

Regular readers will have noticed that the relationship between integration and competition is an topic upon which I have posted a couple of times in the last few weeks. In my view all the commentators pointing out the importance of creating integrated care services for the NHS are correct. Read the rest of this entry »

If integration of NHS care is the answer, what exactly is the question?

Filed Under (Competition, Kings Fund, Patient Choice) by Paul on 03-06-2011

One of the more interesting aspects of the period that the Government has taken to have a bit of a think about its reforms has been the way in which organisations that have had a long term solution to the problems faced by the NHS have used this space to suggest that their solution can solve its problems. Read the rest of this entry »

In 2011 there is still a debate over whether the public have the right to a better choice of GP.

Filed Under (GPs, Patient Choice) by Paul on 25-05-2011

One of the most interesting outcomes of blogging regularly is that I am often surprised about what is contentious, and what is not. Last week I discussed some evidence about the outcomes of patients being able to choose their GPs and received a range of different comments, most of which argued against giving the public the right to choose their GP. Read the rest of this entry »