Food for thought

Dr Carter, the Head of the Royal College of Nursing has been busy over the last week or so.  First, he says that nurses spend too much time on theory in classrooms and not enough time in practice.  Then he he argues that family members should help out at mealtimes.  It seems that for both of these statements he has taken quite a bit of flak.

For me, whatever the rights and wrongs, the debate points to a bigger problem.  Taking care of business has meant that the NHS has, over time, systematically broken down the business of taking care - into functional roles, specialised tasks, targets, activity volumes and the like - in the misguided belief that this will produce greater efficiency and productivity and a better patient experience.  We have commoditised our relationship with public services to such an extent that staff can't do what they want to help people and users expect "the system" to do things for them, not with them.  We then wonder why patients end up drinking water out of vases.

My experience with applying the Vanguard Method shows that if you treat people as people, solve their problems when they put up their hand for help and design the systems responses perfectly to the demands that are placed upon it, you end up with ordinary people doing extraordinary things.

Why would you suppose that training a nurse to degree level will provide better care on a ward?  When it comes to care, we should be training people to consistently and reliably undertake the type of tasks that will be typically and frequently predicted to be needed.  We call this training against demand, others call it common sense - either way, you don't need a classroom for it.  Certainly you would not miss out on a huge tranche of staff, in this case health care assistants, by taking this approach.

And if we could solve peoples' problems when they put their hand up for help, the relationship between people who use services and the services themselves changes so dramatically that outrage about being involved in helping a family member evaporates.  For a start, many of the people who are currently in a hospital (because that is what the pathway prescribed), end up not needing that, or many of the other services we try to fit people into.

I agree with Dr Carter's sentiments but wonder if they miss the point.  I continue to learn about the way we have designed the NHS, but whatever the conclusions of the experiments I am undertaking, it is clear to me that our obsession with industrialising public services means that we are, systemically, missing the point about what matters to people.

To know is not to understand

My experience, having applied the Vanguard Method in health is that it is true that GPs know many of their patients.  But do they really understand them?  I blogged before that in one experiment, in every case, understanding the person changed the pathway.  The chances of this happening as special and not common cause was one million to one.  In another example, in presenting a case study, a GP did know the patient concerned, but had absolutely no idea of the sheer scale of contact that this person was having with the system - to little or no apparent benefit.

The insights that these experiments give the leaders who undertake them is that the system is designed to be systemically incapable of providing person shaped solutions to the problems people have.  As a result it drives waste and dysfunction on a monumental scale.  But because of the episodic nature of the way we provide care, it remains largely invisible, unless you know how to look.

What people find is that the system starts by medicalising people, immediately prejudicing the opportunity to really understand a person and how we might be able to solve their problem in the context of the way they live their life.  Having started with that we then treat people transactionally and episodically, creating service and pathway shaped boxes to fit people into, rather than person shaped solutions.  Commissioning then becomes the art of creating more services and then finding ways to limit access to them, creating more and more hoops for people to jump through.

They also find that we are designed to assess and diagnose, so that's what we do.  Task focussed, assessing people out of context, trying to fit them into service solutions that have been created by looking volumes and activity from organisational perspectives, rather than really understanding the demands people place on the system and designing responses around their needs.

For me, the current debate around hospital closures falls into the category of convention over understanding.  It seems they are rapidly becoming this seasons black with Roger Burstow now going public on the need to reduce costs in this way.  "We are", he says, "beginning to hit a wave of reconfiguration decisions".  The aim, it seems, is to provide services more efficiently and less expensively.  Care closer to home - that's what patients want.  and it has the added bonus of being cheaper.  If the Kings Fund, Reform, Lord Crisp and now the Minister are saying this then surely it must be true?

Well maybe it is, but one thing is for certain, the logic that drives those conclusions is wrong.  What should drive any discussion on reconfiguration is purpose from a users perspective, not cost.  Health (or should I say wellbeing) economies should be less concerned to shut their A&E because there are difficulties in covering the rota and more concerned about value from a users perspective having understood what it is that patients want and need.

Why is this important?  My fear is that CCG's will become so overwhelmed with the prevailing management paradigm that they will unable to do the very thing that they were set up to achieve - make decisions for people, based on what they need, with people who understand them - their GPs

Board room discussions will focus on issues such as competition, choice, integration, closures and cost.  Efficiency and productivity will become the watchwords, but mostly everything that will be done in their name will add to cost, not reduce it.  The risk is the opportunity to make meaningful change from a users perspective will be lost and those visionary GPs will look back on the aspirations they had for their local populations and wonder what went wrong.

Do hospitals need to close?

Prof Paul Corrigan, a former advisor to Tony Blair has argued that, unless radical action is taken the NHS will need to find £5bn to bail out failing hospitals.  Some hospitals will, therefore, need to close, but its OK because the model of care that replaces it will be better.  It's not the first commentary on this topic, with Lord Crisp being the most recent high profile commentator to argue this.

It is hard to disagree with some of the conclusions, given what I have seen to date having applied the Vanguard Method in health.  What concerns me though is that the logic that is driving these conclusions is one of managing cost and not managing value.  Unfortunately, the reality is that if you manage costs, your costs go up.  What leaders who apply the Vanguard Method understand is that cost is in flow - manage value, end-to-end, from a users perspective, and your costs will go down.

There is plenty of evidence to support this, perhaps the most obvious one being walk-in centres.  Everyone had to have one of these, millions were pumped into building them on the basis that they would take care of the "ambulatory care sensitive" cases, A&E attendances/admissions would go down and everyone's a winner.  Patients get care closer to home.  Commissioners save money.  Trusts create capacity.  Only trouble is that they proved to be so popular they became unaffordable, particularly as there seemed to be little or no impact on what was coming through the front door of the hospital. Overall costs went up.  Managing costs had the opposite effect to that intended.  

Better would have been to design a system to respond to people in the right way when they put their hand up for help based on knowledge and understanding, not create another service solution based on instinct or convention.  Fortunately, when PCTs started closing them, the managers in charge could at least pat themselves on the back for having made a significant contribution to their efficiency savings....

If it is true that hospitals will need to close, better to make decisions like that from a value, not cost point of view.  By doing so we will be sure to be cutting that which ought to be, not that which can be.  We are then in a position to build our business models based on knowledge not convention.

The concept of "solution factories" again sounds plausible, but right now, fills me with dread.  If centres of excellence are not determined from a value point of view then this could be another example of blindly plumping for a model based on an assumed economy of scale.

I worry that decision makers will opt for approaches like this without first understanding what perfect looks like from a users perspective.  The risk is they apply current convention and logics of cost and activity as the basis for change.  If that happens then as plausible as Prof Corrigan's analysis might be, it is almost certain that the wrong decisions will be made, with the system ending up paying more, not less for the new model.

Paradigm shift

A quick scan of the literature over the last 18 months underlines the acknowledgement by the system that we need to do things differently.  In fact, a look back across the history of the NHS shows that there is a repeated recognition that we haven't got things right.  You would hope that such a conclusion would be reached given the amount of change it has been subjected to.  Otherwise all reforms would have been pointless, right?

Every day the NHS and the people who work in it do incredible, life changing things that are rightly admired.  But, either because of personal experience, or because of the stories that we hear so regularly in the press, or because our leaders tell us things are not right - be they former CEO's admitting that the NHS built too many hospitals or our political leaders who tell us that the NHS is not responsive enough and not getting the same outcomes as other comparable nations - or the colossal waste that is PFI, or the strange but true stories of Independent Sector Treatment Centres paid tariff plus for work they didn't do.  Or NPfIT.  Whatever it is there remains a sense that perhaps we haven't got it quite right.  In this context, quite why, in his recent critique, Gerry Robinson felt that the one thing that was missing from the reforms was a central planning function baffled me.

So we talk of the need for paradigm shifts and invest time in supporting people to be able to successfully lead health economies through this difficult time.  But despite all the events that one attends talking about how the Fosbury flop was a completely different paradigm from what went before; or how blue tits were able to adapt to the change to foil tops on milk bottles and still take the lids off to get to the cream whereas robins couldn't, the breakthrough hasn't quite happened.

Why is this?  I believe that it is because what is missing is a method for looking at how we "do"change.  We continue to believe that the answers lie in competition and incentives, targets and performance indicators, M&A and economies of scale, lean and six sigma without understanding what it is that people want and need when they put their hand up for help.  We then end up being seduced by ideas for "betterment" that we import or apply (e.g. Healthcare Maintenance Organisations, competition, choice etc) without first taking the time to understand.

One could be forgiven for concluding that this is the result of lazy thinking.  In the rush for change the desire for a "go to" answer becomes overwhelmingly compelling.  Or maybe its because we have become so used to commoditising our relationship as citizens with public services that all change is framed from the perspective of costs and activity, rendering us incapable of conceiving of change from any paradigm other than the current convention.

Whatever the reason, significant, radical, transformational change will not happen unless we are able to change the way we think about the problems we think we have and the methods we have to solve them.

Can the transformational change be as elegantly simple as I have described - focus on people and be clear about the purpose of what we do from their perspective; agree the measures that tell us that we have delivered that purpose and then, and only then, decide the method by which we systematically and sustainably deliver purpose?  Judging by the results of my experiments, I think so.  It is still early days, and as I have said before, I am still learning but the signs are very promising.  As I learn more I will share the results.  But what is clear is that current convention is a poor method for change.

Putting the "P" back into the NHS

David Nicholson wants the "N" put back in the NHS.  For those of you who have been thinking the last 6 months or so has been about people taking the "P" out of the NHS, I thought it would be nice to think about putting it back in again.  The "P" in question?  People.  What I see when I apply the Vanguard Method in health are local health economies and an NHS (in England) that are systemically incapable of understanding people.

A bit trite to say?  What if I told you that of a cohort of people that formed part of an experiment to find different ways of doing things, not one of them had been appropriately understood.  Because we then understood them, not one of them went onto the pathway prescribed for them.  Because we dealt with their problem, their experience was transformed - either by having a better life or, in one case, having a good death.  Because we did this, admissions were avoided, lengths of stay reduced, discharge to residential/nursing homes didn't happen.  The chances of all the cohort being special and not common cause? One in a million.

Here's a challenge for you.  Ask yourself whether or not, if you put all the assessments that different professionals make about a person together, would that give you a view of the whole person and their problem to be solved.  If not, do you think there is a problem here?

We talk about putting patients at the centre of everything we do, but we are systemically incapable of doing it.  My experience in having applied the Vanguard Method in health is that far too much time is spent on pathways, targets, economies of scale and other management things considered to be the bread and butter of management.

And yet it focusses good people on doing the wrong things.  The problem was, for me, summed up by what Lord Crisp said yesterday.  He effectively admitted that billions of taxpayers money was spent doing the wrong things which now have to be undone - but at least you can get through your A&E in 4 hours....  It was a shocking admission in my view, but an inevitable consequence of not taking the time to understand people and the communities they live in.  Unless this changes there will continue to be "missed opportunities" and much more wasted money.

Management iatrogenisis

One of the biggest challenges facing health systems is that of understanding patient safety.  It is suggested that the equivalent of 30 Boeing 747’s crash every month in America, 6 in Britain and 2 in Australia as a result of preventable medical errors.  Estimates vary but the rate of error and adverse events is in the order of 10% of all admissions.  In about 2% of all cases major disability or death occurs.  It seems that a major reason for this is what is known as medical iatrogenisis, or harm induced by healthcare itself.  It’s because the harm happens one patient at a time that this is a hidden epidemic and there isn’t the outcry and immediate action to resolve.

For systems thinkers this is shocking stuff.  The statistics make grim reading: a 1:10 chance of being harmed during a hospital admission; a 1:50 chance of a system induced death or disability; a 3:10 chance of ultimately dying normally but with an untreated pathology.  If all these were completely independent it has been estimated that the risk of misadventure or under detection by health system act of omission or commission of some description is 92%.

The good news is that at least your local hospital you will get through A&E in four hours....

I was reminded of this idea of medically induced harm following the recent debate about the prescribing of statins.  


Perhaps there is a deeper problem at play though.  Maybe it's not medical iatrogenisis (as genuine an issue this may be) but management iatrogenisis that is the problem.  In other words, harm induced by the current management paradigm and its preoccupation with targets, budgets, economies of scale, standardisation, centralisation, organisational configurations and any number of management concepts that focus doctors, nurses and other staff on the wrong things.

What I see as I study health systems is that it is finance that drives behaviour, not purpose from a users perspective.  It is the management of risk that concerns people, not solving a persons problem.  It is the delivery of targets that are uppermost in people's minds not understanding the type and frequency of demand on a system and designing for perfect against that demand.

For systems thinkers understanding the purpose of the system from a users perspective is the critical issue.  If the purpose of the system is to cause preventable harm then we can all pat ourselves on the back and congratulate ourselves on a job well done.  Presumably that is not what you want for your system though?

The alternative?  Study your system and understand the types of demand you face.  How frequent and predictable is it?  Is it demand that is valuable from the users perspective - i.e. "I need help and you have solved my problem" or is it what we call failure demand - the failure to do something or do something right for someone?  Then look at all the reasons that get in the way of the system delivering what a person needs as and when  they need it.  If you have the same experience as I have had you may conclude that most of the initiatives designed to improve the system are having quite the opposite effect.


What to do once you have this knowledge?  Experiment.  Allow the patient to set the boundary of the system.  Make expertise available as and when required, not through complicated referral processes or eligibility criteria.  Become pathological in your quest to understand.  But understand people first, not processes.  That can follow.


There may be false starts, you may make mistakes.  But so long as that is part of a learning and adaptive process, with the right leadership and the right framework for change the system will end up in the right place.


In doing so you might find that, instead of spending time worrying about abstract notions like readmissions, you sort Terry's alcohol dependency issues out and avoid his repeat, episodic and transactional hospital visits.  By understanding Alfie's need for independence you think of replacing the buttons on his shirt with velcro so he can dress himself, not depend on someone coming into his home to offer assistance.  Rather than be concerned about eligibility criteria, you avoid the flightpath to dependence and expensive residential or nursing home placements by not putting Alice in hospital and labelling her confused and incontinent because she has been assessed out of her normal context and there has been no-one to answer her buzzer when she needs to go to the toilet.


Many of the conventions we simply take for granted, the split between primary and secondary care, the purchaser/provider split, the health and social care split then become redundant.  Artefacts of a world based on the notion that industrialising services was a good idea.

The harm we are causing is happening one person at a time - that doesn't make it any less shocking.  It is also happening one target at a time; one initiative at a time; one policy at a time.  And for all efforts that staff make in spite, not because, of the system; for all the reports, KPI's and balanced scorecards that say that there is no need for concern, everything is under control, don't be fooled.  The system is broken and our attempts to fix it using traditional management approaches is the cause, not the solution