All consuming

Quantification is the description of reality with numbers.  These numbers make you feel secure; provide you with a sense of precision.  We accept, uncritically, the underlying mathematical assumptions behind very complex situations, assuming in the process that reality is identical to our rational reconstruction of reality.  So Boards end up believing, for example, that delivering a 4 hour target is a measure of both performance and patient centred "goodness" when in reality it drives the wrong kinds of behaviour and does little to solve peoples problems when they put their hand up for help.  


There is a lot of quantification in the NHS.  Boards look at lots of stuff.  Sometimes its even useful.  I would say don't get bogged down by performance information that is produced by the management factory.  Usually it tells you nothing.  At best it lulls you into a false sense of security.  At worst it can lead you to make harmful decisions.  If the CQC is anything to go by they also describe a reality far removed from that which patients actually experience.

In applying the Vanguard Method in Health I have been trying to stitch together person shaped consumption, end-to-end over time.  It's not an easy thing to do.  The NHS does not look at information in this way.  It is very revealing.  For hospital data though, the pattern is unequivocal.  In every system I have studied:

• about 1.5% of people consume roughly one quarter of hospital inpatient and day case resources
• 5% of people consume about 50%
• under 20% of people consume over 80%.  

What I have seen would lead me to believe this is the same pattern in every wellbeing economy.  What I conclude is that leaders in wellbeing economies are blind to this.  They know, at a level of principle, that there are a few responsible for consuming the many.  But quantification rules and numbers showing that targets are being delivered rule the day.  So these people get lost in the melee that is day case rates, new to follow-up ratio's and ALOS.  The target culture is driving the wrong behaviour, solving the wrong problems, driving in cost, causing waste and harming patients.  The solution is to understand people in the context of how they live their lives.  Not very fashionable perhaps, but no less true all the same.

In terms of numbers of people, they are small.  Certainly small enough that , as a system, wellbeing economies could organise themselves much more effectively to understand their stories and solve their problems.  From the data I have, the same proportions apply equally to use of other parts of the system.  And they seem to be the same people.  So to put it into context, in one Trust about 700 people account for about 20% of resource consumption.  So when we talk about scale let's put into into context of reality.  700 people should be within the gift of wellbeing economies to design solutions for surely?

On  the other side of the coin about 50% of admissions to hospitals stay less than 72 hours.  Now, there are obviously many more of these people, but when I study these cases a significant proportion of these could be supported without the need for hospital admission.  Perhaps more illuminating is that the closer they are to breaching 4 hours, the more likely it is that an admission will occur.  At a level of overall system performance and solving peoples problems, I contend that the targets are not working. 

So why do I keep going on about understanding?  I reported before that in one experiment, not one person went on the prescribed pathway once we had understood them and the way they lived their lives.  The chances of this being special cause for all of them is one million to one.  And the hard facts?  Well for that cohort of people there was a:

• 11% reduction in placements (nursing/residential)
• 16% reduction in acute admissions
• 42% reduction in community hospital admissions

I have seen that wellbeing economies are systemically incapable of understanding how to respond to knowledge about people.  The system does not see people as people.  This is a major design flaw and the main reason driving costs in the system.  I would argue that it's also a main driver of harm to patients as well.

The system is currently all consumed by the chasing of targets, the delivery of the bottom line, the implementation of new models of care at scale and pace.  But if we could better understand all the consumption, particularly in the context of how people live their lives, the opportunities for doing better things appear to be colossal.  For me it completely changes the way we conceive of what works.

Reality then becomes what we are really doing for people rather than numbers on a spreadsheet.

The map is not the territory

"Most people imagine that the present style of management has always existed and is a fixture.  Actually it is a modern invention - a prison created by the way in which people interact"

W E Deming

In a classic experiment Letvin and Maturana et al (1959) revealed that a frogs eye can only "see" four types of phenomena:

• clear lines of contrast
• sudden changes in illumination
• outlines in motion
• curves of outlines of small dark objects

In other words, it "sees" what it needs to in order to eat and avoid being eaten.  Gregory (1990), in "The Psychology of Seeing" wrote, "the senses do not give us a picture of the world directly; rather they provide evidence for the checking of hypotheses about what lies before us".

In other words, our mental models help us to see a map of the world, not the world itself.  Or, as Korzuybski put it; "the map is not the territory".

My proposition is that the way those of us who work in the NHS view the world and think about what works, defines and confines what we believe is possible to achieve.

That would explain why the HSJ report (£) that in Towards Service Excellence the DH has come up with the idea that "business intelligence" such as collecting and organising data and "major clinical procurement", such as back office functions such as IT, estates management, human resources and finance and communications services are best done at scale, probably at a national level.

What I have seen would suggest that this approach would be the wrong thing to do.  In two weeks of observation and data analysis I would wager that I could tell any wellbeing economy more about what is happening to the people who ask for their help than any report they currently have or would be likely to get from a national team.  My experience tells me that it is highly unlikely that any NHS organisation looks at person shaped data right now - that's why I would need 2 weeks, just to get it into something resembling that kind of shape.

From my perspective data and business intelligence needs to be dynamic.  But more importantly, those using it need to be dynamically engaged with it.  CCGs will need local data not a regional hotch-potch based on current pre-occupations and configured in a way that "evidences" services which could be "cross cutting" (read delivered regionally and at scale). 

As for commissioning, from what I can gather having listened to rather than seen first hand, the gist of centralised NHS commissioning is no net gain.  Because suppliers have been ripping off Peter to pay Paul for years, when Peter and Paul come together in the same organisation the supplier just takes the average of the two prices and voila - no net saving.

My model contradicts contractual and transactional logics and, as a consequence, the whole notion of competition.  What I have seen work for the benefit of all parties are single supplier partnerships which are grounded in end-to-end understanding and collaboration.  A notion that also challenges the whole infrastructure of commissioning itself - but that's for another post.

These kinds of solutions are borne out of a belief in economies of scale.  Economies of scale are a myth and CCGs should be very wary of falling into the traps they create.  If you want to find out more, take a look at The Systems Thinking Review website.  There is so much evidence on how bad an idea that shared services is and how much money they waste it is almost embarrassing.  Here's a few tit-bits though to whet your whistle (with thanks to Howard Clark):

• The evidence of this flawed theory can be found everywhere. In HMRC or South West One shared services which predicted savings of £176 million over 7 years and actually recorded a pre-tax loss over its three financial years. Duplicate payments sitting at £772,000 and a struggle to manage £12.9m in outstanding debts.
  
  In the DfT Shared services which bust its estimated budget by almost doubling the cost (from £500 million to £750 million).
  
  In Australia, the failures in shared services have been spectacular. First Queensland's which cost in the region of $150 million and was projected to save $100 million a year actually only saved $13 million after 5 years. This didn't take into account the set-up costs.
  
  Finally West Australia last month ended their shared services after a total cost of $444 million is being decommissioned. It is expected the decommissioning will cost anything up to $2 BILLION dollars

So, the map is not the territory and the map we are using is taking us in the wrong direction anyway.  But as someone once said, if you don't know where you are going any road you take will get you there.  Just like the frog at the start of this post, we are institutionally seeing only enough to help us survive - to eat and avoid being eaten.  We are not seeing who is consuming resource and why because we are not prepared to take the time to understand.  Only when we do this will we start to make genuine progress on improving peoples' lives.  Time we started to evolve.

There's more to life than service

Dr Clare Gerada, Chair, Royal College of General Practitioners gave a speech today at their conference.  You can see the full text of it here.

It may seem an odd thing to say but it seemed like a brave speech to make.  Odd, because as a medic you would expect Clare to be speaking about how important it is to care, wouldn't you.  Brave because Clare's speech cut against the grain.  The grain that says marketisation, choice, competition and a whole load of other management speak is good.  I wish I had been there.  I would have liked to have heard someone in Clare's position say it is not.

I have read some of the comments about the speech.  Again, it may seem odd given they were made by GPs, but the tone of what I read was quite negative.  Hopefully others have started to redress the balance.

I am starting to understand why people would respond in this way though.  We have become so seduced by the prevailing economic and management paradigm and its relentless focus on achieving efficiency through scale, specialisation, functionalisation and standardisation that we have dislocated ourselves from that most simple and humane characteristic - to understand and respond with care.

No wonder that people refer to budgets, targets and KPI's in their responses.  It is the everyday language of public service.  It is the "real world".  And it simply goes unchallenged.  Something I spoke about before here.

But what I see when I study wellbeing systems are people being moved from service to service, function to function, pathway to pathway, when what they really need is for people to understand them.  And by that I mean understand their strengths as well as their needs.

Too often have I seen the system response being to offer a service shaped solution whether that be personal budgets or nursing home; intermediate care or meals on wheels.  But I have seen for myself that this system response is inadequate for what people need.  And it ignores the strengths they bring either themselves or through their community.

For too long, building relationships with people and understanding them in the context of the way they live their lives has been ignored in favour of hard nosed business disciplines.  It is an approach that has cost us billions of pounds and created huge amounts of unnecessary suffering.

We have been searching for answers to problems we might not even have by looking in the wrong place.  We concern ourselves with marketing nonsense and "killer questions" like "would you recommend us to a friend or relative" when the real killer question is "what matters" to people.

Through my experiments, by understanding the lives and wishes of people, ordinary people end up doing extraordinary things.  They provide person shaped solutions.  And the system benefits.  As I have said, we are still learning, but take a look at what understanding did for these 93 people involved in one experiment

12        prevented hospital admissions

25        reduced lengths of stay in hospital

6          prevented admissions to long term care homes

10        prevented carer breakdowns

29        prevented packages of care

18        reduced packages of care

7          prevented equipment provisions

And happier users and staff. No targets, no plans, no talk of integration or other such notions.  Just understanding.  Imagine doing that at scale. 

The "real world" though offers help through a menu of service.  We have reduced people to "customers" and, ironically, as a result restricted choice and our ability to solve peoples' problems.  We end up concerning ourselves with notions of rationing and prioritisation (cutting/limiting services) when, from what I have seen, nothing of the sort needs to happen.

Menu driven standardisation makes up part of the system response both to care and to rationing.  By providing a menu of service it provides the illusion of control.  What I have seen is that it, in fact, drives up costs and causes unnecessary harm.

So my message is, there is more to life than services.  CCGs do not need to concern themselves with notions of betterment that sound plausible but do not address the reasons why people put their hand up for help.  Instead of spending millions of pounds on leadership courses they need to get to understand the people who use their services in the context of the way they live their lives.

Reading Clare's speech gave me cause for optimism.  She will need strength of character and a lot of nerve to hold the line - but I firmly believe that her principles are right.  The "real world" is an invention.  If what I have seen is true, we can re-invent it and do a lot more good in the process.

Velcro man

Some of the details of the following story have been changed.

Alfie is 90 years old.  Irene, his wife of over 60 years had been taken into a nursing home.  They were both finding it hard to cope at home in their bungalow as her dementia progressed.  Alfie is a very proud man and visited Irene every day in her home.  It was important to him that he was always well turned out and he took great care over his appearance.

He had a "wobble" and was admitted to hospital, just to be safe, so he could be assessed and the right level of support given to him.  Following multiple moves within the hospital, Alfie was discharged to a community hospital for rehabilitation.  He had a number of assessments in both the acute and community hospitals, including stairs assessments.  Eventually he was discharged home with a commode.

The system was aware of Alfie now and various standard packages of care started to be offered, including help with dressing and meals on wheels.  He had also begun to be admitted to hospital following "wobbles".  But he remained fiercely keen to visit Irene and found it distressing when he couldn't do this.

When Irene sadly passed away, his difficulties in coping seemed to increase.  He had pretty poor eyesight for a start and trouble with his hands meant that sometimes he couldn't manage some simple tasks of dexterity.  More admissions followed, with more assessments and increased packages of care to help him maintain his independence.

On his last admission, when we first met him, he had experienced another "wobble".  Within the first 24 hours of his stay he had been moved to four different wards and had been put in seven different beds.  When he wanted the toilet he got disorientated and couldn't work out where the toilets were.  He was given a bottle, but due to his dexterity and eyesight problems (it was the middle of the night) he missed and soiled himself before slipping on the wet floor.

Labelled confused and incontinent a further sequence of assessments was initiated.  He was now on a pathway to a nursing home via a community hospital.  The system had decided that he could no longer cope at home so he needed more intensive support.

We set about trying to understand his story.  When we spoke to him he told us that he hated the commode he had been given so, even though he found it hard to see where he was going at night, he would try and use the toilet anyway.  On occasion that meant he would fall.  Sometimes he would tell the people who came in to help him with his dressing and meals on wheels.  They would tell the GP and he would then be taken into hospital.

He told us that, although everyone was very nice, he couldn't understand why he was in hospital and why so many people came and asked him so many questions.  He got upset when he talked about how often he was moved around and how confusing that was for him, but he insisted that he wasn't "confused".  He didn't want to bother the nurses but when he did ask for help he felt that sometimes he wasn't listened to.  He was also distressed about being told he was incontinent.  He couldn't understand why that would be.  He did find the repeated stairs assessments amusing though and had given up telling people he lived in a bungalow.  He just wanted to be left alone to live his life.  As grateful as he was for the help, he didn't really like the idea that he needed help with dressing.  He also liked to get out for lunch, rather than wait in for the meals on wheels.

So we had a person who was having some difficulties in maintaining his independence, due to a combination of factors including his poor eyesight and problems with his hands.  He was also lonely having lost Irene and missed mixing with his friends.  That made him quite down.  So could we do anything to help and maintain his independence?

The first step was to install automatic lighting in his bungalow to help him get to the toilet at night.  Since then there have been no falls.  We arranged for a friend to take him out to meet his friends for lunch.  We also noticed that he liked toast but couldn't get the toast out of the machine.  The answer?  He started buying slightly taller bread so he could easily remove the toast.  But the thing that really inspired him was the idea of putting velcro on his shirts.  That way he could dress himself.  He would take great delight in showing all his friends too and earned the moniker "Velcro Man".

But so what?  What does all this mean?  Well, in this case the pattern of repeat admissions was broken; the standard packages of care were removed as he had no need for the support that was being offered.  And the inevitable admission to a nursing home was avoided as were the repeat admissions to the community hospital.

Having understood him better he started living life rather than living the life the system had given him.

Our learning?

• if it goes wrong early on, there is a glidepath to institutional care.  Alfie was neither confused nor incontinent but the system was gearing up to respond to him as if he was
• the system has brilliant assessment systems but not such good understanding systems
• the system is tasked based and designed transactionally and episodically, so much of the actual consumption of resource that people make is invisible to the system.  For example, length of stay benchmarked well but if you look at it over time a different pattern emerges
• offering a standard package of care does not = maintaining independence
• many of the solutions offered are over specified anyway and create their own demand
• the pathway approach may be over emphasised.  In every case where we have understood people, none have gone on to the pathway prescribed for them.  The chances that they are all special cause is one million to one
• micro solutions have a macro impact - expenditure in all parts of the system significantly reduced
• if we can learn and understand people at the very start costs come down, waste and harm reduces and outcomes are better
• the staff (doctors, nurses, allied health professionals) who got to understand Alfie love it, as did he (and all the others who we have met)
• its not easy to do this but understanding can become the new "normal"

The answers for Alfie, were elegantly simple but radically different.  By putting our relationship with Alfie at the heart of what we did we were able to solve his problem and give him the life he wanted, even if it was without Irene.  No targets, no pathways, no moves from one specialist service to another.  No plan.  Just understanding. And a willingness to create solutions based on this.

The challenge is to test this approach on a bigger scale.  It is still early days, and our learning is building all the time.  I am confident that the principles upon which we are building solutions with people are solid and the opportunity to redefine the way we offer support to the people who need it can be radically redefined based on knowledge.  But we shall have to wait and see.  It takes courage for leaders to operate in this way.  I hope to be able to share more, in more detail, with you over the coming months.

Policy Zombie

I enjoy a good horror movie every now and again.  Turn the lights off, huddle under the duvet and then jump at every creak and groan you hear your house make.  I've felt at bit like that at times watching the passage of the Health and Social Care Bill.

One of many themes that is played out in the movies is the idea of the undead, the zombie – alive but not as we know it.  Zombies are easily recognizable:

• They desire human flesh – they don’t eat other zombies
• Any human bitten by a zombie becomes a zombie
• They cannot be killed unless their brain is destroyed

And, of course, they are relentless.  Much the same can be said to describe management thinking in general and in the NHS in particular.  There are ideas that, no matter how many times you think you have killed them, keep coming back to haunt you.  Ideas that the evidence should have defeated several times over rise from the grave again and again.  It is remarkable how resilient they are.  Perhaps we haven't targeted the brain well enough.

Ideas like targets work, or you can inspect rather than design quality in, or economies of scale are more important than economies of flow, or act on your people not your system, or people want “choice”, or incentives work - all refuse to die.

In health, although I am just learning, already I can see a pattern of thinking emerging; there is a bottomless pit of demand and because services are free patients will make frivolous demands and consume voraciously, that cost control inevitably leads to rationing, that we have to prioritise care and agree eligibility criteria, or more and/or better healthcare is the only or at least the major way to improve health.

I hear people talking of a grey tide that will swamp services.  That the management of chronic conditions is expensive and that new technologies and medicines will only make the delivery of healthcare more expensive.  Is all this really true? At the moment, from what I have seen, I remain unconvinced.  Certainly the methods employed to deal with these perceived problems are not "fit for purpose".

Worse though are the management ideas that affect the way organisations behave everyday.  I’ll take one example, the 4 hour target.  Leave aside for the moment how things “used to be” before the imposition of the target and focus for a moment on what people who deliver services actually say.

The College of Emergency Medicine has said that the target puts staff under “incredible pressure”.  The drive to meet the target at any cost has forced members of staff to tears, resulted in senior medical staff being taken down a disciplinary route and prioritized deadline delivery before quality of care.  Just what we need.

The experience of patients of Mid Staffordshire NHS Trust proved that making target delivery the priority, or as I would say, the de facto purpose of the system had punishingly cruel results.

Then think for a moment about what actually happens to patients.  I have seen firsthand how the system drives people through hospitals creating demands on ward staff and increasing the risk to patients, not just that they may come to more harm than their original medical condition, but also that they end up being more dependent than when they started with all the cost that goes with that.  When I study demand, end-to-end, I see huge swathes of activity undertaken with no value to patients whatsoever.

Time and time again, either through direct complaints or public domain stories, we hear of how the NHS has failed people.  And yet time and time again we revert to the same management thinking that created the mess in the first place.  Why is it that the Health Service Ombudsman says that the NHS is not dealing effectively with complaints?  Why has the CQC reported on shocking levels of patient care (again)?  Why did the Royal College of Surgeons publish a report on the "forgotten patients" who were being adversely affected and even dying due to poor organisation of care?  Why the continual reports on Panorama or Dispatches about deficiencies in how care is delivered?  Why has the NHS binned NPfIT?  

Something is wrong here.  The Bill won't change this.  Neither will basking in the reflective glow of positive reports about how well the NHS compares to other international health systems.  Nor will "better" or "simpler" structures.

To succeed the NHS needs to change its focus to one that understands purpose from a users point of view, uses measures that relate to the delivery of that purpose and designs from studying and experimenting rather than "planning" or "specifying".  Doing that will drive out costs, by managing value, far in excess of anything that could be conceived through conventional thinking.  It will also create system responses that are aligned to what people need to solve their problems - truly "fit for purpose".

It may not be a silver bullet because the change will not be immediate, but only a change in thinking can bring the profound transformation people are searching for.  Just remember to aim for the brain, otherwise we risk sleepwalking, zombie like, into a future of more of the same, just with different organisational structures.

Post publication ammendment: the idea for this article came from the excellent "Lies, Damned Lies and Healthcare Zombies: Discredited Ideas that will not Die"

Compelled to comply

"Ordinary people, simply doing their jobs, and without any particular hostility on their part, can become agents in a terrible destructive process. Moreover, even when the destructive effects of their work become patently clear, and they are asked to carry out actions incompatible with fundamental standards of morality, relatively few people have the resources needed to resist authority."


This quote is from "The Perils of Obedience" by Stanley Milgram.  He was reporting on the results of his famous experiment in which people, prompted by an "experimenter" (a person in a white coat), administered increasingly high voltage electric shocks to people if they failed to pair words together correctly.  65% administered the final massive shock of 450 volts, despite having received a painful enough test shock themselves before the experiment started.  The people being shocked could also be heard screaming in pain, banging on the walls pleading for them to stop and then total silence.


Most who pressed the button to administer the shock expressed some form of discomfort with the requests to continue, with some even refusing to comply eventually.  None of the participants who refused to administer the final shocks insisted that the experiment itself be terminated though.


It shows the power of authority and the power that "the system" has over people.  When I study wellbeing economies I often come across "experimenters".  But rather than saying "administer the shock" they replace it with things like "economies of scale are a good thing", or "we must drive down unit costs" or "we need to be transparent about prioritising and rationing".


I get a bit puzzled by all of this.  For me, when I see people do things at "scale and pace" or try to manage their costs, I see costs go up, not down.  And they don't do much more to reduce the frustrations of working in the system that people express nor, most importantly, do they directly address the problems that people have and our ability to solve these problems.


The language in use is so pervasive it is easy to miss it and accept, unquestioningly, the assertions that are made.  Take the Nuffield Trust report on "What is happening to health spending in England?"  This gives an interesting account of the financial challenges the NHS faces.  Their conclusion?  "The NHS will only be able to manage against a background of rising demand and an aging population if there is a sustained improvement in productivity.  This means bearing down on unit costs, particularly in the acute sector" (my emphasis).


No it does not.  Taichi Ohno, the founder of the Toyota Production System discovered that costs were in the flow of work.  He said; "to think that mass-produced items are cheaper per unit is understandable but wrong".


Yet we apply this kind of thinking to services in general and the NHS in particular without really thinking about it.  We could restate Ohno and say "to think that service activity is equivalent to cost is understandable but wrong".


Systems thinkers know that cost is in flow.  Intuitively, those who do work in the NHS know that too.  But because we accept notions like scale and unit costs it leads us to do more of the wrong things.


So instead of understanding individuals and designing for perfect for them, we create silo functions that we pass people through - what I call service, rather than person shaped solutions.  Economists cal it supply led demand.  But because we call them clinical pathways we assume that this is OK.  What I am seeing is that it is not and it is driving up cost not reducing it.


A practical example of our fascination with cost was highlighted in this weeks HSJ.  They reported that Sir Bruce Keogh, NHS medical director, has written to PCTs warning them against referral restriction policies, particularly bans on procedures of allegedly "marginal or limited clinical effectiveness".  PCTs it seems are restricting access (in "panic moves" according to British Orthopaedic Association president Peter Kay) to save money.


Who can blame them?  When times are tough why wouldn't you focus on stopping doing the things that you can see directly cost you money.  And maybe they are right to do this.  The difficulty I have with the approach though is that it is not done from a position of knowledge about what matters to patients.  In other words, I wouldn't start there.


What I see when I study wellbeing economies is a predisposition to believing in concepts like scale and cost amongst other things.  This leads people to focus on managing activity and volumes rather than thinking about people.  So we create more service rather than person shaped solutions and overall costs rise as a result.


Clearly, at times, this means we do things better.  But such an approach leads us to ask "how do we make better rationing decisions", which I think is the wrong question.  My view is that we can do better things and start to ask the question "can we do without rationing and generate a surplus".  But we need to ditch the thinking that leads us to recreate the same problems but with different organisational names or structures.


Milgram reminds us of the power of authority and our ability or willingness to do things that our intuition, gut or moral views would otherwise not have us do.  Intuitively we know that the route our leaders have taken us down in the pursuit of improvement in the NHS is wrong.  Reports by the CQC and others confirms this intuition to be true.  Fortunately we have the resources to resist and find a better way.  In doing so we can help ordinary people, simply doing their jobs, do extraordinary things.

Why don't we get the care we deserve?

26 Green and White Papers, 14 Acts, a doubling of funding, more doctors and nurses, and better buildings.    Competition, choice, increased regulation, world class commissioning, benchmarking, consultant contract, GP contract, dental contracts, Agenda for Change, Map of Medicine, turnaround, demand management, the improvement movement, National Service Frameworks, Evidence Based Medicine, guidelines, clinical pathways, personal budgets, Essence of Care, Energising for Excellence, Safeguarding, Monitor, PFI, AQP, HAI, NPfIT, FTs, PCTs, PBC, BCBV, PROMS, CNST, PbR, CQC, NSFs, EWTD, QIPP, QoF, targets.  From Our Health, Our Care, Our Say to From Good to Great and any number in between via untold numbers of consultations on all sorts of ideas.

All this since 1997 and still we have the Chair of the CQC, Dame Jo Williams saying; "Too often our inspectors saw the delivery of care treated as a task that needed to be completed. Those responsible for the training and development of staff, particularly in nursing, need to look long and hard at why the focus has become the unit of work rather than the person who needs to be looked after – and how this can be changed. Task-focused care is not person-centred care. Often what is needed is kindness and compassion, which cost nothing." The entire NHS needed to ensure that it made big improvements to end the scandal of poor care", she added.


But it's ok because patient satisfaction levels are at a record high and at least you can get through your A&E in 4 hours....


The reason given for this outrage?  Well Janet Davies of the Royal College of Nursing thought it was because in a time of a "squeeze on finances" it is difficult to maintain standards of care.  If only we could get the numbers of nurses right.  So there you have it, the RCN representative saying its about money and numbers.  I can't remember the reasons that were given for appalling levels of care when money wasn't an issue.  I should be shocked by what she said, but right now I feel exasperated.


The real outrage is that we have squandered billions of pounds over decades designing a system that doesn't care.  And it doesn't care because it is focussed on the wrong things.   The list of "stuff" we have done at the start of this blog is not exhaustive.  With each iteration it has removed people who do the work further away from doing good work.  Goodness, it seems, happens in spite, not because, of the system.  But who will conclude that this way of viewing the world has not worked?  More likely people who believe in the current conventional management paradigm will argue that we haven't gone far enough, or didn't implement them well enough.  Some will even say its a people problem.  After all, how difficult can it be to just be courteous and polite to someone.  I couldn't disagree more.


The fundamental issue is that the NHS is systemically incapable of understanding people and creating people shaped solutions for them.  Our leaders have industrialised our public services and commoditised our relationships to such an extent that people are units of activity, not human beings who need understanding in order to help them.  


We don't understand demand.  That it is person, not service shaped, so needs person not service shaped solutions.  We don't train against demand so we end up with staff unable to carry out simple duties.


We believe that we need to ration and prioritise but we are completely blind to the monumental levels of waste in the system.  And not waste from a lean perspective, that we have too many steps in any given process, but waste from a systems thinking perspective, that we do not create value from a person point of view, end-to-end over time.


We have lost sight of purpose from a users perspective, seduced by the lure of an economic view of the world that makes performance worse not better.  And in doing so we have not only let down the people who depend on us but the staff who work in the NHS too. 


The bad news is, the system isn't working and the Bill will not help.  It's the wrong thing wronger.  The good news is there is a cure. You just need to be prepared to change your thinking.

The Bill - another policy failure or a failure of policy?

The Bill is Wrong...

In my first blog on health, I predicted the Health and Social Care Bill will fail. The fact that it is even called that is one clue as to why - as if ‘health care’ and ‘social care’ are separate.  It seems that 70% of GPs, 90% of managers, 400 public health consultants, 100's of consultants, most serious commentators and all the Royal Colleges agree. But 

The Debate Is Wrong Too...

Their reasons differ but mine is simple. It's the way we think about the design and management of work that is wrong and the Bill does nothing to address this.

It's not public or private, market or state, competition or collaboration. It's not even integration and the damage this Bill will do to that. These debates are all features of how we conceive of the design and management of work and it is this itself which needs to change.

Rational Debate: The Wrong Answer to The Wrong Problems...

An essential step to understanding what is so wrong with the conventional conception of how to design and manage work is recognising that debates, such as that surrounding the current Bill, are central to the problem. They distract our attention from going and getting knowledge of what really works and leave talented and insightful people stuck in conversations which polarise their focus rather than creating collective action.

Opinion based argument is no substitute from empirical understanding. We need to dismantle the paraphernalia of institutions, yes, but we need to do so through local experimentation, framed within a clear and binding purpose, to reveal what works. This Bill and the debate surrounding it contribute nothing to that endeavour.

Change Based On Knowledge...

So if the key to creating collective action is getting knowledge ‘in the work’, what do we learn when we do so? The answer is shocking but profound. Do you know that the most common thing that users who are involved in my experiments say to me? "At last, someone is listening". Despite hundreds of contacts with the system over years, this is consistently one of the first things that they say. At first I found it staggering but then I realised that we have systematically removed continuity from service, treating everything as a transaction - framed within a function, couched within an organisation, wrapped up within a profession, housed within a building, managed, measured and remunerated within episode, after episode, after episode. 

We have a major system limiting belief that prevents us from making listening and understanding a normal experience for people. We forget that understanding people is a process, not an event. Developing and maintaining a true understanding of a person requires relationships to be tended to end-to-end, over time. But in a system which sees transactions and activities as costs, relationship are lost amongst the myriad of other foci such as throughput, sweating assets, minimising unit costs and the familiar suite of management preoccupations borne out of scale thinking. 

All of this conspires to destroy our systems ability to build and maintain relationships, thereby destroying our system’s ability to understand and attend to the real problems affecting peoples’ lives. This thinking is scale thinking. Scale thinking is a myth.

A Better Alternative – Understand and Manage Value

In all of my experiments so far the learning has been unequivocal. We must put relationships at the heart of the design. This is a conclusion, not a pre-requisite. The pre-requisite is that we must focus on understanding and managing value to those who use our system. Value is not defined with reference to cost. It is defined with reference to our ability to achieve purpose (defined ‘outside-in, from an end user’s perspective) by always and only doing that which is directly pursuant to purpose.

Managing Value Improves... Everything!

The application of the Vanguard Method in health is still new and I am learning all the time.  Early results are, however, encouraging.  One visionary clinician applied the Vanguard Method to his service and saw first hand the profound results as a consequence.  Before, 60% of his stroke patients were being seen and treated in the stroke unit.  Afterwards it was 100%.  Transfer times to the stroke unit dropped from an average of 1.6 days to 2 hours.  The percentage of patients spending at least 90% of their time on the stroke unit improved from 30% to 80%.  Average length of stay dropped from 16 days to 6 days resulting in 17 fewer beds.  All in, the cost of running the same service in the hospital reduced by 23%.

But these are just the numbers.  They don't tell the story.  What the Vanguard Method does is to put people who do the work in control of the work.  Because they see that the results of their efforts to improve the work are making a profound impact on the experience of the people they care for, morale improves.  Relationships become more productive both within and across teams.  The relationship with managers moves from one of control from a hierarchy to a more collaborative one where the manager acts on the system and removes obstacles that are beyond the immediate control of those doing the work.  They can then carry on creating value for users in the pursuit of perfection.

So costs come down, staff do good work, outcomes improve and patients and their carers love it.  All because the starting point is to understand purpose from a users perspective and people are given a method to get knowledge.  No targets, no incentives, not even a plan.

The Bill is constructed in a way that pays lip service to putting those closest to the work in control because it does not provide anyone with a method for realising the benefits of this approach.  And all the other stuff that is in the Bill will crush the life out of people trying to do good work anyway.

Policy Based Evidence or Evidence Based Policy

The Bill and much of he debate surrounding it can be characterised by the difference between searching for evidence to justify a position vs searching for evidence to establish a position.  That means people make things up.  Just ask Ben Goldacre.

This is why, despite the train wreck that is the US system in terms of cost, coverage and outcomes, the Government clings to a couple of pieces of research that seem to suggest that, in some cases there may be some benefits to competition.  For those who have not read Atul Gawande he is worth a read.  He makes the point that it is harder to get people together to design solutions that solve peoples problems if the de facto purpose of the system (my words) is to maintain or grow revenue.  It hasn't stopped various academics coming over from the US telling us how we should run our system.  I don't think so.

The challenge for policy makers is to move from opinion to knowledge based on a profound understanding of what works, gained from experimenting.  What is needed is a pathological focus on purpose from a users perspective, not competition.  What we design should, therefore, be a consequence of knowledge, not an inevitability of policy.

Final thoughts
The Vanguard Method in health is new and I am still learning.  But my diagnosis, having studied well being economies, is that we are chronically bad at understanding peoples problems.  My experiments suggest that a focus on understanding purpose from a users perspective can generate profound changes.  Unless we start there, the Bill will, at best, simply do things better.  More likely things will get worse.  Certainly we won't be doing better things.

Disruptive thinking

I have noticed that a lot of the discussion about reform in the NHS has talked about the need for radical transformation if we are to solve the issues facing the NHS in the future.  Innovation is seen as necessary and important.  Often its based on the notion of disruptive technologies described by Clayton Christensen, whereby incumbents fail because they don't compete and keep up technologically.

I know that technology has played an important role in advances in medicine but what strikes me is the weight given to the restorative powers of technology when often reality doesn't live up to expectation.  A reliance on technology to solve our problems puts the emphasis in the wrong place.  A hope that there is a technological solution seems, to me, to be the wrong approach - hope is not a strategy.  And too often the computer says "no" because in our quest for standardisation we forget that this approach does not help us absorb variety.  So people become wrapped in an endless loop of referral, assessment and treatment as they pass through one standardised service solution to another.

Better would be to have disruptive thinking.  The kind of thinking that values understanding people in the context of their lives.  The kind of thinking that recognises that centrally driven arbitrary targets get in the way of developing relationships that are geared to solving peoples' problems. The kind of thinking that provides an understanding of a person and their experience in having their problem solved end-to-end, over time.  The kind of thinking that realises that all the money we spend on patient satisfaction surveys is completed wasted because it doesn't tackle the real issue that affects how people perceive the service they get - that we have commoditised our relationships to such an extent that we value the abstract more than the actual: unit costs and utilisation instead of understanding; choice and competition over compassion; PbR and PFI over people.

What we know is that the way you think, defines how you design the system, which will create the performance you get - Thinking - System - Performance - a simple but profoundly powerful way to help leaders act on their system in a positive and transformational way.

An article in yesterdays HSJ (may be paywalled) suggested, as I did, that the financial problems Trusts are facing may in fact be bigger than reported.  Those Trusts that are struggling financially will be receiving "support" from the DH that will be "forensic" in the detail of its approach.  No doubt there will be some things that are done better as a result of any intervention - but it won't be enough.  In fact, I would predict that they will make things worse (see here).

If we are going to be forensic about anything it should be about understanding people and creating person shaped solutions.  And we can only do that if we challenge the way we think about the design and management of work.  Only then will there be the truly transformational change that people are seeking.  Changes, like integration and collaboration, will fail to deliver the radical benefits people believe they offer if they are created within the current management paradigm.  They too will be subject to the current thinking traps that continue to hamstring attempts to do better things rather than to just do things better.

We talk about change management thinking when what we really should be doing is changing management thinking.  Or to coin a phrase "Change thinking; save lives"

Bottom shuffling, squeaky bums and sadomanagerialism

It must have been a bit of an awkward, bottom shuffling moment for the Coalition government to read the letter from about 400 senior public health doctors to the Lords about the NHS reforms.

“It is our professional judgement that the Health and Social Care Bill will erode the NHS’s ethical and co-operative foundations and that it will not deliver efficiency, quality, fairness or choice," they say.

“We therefore request that you reject passage of the Health and Social Care Bill.”  Ouch. That's got to hurt.

Dr David McCoy, a senior clinical research fellow at University College London as well as a public health consultant in the NHS organised the letter. 

He writes in the Telegraph: "Organisational disruption has resulted in huge amounts of money, time and energy being diverted from real work, including the sustained development of shared knowledge, understanding and trust across the different elements of the health care system, local government and communities - vital for the building of participatory and integrated responses to rising unemployment, youth alienation, fuel poverty, social inequality and homelessness."

Its a bit of a puzzle that so many learned people and organisations who clearly see the benefit in understanding and working across the whole system are so at odds with a reform that at its heart is supposed to be about the same things.  It's particularly ironic given that if the government hadn't said anything they could have simply used the changes the Labour government had already made.

And, judging by the official reports, none of what Dr McCoy fears will happen seems to be happening.  In fact the Q1 report on NHS performance paints a pretty positive picture.  Performance, at least in the way the NHS measures it, is improving in all areas from hospital acquired infection to rates of referral from GPs.  And the money is looking good too; no mean feat given the scale of the challenge.  SHA's and PCTs are forecasting an overall surplus of £1,165m.  NHS Trusts (exc. FTs) are forecasting an overall operating surplus of £61m at Q1 for 2011/12.  You could be excused for wondering what all the fuss is about.

Yet for some it seems we are already in squeaky bum territory already as finances take a battering even before the winter hits and Execs begin to wonder if, having declared a break even or surplus position, they are going to cross the line.  If you work in one of the Trusts that have already declared a deficit (£56m deficit has been declared by 3 PCTs and £170m deficit by 6 NHS Trusts) as bad as it seems at least the powers that be know - they hate surprises.  And you have the added bonus of having additional "support" from them.  If you are in one of those who have declared break even or surplus and the money is going south, then hold on to your hats - things are going to start to get really tough.

But have no fear because the sadomanagerialists will make sure that targets will be met and budgets balanced.  Usually its through the tried and tested methods of  "whatever it takes" or "just sort it" layered with some veiled, or increasingly overt, threats to livelihoods and the like.  It's another one of those puzzles - how bullish I have found the NHS culture to be, despite it ostensibly being a caring organisation.  

Sadomanagers believe, as Oliver Letwin does, that there is no better way of improving performance than to have people in fear of their jobs.  They believe that turnaround consultants know what they are talking about.  They believe that tighter performance management and budget holders getting a grip will solve their problems.

But they are myopic or, in some cases, blind to the problems that fear driven change brings from the perspective of users and staff.  Instead they comfort themselves that their brutality = leadership.  Tough decisions are needed after all.

What I see, applying the Vanguard Method in health, is that the opportunity to do better things rather than things better is significant.  But it relies on understanding, a commodity that is different to "knowing" and currently in short supply.

Method over madness

I have found it quite a depressing end to the week.  I'm not sure I have quite recovered from the RCS report that we are putting patients lives at risk.  Or was it the brouhaha over PFI causing the NHS debt problem.  Perhaps it was the letter from Sir David saying that NPfIT is going to be wound up as a central programme.  It might have been an earlier story about waiting times being allowed to slip to save money.  Or was it reading Dr Stephen Bolsins account about whistleblowing in Bristols paediatric cardiac unit.

Perhaps it was the news that Unipart was flogging lean as the answer to the NHS's quality and cost conundrum.  It even managed to somehow spin the mess that is HMRC lean into something positive.  But then I suppose it is relatively easy to save millions if you are simply not interested in providing people with a good service.  The Unipart CEO says lean is the answer, a committee of MPs considers HMRC to be incompetent - you be the judge.

Whatever it was, it wasn't helped by re-reading the article by Oliver Letwin that what the public sector needs is a good old fashioned dose of fear.  Make 'em fear  that they will not be able to put bread on the table.  That'll raise productivity for sure.  Considering this is from the "nudge" meister himself this takes some beating.  Mr Letwin has invested several thousands of pounds of taxpayers money in an unproven hypothesis that the public can be encouraged to do the things the government, or society wants in a far less dictatorial or top down way than has hitherto been the case.  And here he is trotting out the same tired old stereotypes that most reasonable commentators know there is no evidence to support.  Trouble is, some of our esteemed leaders fall into the same camp.

Or maybe it was starting to plough through what seems to be an excellent report by the Kings Fund (although I haven't read it all yet) "Understanding new Labour’s market reforms of the NHS" and how, despite some of the keenest brains in the country working with passion on trying to improve the services the NHS provides, the benefits accrued are relatively marginal.  And that ignores the fact that we haven't really tackled the challenge of dealing with chronic illness and the frail elderly.  Oops.

Certainly it wasn't helped by the equally excellent blog on "what is the point of choice".  Indeed.

But for all the searing analysis, what is missing from the debate is any sense of direction about what needs to happen next.  Even the Kings Fund, much of who's work I admire, appears to be locked in the "solutions" box.  Integration and collaboration are vying with hospital closures to be this seasons black.

The real challenge we face is how we think about the problems we have.  The failure of the Labour reforms is testament to that.  The fact that the coalition government describes the current package of reform as a natural evolution of the reforms of the previous government is no cause for comfort.  Two wrongs don't make a right.  More searching for levers and incentives, regulation and control will not do.

Implementing best practice or the next "go to" solution is not the answer either.

What is needed is a method for thinking and for understanding over the madness that is the current management paradigm which is removing us further from understanding people with every iteration.  Only then will we be able to conceive of the transformation that many seem to be seeking.  My experiments with the Vanguard Method in health continue to show great promise, so I will remain optimistic we can move from doing things better to doing better things.  I will share more as the results emerge - still too early to draw firm conclusions but I am very encouraged so far.

Killer targets?

Tens of thousands of patients needing emergency non-cardiac surgery and intensive follow-up treatment are having their lives put at risk by poor NHS care and delays in seeing senior doctors, according to a damning report by the Royal College of Surgeons reports the Guardian today.

In a shocking review, Iain Anderson, author of the report and General Surgeon at Salford General Hospital uncovers layer after layer of inadequacies in the way care is offered to this "forgotten group" of patients.

“Peri-operative care of higher risk general surgical patients in the UK appears to have significant deficiencies" the report says.  "Outcomes are variable, appear worse than other countries and generate a large health cost through prolonged hospital stay and use of intensive care."  It continues, "while there are several specific initiatives (eg hospital-acquired thrombosis) and patient pathways for single operations (eg aortic aneurysm), there is a lack of overall recognition and strategy for the care of all patients at higher risk of death and complications.”

Norman Williams, president of the RCS, said that the focus on reducing waiting times for elective operations had led to a large group of mainly elderly patients finding themselves "under-prioritised to the point of neglect" in some hospitals.

And the brutal fact is, nobody knew about it.  Well, except we do, kind of.  After all it is just another one of a series of reports that have uncovered the breathtaking inadequacy of the system and its lack of capability to respond to the demands that people place on it.

Anyone working in the NHS knows that it's best to avoid getting ill at the weekends, that if you have something seriously wrong with you, you really ought to see a consultant not a junior and that best to avoid the August rotation of juniors.  And many will have seen first hand how the chasing of the 4 hour target creates the unintended consequence of poorer outcomes for some.  What this report shows is that much of the damage may be invisible because it occurs at a different time in a different part of the system. 

But nobody did know about it, aside from the anecdotes we tell each other and what we see for ourselves because we don't have knowledge.  We concern ourselves with "killer questions" like "would you recommend us to a friend or relative", when the real killer question is "what matters?" from a users perspective.  There may be some Boards of some Trusts/PCTs/CCGs who were or are aware, but more likely the fixation will be on more general approaches to safety like, reducing HAI and getting people to wash their hands, hospital at night or other specific initiatives.  The reason?  Because Boards are told that "good" equals implement the initiative/best practice and "deliver the target" - whatever the target of the day might be.

So despite the revelations that "care on wards is sub-optimal" (where have we heard that before), that the system is not designed to cope with long term conditions, that the logic of competition risks creating fragmentation rather than collaboration and so on, the system continues to be seduced into applying more of the very things that are creating the problem in the first place.  Complex relationships and the quest for understanding then becomes broken down into functional tick boxes and the system becomes paper not patient safe.  And the repercussions of this approach are serious - people are not getting the outcomes one might expect and in some cases are dying unnecessarily.

Leadership in local wellbeing economies then becomes headership - heading up the latest initiative on choice, privacy and dignity, any willing provider, walk-in centres etc - rather than really understanding what is going on and designing for perfect for people based on knowledge.

Applying the Vanguard Method in health has shown me that the single biggest issue the NHS and wellbeing economies face is a thinking problem.  Not a financial problem, not a people problem, not a rising demand problem, but the way we think.  We think we know the problems that we have to resolve but we don't actually understand them.  We think we know what works to improve things but we end up creating more service rather than people shaped solutions.  We think we are performing well because the dashboard says so but people are still dying and drinking water out of vases.

This is not about the people who work in the NHS.  One can only imagine how harrowing it must be to be unable to do what people need to help them live a good life or die a good death.  For those who lead wellbeing economies, it is also no surprise that we tend to rely on conventional management approaches as that has been the bread and butter of NHS management for a couple of decades now.

It is about how, as a system, we conceive what "good" looks like.  Systems thinkers believe that good is person shaped, end-to-end.  Get knowledge, create relationships, design for perfect from a users perspective and create measures that tell you how close you are to that.  I wonder how many Boards around the country will be adopting that as their approach to news of this report.

A new bargain, the same approach

Ed Miliband talked yesterday of a "new bargain" for Britain.  Recognising that Labour sometimes got things wrong, he talked of the need for government to reflect the publics values, not Whitehall's.  It seems that he might be up against it, given the prevailing management paradigm.


An interesting article appeared in the Health Service Journal the other day written by Mark Britnell, global head of health for KPMG.  It sounded like he had an important job so I thought I should read it.  In it he talks about integration and wonders if enough attention is being paid to clinical leadership, clinical information and "bundled payment" mechanisms.

These reflections are on the back of another article where he makes the point that with all the heat around the Health and Social Care Bill there may be a risk that the debate misses the key question – are what is proposed in the Bill the right ones to deal with the issues that “ageing demographics, increasing long term conditions, rising consumer power and costly technologies and pharmaceuticals” will bring.  His solution - as the NHS funding model is no longer resilient, we should consider other insurance type models that, according to Britnell, have been successful in other countries in the world.

Both articles put forward plausible sounding ideas, so what’s the problem?  Well, if there is one thing that applying the Vanguard Method has taught me it is that the way the system is designed that determines what happens to people and how costs are incurred.  No doubt clinical leadership is important, but what I see is that this is a devilishly difficult thing for someone to do if the system within which they are operating is designed to get in the way of understanding.  For me, it is not about the people, it is about the method.  And the methods we use to conceive of change in the NHS are holding would be visionary leaders back, not liberating them.


It is also nothing to do with reforming funding mechanisms at a global level.  None of the international systems he talks about are immune from the financial pressures that the NHS is talking about facing.  If, by way of understanding what people want and need, we end up with a discussion about funding mechanisms, then so be it - just don't start there.


As I journey through health, I have come across people who intuitively feel there is something not right with the system, but can't put their finger on it.  There are others who are actively pursuing a different path - thinking differently about the issues the NHS faces.  But they are yet to be bound by a common voice - a method that makes sense of the intuition, hunches or evidence they have that things need to change.


I believe if people are to be able to act on their hunches in a robust and pragmatic way, then we need to be serious about designing people rather than service shaped solutions.  What I have seen is that the biggest barrier to quality is the quality of relationships.  My experiments is providing me with robust evidence that if we can build better relationships, the system can reduce consumption in ways that no target or incentive centrally made could ever dream of.  The "new bargain" needs to be person shaped, not centrally driven.