Moment of truth

Some of the details of the following story have been changed


Della had been in hospital for just over a week, following a fall in her nursing home.  Initially admitted for observation (just to be safe) and expected to be discharged within 24 hours, things were not going well.

Having Alzheimer's she was proving to be challenging to ward staff.  Starting with a diagnosis of confusion her notes plotted a history of deterioration both in terms of her medical history - "continuing confusion", "more confused", "increasingly confused", "confused and distressed" - as well as in terms of her relationships with staff.

Her behaviour was reported as increasingly erratic and was now recorded as violent with several incidents of her lashing out physically as well as verbally.  Della refused to comply with simple instructions and even the most basic of nursing tasks were proving impossible to carry out as she consistently pushed staff away.  Now a nuisance on the ward both in the day and at night, she was creating problems for ward staff in having to deal with the effect of her behaviour on other patients and their relatives.  Ward staff were now actively avoiding her out of a mixture of self preservation and, to be honest, because she wasn't really that likeable.

Frustrated and exasperated, the ward staff asked for help, convinced there was nothing more they could do for her.  So along comes a highly trained, extremely professional nurse with years of experience.  If she can't sort it out no-one can.

On arrival in the ward the staff explain the situation.  They have followed all the necessary protocols and procedures but her violent and unnecessarily aggressive behaviour toward staff was having a negative impact on the whole ward.  Both staff and patients were frightened and staff in particular were not prepared to tolerate her behaviour any longer.  After all, there was nothing medically wrong with her and the Trust had a zero tolerance approach to inappropriate behaviour of patients to its staff.  Something needed to be done.  At least move her to another ward.  Get her off the ward.

Suitably briefed the nurse approaches Della.  As she neared the bed she noticed that Della appeared unkempt.  Not surprising perhaps, given the history, but noticeable nevertheless.  Getting closer their eyes met.  Immediately she could see that Della appeared more agitated.  By the time she reached the bed Della was primed, ready for action.

Sure enough, barely had the words, "how are you today Della?" passed the nurses lips before Della launched a torrent of abuse.  Staying calm and despite the attempts by Della to push her away, the nurse continued to probe.  After all, how could she help if she couldn't understand what Della's problem actually was?  It seemed, though, that with each attempt to get through to Della, it was just inflaming the situation even more.

Concluding that keeping quiet might be a good approach, the nurse listened to Della, maintaining eye contact, determined to help, but not sure how.  As she listened she could see that Della had clearly lost weight compared to what was recorded in the notes at the time of admission.  She was also concerned at what looked like ulcers forming on her mouth, which led her to question whether Della was in fact dehydrated.  Was this also contributing to her confusion?

Some time passed when there was a natural pause in Della's ranting.  She was nearly 80, so even she needed to stop to take breath.  Reaching over, the nurse cupped Della's hand gently in hers.  "Are you cross?" was the only question she asked.  Della's response?

She burst into tears and grabbed the nurse.  Not to harm her, but to hug here.  "At last", she said through the sobs, "someone is listening to me".  For what seemed like forever, but was probably only moments, they embraced.  Back at the nursing station, the staff who had all turned up to witness what they knew was going to be a car crash of a meeting, could only stare in disbelief.  "You had better put this in the notes" said one, half joking, "she has gone completely mad".

In the hurly burly of the the daily ward business, Della had been overlooked.  The staff didn't have time to get to know her.  Of course she was feeling anxious and worried about being admitted to hospital.  And when she felt she wasn't being listened to, she became more anxious.  Ultimately her behaviour came to be seen as unreasonable.  The result?  She became undernourished and dehydrated, both of which contributed to the way she behaved with staff on the ward.  Both of which served to prolong her stay in hospital.

In one moment, one person asked one question that got to the very heart of what an individual was dealing with.  By taking the time, being prepared to sit and listen, to hear and understand, that persons experience was completely transformed and the flightpath to dependency reversed.  Until that point no-one could see the opportunity to engage with Della.  Everyone was too "busy" dealing with the things the system required them to deal with.

In that moment, the importance of taking the time to understand someone and solve their problem was recognised.  Everyone was affected.  It was an incredibly powerful affirmation of the power of the simple art of nursing.  A small but profound moment in the lives of all those present.  The truth is that the system is designed to prevent this from being normal.

Time to move from good things happening in spite of to because of the system and allowing good people to do good.

Spot the difference

There has been a lot of activity recently with much reported about the benefits of integration.  Integrated  Care Organisations are all the rage and there has been a lot written of the reported success in the way organisations like Kaiser Permenante and Intermountain Health have managed to deliver benefits to patients as a result of their efforts to integrate care.

So it comes as no surprise that integration is being promulgated as a solution.  But what problem is it a solution to?  The answer seems obvious. Integration is a solution to the problems created by silo working. Problems such as:

• Behaviour which optimises functional efficiency at the expense of whole system efficiency, moving problems between silos rather than solving problems end-to-end.
• Failure to share knowledge, skills, expertise, resource, etc therefore constraining delivery, improvement and the spread of good practice and innovation.

So silos are bad, hence integration is good (goes the logic).

But does integration address all (or indeed any) of the causes of silo working?  For if it does not then integration will be a false dawn, a promise unfulfilled.

Consider some of the causes of silo working:

• Different measures
• Different budgets
• Different policies
• Different terms and conditions
• Different roles
• Different professional bodies
• Different professional/clinical hierarchies
• Different management and management hierarchies
• Different commissioners
• Different commissioned scopes
• Different contracts
• Different incentives
• And so on...

The list is not intended to be exhaustive, only to illustrate that silo working is a product of difference.

How many of these differences does integration address?

Having applied the Vanguard Method in Health the answer is ‘none by necessity’.  In other words, one could ‘do integration’ without removing any of these differences. As such integration cannot be the solution to silo working because it does not systematically or systemically address the causes of silo working.

Consider this

An integrated team of OTs, Physiotherapists, Social Workers and Mental Health professionals are co-located and put under common management. The referral process is streamlined to create a common front-end to this new service. ‘Integrated Care Co-ordinators’ are created and represent a new, integrated role which bring MH and Social Care referral takers together with those staff who once triaged district nurse and GP services. These people now take referrals for all these professions and direct them into the most appropriate queue (or queues) for the different professionals.

Because each professional places great value in their profession the new integrated service employs professional leads for each role – OT, Physio, SW, MH. There is a GP lead who happens also to be chair of the PEC. These professional leads allocate the work from their queues to their direct reports. The basis for allocation is as follows:

• What is the urgency of the needs this person has which relate to my profession?
• How long do I have before this person will breach the SLAs which apply to my work.

The SLAs for the different professions are different from one another – a consequence of old measurement regimes which haven’t gone away and which are given close attention by the hierarchy.

Today’s referral is for Mr Jones who needs a GP visit, DN, SW and Physio input. The referral is made by a concerned neighbour who says that Mr Jones has only just left hospital and doesn’t seem to be coping. The GP sees him within a few hours. The DN sees Mr Jones within 3 days because, whilst the needs described in the referral are not urgent, they will need attending to fairly promptly. The DN can’t understand why the hospital keeps on discharging people without making a direct referral to her team.

The SW and Physio will not see Mr Jones for several weeks because of their backlog and the fact that their SLAs give them 28 days to respond. The SW sends a letter to confirm to Mr Jones that he will be seen at some point in the next 26 days. This letter is posted within hours of the referral being received, satisfying the SW target of contact with referred patients within 2 days of referral. The Integrated Care Co-ordinator finds this very confusing because he only sends these letters for referrals which he allocates into the SW queue and for no other profession. Mr Jones finds the letter confusing too as he is blind and has no-one to read it to him. When the DN turns up 2 days later she tells Mr Jones what it says and that it is from a SW colleague that sits next to her in the office

When the SW turns up to see Mr Jones, fifteen days later and ahead of schedule, he finds that Mr Jones is not home. Back at the office, over lunch, he speaks to his DN colleague and asks if Mr Jones was in when she visited earlier that day. She tells him that Mr Jones has been readmitted to hospital and they both roll their eyes saying, “If only the hospital were as integrated as we are then they would have told us. Still, it’s testament to how integrated we are that I can find this sort of thing out over lunch!”

Does this seem far-fetched? If so then be reassured that this story is entirely real and directly observed within one of the UK’s premier examples of integration.

Integration thus conceived is no solution. It is the wrong thing righter at best.

A Better Perspective from Which to Integrate

My contention is that we should remove talk of integration and replace it with putting the following principles at the heart of all strategy and operational management:

• Purpose – measures – method
• Design against demand
• Partnership through collaboration and mutuality

These would manifest as follows:

The purpose of our health and care system must be understood ‘outside-in, as a system’. That is, it must be understood, not from the perspective of those providing service but from the perspective of those using services. Moreover, our view of purpose must be framed as person shaped and end-to-end.

That is, not looking at parts of people (e.g. pathways) or at snapshots of people’s lives (e.g. episodes). 

This purpose must become the purpose of all and everything that is done by the system. Different agencies, providers, commissioners, professionals, etc must be bound by this purpose and no other. To that end, all contractual arrangements must be grounded in this purpose and all remuneration of contracts must depend on demonstrable commitment to delivering against this, and only this, purpose.

Measures must be derived from this single and shared purpose, relating to what matters to those who use the system not what matters to those commissioning or providing the system. These measures must demonstrate the capability of the system to meet its purpose end-to-end and over time. These measures should therefore demonstrate variation over time, not relating to static data points and arbitrary standards and targets. Measures which are predicated on arbitrary numbers (e.g. 18 weeks) will always distort the system and confuse the system’s true purpose by creating a de facto purpose for those subject to the measure. Measures rooted in purpose are therefore key to fostering partnerships based on co-operation and mutuality. Such measures will also be core to the development of better contractual mechanisms which unite the whole system behind achievement of purpose.

Methods for delivery must be continuously improved in light of the knowledge gained through measures which relate to the one, true purpose of the system. These methods should be designed against demand. That is, the knowledge, skills and expertise which manifest as roles and services should be designed based on the type and frequency of what is required to respond to predictable demand. This will challenge traditional role and service boundaries, reconfiguring professional expertise around patients not squeezing patients through a profession shaped funnel. Failure to engage meaningfully in the endeavour of designing against demand should be seen as a demonstrable breach of contract – a failure to act in the spirit of co-operation and mutuality. Such behaviour should not be tolerated by the system. Its causes should be understood and removed.

Spot the Difference

In talking about the social determinants of health, Prof Sir Michael Marmot talks about the need to understand the causes of the causes.  The same principle needs to apply here.  If integration is the answer, the question has to be what has caused the system to be disintegrated?  It is only when these reasons are known and acted upon can integration really deliver on it's promises.  Until then, whilst the differences may be harder to spot, we will simply have created different organisational structures for the same old problems to occur in.

BOGOF

I often get marketing material sent to me trying to maintain my loyalty to a particular store or brand or airline.  Clubcard points, Nectar points, Airmiles – all designed to provide me with some reward for my use of their facilities.  In their parlance I am, it seems, a “frequent flyer” and worthy of recognition and reward as a result.

We use the term “frequent flyer” in the NHS too.  What could it mean in a supermarket world; get one hip and have the other one done free; get admitted 10 times and have an extra weekend thrown in for all the family; get a 3 month supply of Orlistat and earn 20% off a Happy Meal?

It seems the comparisons to supermarkets doesn't stop there.  A recent article claims that the NHS isn't working so it should be more like Tescos.

I have written before that, having studied wellbeing economies, I too believe the system isn't working.  And it isn't working, not because we are not "Tesco enough", but because we apply plausible but essentially wrong ideas to the running of public services.

If investment in the NHS has not been matched by improvement it is because we have invested in the wrong things, believing them to be right.  We believe in the notion of economies of scale, blind to the costs they cause because they are hidden.  And when was the last time you heard someone talk sensibly about diseconomies of scale?

We think inspection drives improvement, that quasi-markets are levers for improvement, that people can and are motivated by incentives, that leaders need visions, managers need targets and IT is a driver for change.  But, despite being  the foundation of public sector reforms, they are all wrong-headed ideas.

All these reforms have their basis in economic theory which leads us to be persuaded that call-centres, back offices, shared services and outsourcing are "no brainers" with "obvious logic".  In reality they are deceptive and dangerous ideas that both create and hide waste.

It is these ideas that fuel the notions that we should be more like Tesco or a similar business.  A further commoditisation of our relationships.  It is my contention that we need less talk of business models like Tescos and more talk of developing relationships and creating value for people because we understand them in the context of their own lives.

The NHS is not a supermarket.  Never mind that much of resources consumed are done so by people with ongoing health needs, or by people close to death, or indeed by people living with mental health problems.  You would be forgiven to think that most resources are consumed by people are fit and healthy.  My evidence suggests this is not true.  And yet government policy seems to be driven by a belief that transactional relationships are all that people need to live a good life or die a good death.

Never mind that the main causes of ill health relate more to your status than anything else according to Prof Sir Michael Marmot.  A recent report on the failure of mental health strategy is testament to that.  Quite what a supermarket approach will do for that is anyone's guess.

The NHS is not a supermarket.  The people who consume healthcare do so, largely at times when they are sick or in periods of distress.  It is a service that is driven by need rather than want in a way that undermines conceptions of choice as we conceive of them.  Supermarket consumers tend not to sleep over in them, and rarely consent to being examined or have a procedure performed on them.  Health services are inherently intensely personal.  Supermarkets do not require their customers to expose themselves emotionally and physically in he way that health services do; nor do they need to be as aware of context in terms of education, employment or housing.

I agree that the NHS is not working, but not because we don't do enough supermarket type stuff, but because we do too much of it.  What works is building relationships with people.  Understanding them as people and delivering what they need to live a good life and die a good death.  The answer, for me, is to jettison the psuedo-science that is economics and the opinions and collection of ideologies that go to make it up and focus on understanding people in the context of the way they live their life.

And to those who would disagree?  Well I guess you could always BOGOF.

Institutionally peopleist

I am not a peopleist.  I have nothing against people.  Some of my best friends are people.  I will sometimes even let them into my house - under certain conditions.  I even married one and, if I'm honest, have gone so far as to make some of my very own.  Being one myself (a person that is) I would say I am in a good position to talk about people.

The problem is that, systemically, the NHS doesn't like people, staff nor users.  Which is a bit of a shame really, given there are so many of us.

That is why you have Dr Kim Holt, a paediatrician who blew the whistle on sub-standard care at Great Ormond Street, paying a hefty personal price, along with 4 other colleagues for the simple reason she had the courage to stand up for patients.  In her case, not only do we have a system designed not to recognise and solve the problems people have, but one that actively destroys its ability to learn from this and make things better, something I spoke about here.

It also explains the debate between Roy Lilley and Dr Clare Gerada at a conference called "The Battle for Ideas".  I am not sure how the debate went but Roy was kind enough to share his speech.  I found it  thought provoking.  You can read it here.  His observation is that GPs are stranded in a no-mans land between vocation and commercialisation, facing a future where they are driven to save money rather than do what is right for people.

In other words, we have a group of people who say that want to care, but a system designed to prevent them from doing just that.  Why?  Because the prevailing management paradigm is so pervasive that much of the debate around health in particular and public sector services in general is couched in the terms of economics and cost not relationships and value.  We use terms like "empowerment", "incentives", "productivity" and "efficiency" unquestioningly - blind to the fact that much of what we do in their name is driving waste and failure on a colossal scale.  What I am finding when I study wellbeing economies is that the system isn't working.  Unless, of course, the purpose is to design a system that fails the very people who use NHS (and other) resources the most (ref any number of CQC reports).

People do not exist in this world.  They are appointments, new or follow-ups, day case rates, cancelled ops, 4 hour breachers, bed blockers, delayed transfers of care, pathways - any number of things, but rarely, if ever, people.  I wrote previously about an experiment I did where not one person went on the prescribed pathway once we had understood them in the context of how they live their life.  The chances of this happening as special not common cause - one million to one.  And should anyone ask, I am a person, not a pathway.

So no wonder Roy is able to claim that GPs have been let down by their leadership.  Although this is a problem that cuts across the whole medical profession.  You only have to look at the BMAs response to the Future Forum pause to see that.  Hardly the most inspirational response.  Their key recommendations are so dull I can barely bring myself to share them with you, but you can take a look here.  But at least they mention patients.  Once.  Around consent on the disclosure of confidential patient information.  That's reassuring.

The overwhelming power of current convention is such that it is no surprise that leaders are actually unable to see an alternative and that much of the debate is couched in the same terms as the convention that is causing most of the problems the NHS is experiencing anyway.  There are glimpses of it though - as witnessed by Dr Gerada's recent speech to the RCGP or this post by Dr Tomlinson here.  But it is cutting against the grain of current thinking.

And no wonder a regional breakdown from the NHS Top Leaders programme said 65% of leaders in the capital created a "de-motivating" environment.  It seems management by fear is still considered one of the most effective forms of management.  It is not.

It takes a brave leader to be prepared to take the time to understand that much of what we do in the name of management is bonkers.  But if you study people as they flow through the system you see that we have great assessment processes, but not so good understanding processes.  And as a result we place people on a glidepath to dependency, ignorant of the strengths they may have.

And this is having a profound affect on people and the cost of caring for them.  I have shared some of my findings in earlier posts, but for those that are interested, you can take a look at some evidence based deconstruction of common management fads and why they don't actually work by reading Alfie Kohn or taking a look at Daniel Pink’s work.

Many people have commented about the reforms.  In a nutshell those opposed to the Bill in its current form contend (unflatteringly) that the changes take the "p" out of the NHS and those who work in in it. What we need are leaders who are prepared to put the "P" back in - people - and ask the question, what is the purpose of what we do from their perspective.

In the Battle for Ideas, judging by the results of my experiments, it really is that simple.  Understand purpose from a users point of view, use measures that relate to the delivery of that purpose and design from studying and experimenting rather than "planning" or "specifying".  Doing this will drive out costs by managing value far in excess of anything that could be conceived through conventional thinking.

The sooner we realise that understanding people and building continuity in our relationships with them is more important than numbers on a spreadsheet, the sooner we will be in a position to design responses to them that solve their problems.

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.