It got me thinking about how many revelations there have been since I started writing about my experiences in applying the Vanguard Method in health back in July. We've had the Panorama and Dispatches programmes on shocking abuses of vulnerable people in care homes and poor standards of medical devices, the CQC reporting that levels of care were so low in some Trusts that they were failing to meet legal standards, the Patients Association reporting on the terrible experience of our elders, the Royal College of Surgeons report on the hidden impact of targets in terms of poor outcomes and avoidable deaths for people requiring urgent care, the revelations of hidden waits as people are left untreated on waiting lists and now the Equality Commission revealing care so poor it doesn't even fulfil peoples basic human rights.
But it's OK because the Commonwealth Fund report says that we are one of the best health systems in the world and, of course, you can still get through your A&E in four hours.....
What I see when I study wellbeing systems is that it is the misguided belief in plausible but wrongheaded ideas that is the cause of these problems. Everyone is concerned to save money and get the best value out of the system. But it is the very focus on costs that is driving costs up and dislocating us from the most fundamental aspects of our humanity - to understand people in the context of how they live their lives and care for them with compassion.
Often the evidence of saving is based on reductions in transaction costs. Because x is cheaper than y, we should get x - that will be better, cheaper. Sometimes that may work, but the logic behind this approach is a fascination with unit costs and the consequential need and drive to reduce them and this is wrong. The Nuffield Trust recently published a useful overview of the financial challenges that the NHS is facing. Their analysis was that things are likely to get more difficult over time. Their answer? "The NHS will only be able to manage against a background of rising demand and an aging population if there is sustained improvement in productivity. This means bearing down on unit costs, particularly in the acute sector".
But this simply isn't true. And the Equality Commission report bears witness to this. In the drive to reduce unit costs we have lost sight of what matters to people. As a result we have consigned vast numbers of people to a life of humiliation and degradation. And the fact that it is hidden from view and does not appear on any spreadsheet or KPI makes it no less unacceptable.
The damage that this kind of thinking does is immeasurable both in terms of unnecessary human suffering and cost. I have seen, repeatedly, people being passed through service after service, function after function, organisation after organisation with no value for them whatsoever. 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.
What I have seen is that 1.5% of a DGH population consume about 50% of the resource. The numbers, relatively, are tiny. We don't need to be focussed on average length of stay. We need to get to understand these people and design for perfect for them.
So what do our thought leaders say, the people who will work out how we start doing better things? Well, I think I may have had something of an insight from what I heard at the Kings Fund Annual Conference yesterday.
If I have understood correctly, Sir Liam Donaldson said that it is "right and proper" that doctors are very focussed on individual patients but they must think of the wider NHS too. I am not sure what this means. My learning is that GPs do know their patients but, largely, they don't understand them in the context of how they live their lives. My reflection is that GPs need to be more, not less, focussed on their patients. A better understanding of them, as evidenced from my experiments, transforms the lives of both patients and staff. And it happens to be a lot cheaper. A focus on the micro impacts on the macro, as I have talked about before here.
Sir Bruce Keogh seemed to imply that to focus on the system as the reason for the problems that are reported is wrong. With impeccable logic, Sir Bruce argued (again, if I am not mistaken - happy to stand corrected) that the system is made up of individuals. They just need to be a bit more professional and compassionate. So, ergo, a focus on managing the people will produce better results.
The convenient fact that is missed in this analysis is that the system is designed to prevent good people from doing good. A focus on managing people is quite simply wrong and is a very poor strategy for change. I hope I simply misheard and if I have I apologise to Sir Bruce. If I haven't then it is a belief that I find very worrying. The reality is we have designed a system that is systemically incapable of being patient centred.
Then Ali Parsa extolled the virtues of competition and the innovation that this can bring. As I have blogged about before here, my focus isn't on public/private or market/state. What I am interested in is understanding the "what" and "why" of current performance and how far from perfect we get. But what I heard Ali say was that if barriers to entry are broken down then more private providers can compete and this will drive innovation.
Again, impeccable logic and very plausible. But I was left wondering about all those people on who the system spends most of it's money (our elders) and specifically those receiving care in their own homes - care that is largely provided by private providers.
I began to wonder how many innovative ways there could be to get someone to wipe my bum, or feed me, or hold my hand, or talk to me and take the time to listen. How much more innovative can you get in making a cup of tea or putting someone to bed?
The "real world" though offers help through a menu of service and it is through this lens that we seek to innovate. 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.
We don't need disruptive innovation. We need disruptive thinking. The kind of thinking that starts by asking "what is the purpose of what we do from a users perspective" and values understanding and the development of relationships over time. Instead of looking for answers to binary "killer questions" like "would you want you or your family to be treated here" we need to ask "what matters, from a users perspective".
What we need is to change our thinking about what works. If we do that we will save lives.