Change thinking, save lives

So yet another report is published this week revealing the scandalously poor levels of care received by some of our most vulnerable in society.  It seems some of us are not even safe in our own homes.

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.

Killer targets II

Yesterday Andrew Lansley pledged to take action and change the national waiting time target to ensure that "hidden waits", those people who are waiting for > 1 year, are tackled.  This followed pronouncements earlier in the week that there will be a ban on minimum waits.  Something of a change of direction for someone who, on June 21 2010, declared he was scrapping the 18 week referral to treatment target (RTT) and the right to see a family doctor within 48 hours.

Targets are, oddly perhaps, seen as generally a good thing in the NHS.  After all, who doesn't remember the horrendous waiting times that people experienced before they were enforced both for people waiting for operations and for A& E.  A well constructed target, well implemented is necessary and works, goes the logic.  Without them we would continue to live with the outrageous waits with, in some cases, people dying before they could get treatment.  It is poor implementation that is responsible for the tragic consequences we hear about not the target itself, is the argument.

I don't agree.  In fact, I would go so far as to say I agree with Andrew Lansley.  We should drop targets.  My point of departure with him is what you replace it with.  My view is that in place of targets we should have measures derived from the work.

For some this might sound completely bonkers.  After all, without a target, how would we be able to judge how well we are doing?  And how else would you motivate people to perform?

For others, it might seem like a semantic debate.  What's the difference between a target and a measure derived from the work?  For me the difference is profound and goes to the very heart of how we think about what works.  Targets always distort the performance of a system.  The whole notion of targets is flawed.  Their use in hierarchical systems engages people's ingenuity in managing the numbers instead of improving their methods.

For the people who think I am bonkers, let me give some examples.  I vividly remember in my first job as a general manager looking at the waiting list for outpatient plastic surgery.  The list was in good shape.  No one was breaching, at least not according to the Korner waits (as was).  These were the statistical waiting times which meant that the clock could be re-set to zero and your wait started all over again on the most flimsy of reasons including being offered appointments that were completely unsuitable for your circumstances.

What I wanted to know was how long people had been waiting end-to-end.  From the start of their wait to the current date.  I discovered one person had been waiting for over 5 years, just for their outpatient appointment.  Their Korner wait?  8 weeks and well inside the maximum waiting time.  It was unbelievable, perhaps more so because the person concerned still wanted the appointment!

So what, you might say, that happened years ago.  We have come a long way since then.  Have we?  Consider this.  In Rob Findlays and Anthony McKeevers summary of the waiting list position (here - £?) they point to real and terrible consequences of making people, the forgotten few, wait.  They say;  "Real examples include an infant listed for an operation because of a haemangiona (malformation of the blood vessels) on her wrist, who was still waiting in her teens. There was also a man whose operation was cancelled because of “no theatre time”.  He was found, still waiting to be offered another date, 15 years later"

Then there was the shocking review by the Royal College of Surgeons which I previously posted about here.  In that post I talk about those people hidden by the target, as if wearing a cloaking device, invisible to the system.  In the specific examples given, highlighted by the Royal College of Surgeons report, the result of delivering a target was significant with much impaired outcomes and even avoidable deaths.

We know that there are some Trusts who have allowed their backlog to build up in order to continue to deliver the target.  They are allowed to do this because there is a statistical quirk they can take advantage of.  The target is measured against those who have been treated, not those who are waiting.  So if I am in charge of a waiting list I can drip feed the list with patients who I know are going to maintain my target delivery position, instead of taking people (clinical priorities aside) in the order they are listed.  It's a risky tactic because at some point the balance of the waiting list changes and the risk of reporting failure to deliver the target increases.  We also know that in times of financial hardship, more lucrative cases will be listed ahead of others in some Trusts, irrespective of length of time waited.  Shocking isn't it.

Then there is the issue of people being operated on unnecessarily.  Evidence shows that involving people in decision making about undergoing an operation can result in a decision not to go ahead.  Weighing up the balance of risks and the impact on lifestyle individuals can and do opt for different approaches.  But systemically we don't do this.  We list and treat or validate off the list, not understand and reach decisions together in the context of how people live their lives.

So, those who support the imposition of targets and do so comparing what it used to be like, may be surprised to find that many of the problems that individuals faced then are still occurring now.  People are still waiting too long, potentially being over treated and, in some cases, having impaired outcomes or even dying as a result of the target.  And people are still cheating or gaming the system.  Facts that are hidden from view.  It's just that the numbers we are talking about (around 20,000 compared to nearly 600,000 a decade ago) are smaller.  So that's OK then.

The other popular target is A&E.  Again, I remember the war zone that was A&E during my time as a general manager.  Some people even died on trolleys in corridors, much to my enduring shame.  So getting people through in 4 hours has to be a good thing, right?  The war zone and 12 hour + waits are now consigned to history - aren't they?

But take a closer look at the numbers and a different pattern emerges.  I have found, and reports from the Information Centre support this finding, that as time spent in A&E increases, the percentage of patients discharged with no follow up required falls, while the percentage admitted increases.  If you look at the graph they produce, which I have replicated, activity drops off a cliff at the 4 hour mark.  It is a very unusual thing to see and worth taking a look at.  The numbers will vary but the national data shows that, of those leaving A&E, the percentage of patients admitted to hospital peaks in the last 10 minutes before the 4 hour target is reached - over 60% in this time cohort will be admitted.  Funny that.

In other words, what we think of as good performance, deliver the 4 hour target, is not when you view from the users perspective.  And this fact is acknowledged because in countless publications there is a recognition that large numbers of people in hospital beds do not need to be there.  But large numbers of them are there because of the four hour target.  And they are then put at increased risk as a result.

And for the unlucky ones, it is the start of a flightpath to dependency and avoidable cost to the system  and the catalyst for many of the stories we hear reported in the press.  What I have seen is a process where people are passed from service to service, professional to professional with labels like confused or incontinent when they are neither.

Of course no-one wants to wait unnecessarily long periods of time for their treatment.  But because we approach it from a command and control logic, the solutions are based on a resource management logic, where capacity needs to be increased.  More doctors, nurses, other stuff to get people treated.  So a four hour target is, in part at least, a response to a system wide inability to respond to peoples needs for urgent care in a way that solves their problem when they put their hand up for help.

It's not much better for staff either, as I discussed here.  As the Mid Staffs enquiry is hearing, the pressure of delivering targets has devastating consequences for staff as well as patients and their loved ones.  And, of course, targets limit innovation and creativity as highlighted by Bevan amongst others.

Is there a better way?
The short answer is yes.  The lingua franca of targets might mean they are considered normal but they are in fact counterproductive and should be changed.  They should be replaced by a lingua franca about how the work works and how measures should be designed that support the delivery of purpose from a users perspective.

The better way to improve capacity is to remove waste.  Creating more capacity in and for A&E for example - more doctors, nurses, beds etc, simply adds more resource to a wasteful system, compounding inefficiency.  For elective care the level of waste created by this kind of thinking has been enormous.  Only 85% of the elective work that had been paid for in ISTCs had actually been done according to the DH in 2008.  For diagnostics the position is even worse with only 25% of the work that had been paid for actually being completed.

Better is to put the following principles at the heart of all strategy and operational management:

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

Only then will we move from doing things better to doing better things.

I realise that this is quite a long post.  In fact I have plenty more to say.  I have, after all, only touched on a fraction of the targets that are imposed arbitrarily from people who are not in the work.  There will be those that, so far as the 18 week wait is concerned at least, will not be persuaded.  After all, the longest waits are occurring in relatively few hospitals.  Let's focus on them.  Leave the target alone, to do otherwise is sheer madness they might say.

But however counterintuitive this sounds, all I have said is based on empirical evidence.  And I am seeing a better way through my experiments, the results of some of which I have already posted about but there will be more to follow.  Results which are profound for the system as a whole and the people who rely on it, not just bits of it.

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.