Change Thinking. Change Lives.
Here’s a simple truth...
The performance of our health and care system is a direct consequence of how it has been designed and how it is managed.
Now a profound truth...
Our health and care system is designed and managed as it is because of how those responsible (for its design and management) think (about how to design and manage it).
And so the call to action...
To improve performance those designing and managing our health and care system must change the way they think.
An example...
Janet Bell and Jackie Smith have been running Spring Mount (a home for people living with dementia) for 24 years. In that time Janet, Jackie and their team have delivered unparalleled performance. Outcomes for residents stretch belief and costs are unspeakably low. The morale of those at Spring Mount is beyond compare. This is all being achieved because Janet, Jackie and the team have rejected the myths governing dementia care:
Myths Governing Dementia Care
Dementia makes people...
- Less sociable & unable to enjoy new relationships
- Sexually uninhibited & unable to understand sexual responsibility
- Unable to make a positive contribution to group living
- Unable to self-determine & make choices
- Wander aimlessly
- Unable to learn new things
- Violent & aggressive
- Lose their personality
- Dependant on medication for control
Control requires...
- Targets & standards
- Protocols & procedures
- Policies & directives
- Risk Registers
- Plans & project management
- Supervision & appraisal
- Objective setting
- Budget management & unit costs
When I first visited Spring Mount I was staggered to find a dementia home that was literally bursting with a palpable sense of joy. Residents welcomed me and told me their favourite jokes. Staff came over and chatted as if I were one of the team (they had never met me before). I could not have been more welcomed or more impressed. Neither could the teams behind these Panorama reports, nor years earlier the team behind a similar programme for World in Action. Back in 1999 the Nursing Times had been pretty blown away too.
Which begs the question, “Why aren’t others seeking to ‘do dementia’ the Spring Mount way?”
The answer is illuminating...
Spring Mount’s unit cost to their local commissioner is £575 per week. Other residential homes in the area charges £460 per week. The commissioner thinks that Spring Mount is expensive.
However, the commissioner’s comparison doesn’t acknowledge that in its 24 years of operation Spring Mount:
- Has never had a placement break down.
- Has only once required the use of agency staff.
- Has never used anti-psychotic drugs for any of its residents.
- Has earned such confidence from the social workers who place there that they do not feel the need to review their placements.
- Has enabled such full and active lives for residents that their consumption of other health and care resource is demonstrably different and vastly reduced compared to other care settings (yes, that does mean that Spring Mount residents don’t turn up in hospital with UTIs).
Perhaps most striking of all though is that the commissioner’s comparison is to residential settings which would be utterly inappropriate to the needs of Spring Mount’s residents. To a person, if Spring Mount were to close tomorrow its residents would all be moved to nursing care at a cost of at least £650 per week.
Spring Mount is cheap (that is, cost effective) but the commissioner cannot see it because of their frame of reference. The consequence: the commissioner is now making it increasingly difficult for social workers to place there. For the first time in 24 years Spring Mount has empty beds and no waiting list.
Herein lies the rub...
Six or so months ago Sir Ian Carruthers, Chief Executive of NHS South West, asked on behalf of the NHS, “What can be done to speed the adoption and spread of innovation?” (see Spreading innovation in the NHS: call for evidence and ideas). The consultation was flawed for many reasons but here are three which are especially important:
- It was looking for an accelerator when what isrequired is to step off the brake.
- It assumed that those consulted know how to differentiate good performance from bad.
- It assumed that copying practice will improve performance.
The Troubling Reality (and the Exciting Opportunity)
For decades our health and care services have been held back by a policy and management paradigm that cripples delivery, stifles improvement and disguises good practice as bad (and vice versa). This paradigm is pervasive and entrenched. It is so normal that most people don’t even recognise that there is an alternative. It is the worst sort of failure and yet it is trussed up and polished down then broadcast as best practice. Perhaps you will recognise it...
Traditional Thinking
Perspective Top Down, hierarchy
Design Functional specialism
Decision making Separated from work
Measurement Outputs, targets, standards: Relate to budget
Attitude to customers Contractual
Attitude to suppliers Contractual
Role of management Make #’s & manage people
Ethos Control
Change Reactive, projects, by plan
Motivation Extrinsic
It is these conventions of traditional management thinking which keep our policy makers, leaders and managers blind from the opportunity to improve and the desperate need to do so. It is this paradigm which then breeds the very problems which it sets out to solve. This is not because policy makers, leaders or managers are stupid but it is, to borrow from John Locke,that today’s management conventions represent a madness borne out of valid reasoning from flawed assumptions.
Copying good practice will not improve performance, not sustainably or systemically at least. Where good practice exists, such as at Spring Mount, it is a dynamic notion constantly evolving and flexing as a consequence of the different thinking which gives rise to it. To copy practice without changing thinking is to run a fool’s errand. Consider the difference between Spring Mount’s principles for work and those of conventionally run dementia care homes.
Convention
• We must manage residents behaviour, cost & risk
• Cost and risk lie in activity & in residents behaviour
• We must manage activity to control cost, leading to:
– Targets, functions, roles and responsibilities, utilisation.
• We must manage activity to control risk, leading to:
– Inspection, procedures, protocols, specifications, standardisation, policy, schedules, etc
• We must manage residents behaviour to control risk, leading to:
– Managed spaces, visiting hours,anti-psychotic drugs, etc.
Resulting Ethos
• Overt structures for control,control as application of methods of control
• Extrinsic motivation – carrots and sticks
Spring Mount
• We must provide a community in which our residents and their families can live well with dementia
• Cost lies in any failure to provide and enable this community to thrive
• Overt methods of control will destroy this community
• Providing this community means:
– Acknowledging and enabling the contribution which every resident, family member and staff member can make.
– Enabling risk taking and a positive attitude to risk.
Resulting Ethos
• Control is implicit, discrete, purposeful, control as a consequence of solving problems which impede the community
• Intrinsic motivation – pride in ajob well done
It is as Einstein said, “We cannot solve the problems we have created with the thinking that created them”. Copying will not improve performance. Looking for the accelerator to drive best practice forward will burn more fuel but cover no more distance. Commissioning won’t fix it either, at least, not until commissioners and all of those responsible for the design and management of our health and care system recognise that the only problem which they need to solve lies in how they think.
Change thinking. Change Lives.
