The NHS and Local Communities

I met with some PCT people last week. The meeting was in a new Health Resource Centre, built under the Local Improvement Finance Trust scheme(the LIFT programme) for £7m.

The Centre is a wonderful building. It's light and airy, has 3 floors, a lovely atrium and even a half-decent car park. It houses a bunch of GP practices as well as a wide range of community services and a few specialist clinics, previously available only at the local DGH. I was so impressed I even took a couple of pictures.

But then I was taught an important lesson. Putting up a nice building and calling it a Health Resource Centre is not the same as acting as a Health Resource Centre. Whilst I was waiting at the Reception desk, a middle-aged, friendly woman came in and asked, politely, if she could leave a bunch of A5 leaflets alongside the lovely display boards promoting various local NHS services. Her leaflets were promoting a new local voluntary support group for people with Cancer. "I'm not sure let me check", said the Receptionist. A phone call ensued. Then came the reply "Oh dear, I'm sorry but we have a policy only to stock official NHS leaflets. Do your leaflets have an NHS logo on them by any chance? - No, I'm sorry then, but we can't take them".

I was reminded of this little story this morning when talking with my wife. For some reason, please don't ask why, my wife has decided to offer a home boarding service for dogs. She's produced some colourful posters and yesterday popped off to 3 local Vets to see if she could put the posters on their notice boards. All said yes, without hesitation, as did the 4 local shops, scattered around nearby villages, that she approached later the same day.

Apparantly vets and shop keepers consider themselves to be intergral parts of their local communities, but the NHS is still not sure.

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Wonky Teeth and NHS Inequalities

My son has 'wonky teeth'. My wife took him to the dentist (on the NHS). She, the dentist that is, suggested that a specialist should come and take a look at him, to decide if he needed braces . Wife and son agreed.

Six weeks later he went back to the dentist for his assessment. Turns out he could benefit from treatment but didn't qualify for free (NHS) treatment - "he's just on the wrong side of the access threshold". We would need to pay privately for the treatment. Wife asked how much. £2700 was the reply. Wife walked out in a daze.

Now I have a friend who is a dentist. I rang to ask for advice. "Who did the assessment?" he asked. "Mr X" I replied. " Well, he only does private work, why were you seeing him? You should go back to your dentist and insist on a proper NHS referral" he suggested. "I thought that was what we were having in the first place, thanks for the advice" I said.

We followed the advice. Last week my son went to the local DGH for another assessment. This time by someone who is employed by the NHS. He was still borderline but, after a bit of humming and harring, he was accepted for treatment. No charge.

My dentist friend saved me £2,500! Trouble is most people don't have a dentist for a friend, or a GP, cardiologist or social worker for that matter. What happens then?

Perhaps they might contact their local NHS PALS office? I didn't think of this, which is interesting in itself. I've just tried to contact them now, out of curiosity. According to the national PALS website, my local office is 'full-time staffed', but it only deals with written enquiries!

There must be tens of thousands of people who each day feel 'adrift' in the labyrinth that is the NHS, stoically or angrily accepting 'their lot'. Its mid 2009. We need to do better. Perhaps it's time for a professionally run national telephone and online patient agent service that can quickly source good, geographically relevant. sources of advice to help people already 'adrift' in the system review their situations,clarify options and become more assertive 'customers' ?

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New NHS 2.0 Not for Profit Start-Up - Interested?

Health 2.0 is part of the future for the NHS. The term, derived from Web 2.0, covers a large bucket of web-based applications, all designed to give patients, healthcare 'consumers' and communities more information, influence and/or control over their healthcare experience or health status.

The Health 2.0 'movement' started in the States, mostly West Coast. I went to the annual Health 2.0 Conferrence last October. About 1000 people (mostly application developers, clinicians and policy commentators) spent a lively 3 days in a Marriott hotel basement, reviewing over 100 health 2.0 applications and exploring where the 'movement' might go next.

To-date the potential of Web 2.0 has pretty much passed the NHS by. Partly because IT staff are largely preoccupied with trying to get NPfiT 'on track' and most managers aren't that familiar with net based appplications. That's going to change soon. The DH is formulating a new Digital Strategy that will, in part, embrace the experimentation with what is becoming thought of as NHS 2.0

I'm going to start a not for profit to work in this area. The basic idea is to help PCTs and Trusts to explore possibilities with talented application developers. Quick beta versions of NHS 2.0 applications can be generated and tested and those that prove to be most attractive to users can then be picked up and funded more fully. Let me know if you are interested in getting involved. It'd be good to find two or three partners who have something to offer. Also let me know if your organisaion is interested in being an early customer!

There is enormous potential here, (despite the digital divide) to help millions of people make their lives a bit easier by the use of relatively simple, very cheap and practical NHS 2.0 applications. Who knows, some may even turn out, as a by-product, to be useful in helping the NHS achieve some of it's key strategic objectives.

A few of my favourite applications showcased at the Health 2.0 Conference are:

Careflash

Limeade

The Prevention Plan

American Well

My Medlab

PatientsLikeMe

WeAre.Us

Sermo

Healthline

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Leadership Styles in the NHS

Earlier this week I ran a half-day awayday session for an executive team of an acute Trust,  titled "The Leadership Challenge for the NHS. I thought I'd share the slides I used.

Topical as ever, especially since leadership development in the NHS is being reviewed, again, at the moment - see this week's HSJ -  NHS is a Brutal Place for it's Leaders

The key point is partly expressed in Slide 15 - Leaders need to be able to make use of several styles of leadership inorder to increase the chances of getting effective results, on or ahead of time. However, most leaders either can't recognise when to switch between these styles or can't use more than one style. To make matters worse, the NHS system is led, nationally, in ways that mitigate against the most useful leadership styles being used at local level.

Do you think this is right? I wonder what magnitude of 'performance gain' might be achievable if NHS leaders at local level were consistently using the most effective style for any given situation?  Perhaps getting appropriate leadership styles in use at the right time might be just as fruitful an idea to pursue as the miriad of 'transformational service landscape' changes that are being proposed all over the place at the moment?

Btw - the ideas contained in the slides are not mine - "Really" I hear you say!

I pulled them from 3 sources (and mainly the first one):

Leadership that Gets Results: Daniel Goleman, Harvard Business Review, March/April 2000

Execution: The Discipline of Getting Things Done: Larry Bossidy & Ram Charan, Random House, 2002

The Leadership Challenge: James Kouzes & Barry Posner, Jossey-Bass, 1987

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Response to DH on New Quality Policy

High Quality Care for All – Measuring for Quality Improvement: the approach is a document that sets out the Department of Health's view about what needs to happen to make quality improvement the organising principle of everything that the NHS does. It invites comments. Here are mine.

1. Timeliness, efficiency and equity have all historically been seen as significant features of NHS quality systems. The traditional focus on these 3 issues must not be overlooked when designing a new system. The NHS needs to learn how to judiciously 'blend' these historic features into a new approach that rightly has a much sharper focus on safety, effectiveness and the patient experience.

2. Transparency is a new and important dimension that is missing from the proposals. Transparency needs also to be present in a refocused Quality system. Inviting, or even welcoming, public and patient scrutiny is probably potentially the single most powerful dynamic that can be harnessed for creating a culture that priorities quality improvement.

3. It is absolutely vital that local leaders, especially Chief Executives and Medical Directors of Trusts, feel capable and personally able to devote sufficient attention to this agenda. Partly this requires a conscious effort on their part to appreciate the 'science' of quality improvement, to prioritise quality related work, to signal this clearly to the rest of the organisation, including the Board and to communicate other Trust activities within a broader Quality 'mindset'. To find a broader 'quality narrative' if you like.

4. Ultimately leadership of successful and sustained quality improvement is not something that can be delegated to 'quality technicians'. Most clinicians, understandably, will only be persuaded that we are serious about quality when they see Chief Executives and other local leaders being obsessed with the pursuit of quality, over a sustained period of time. Leaders really do have to have to 'be the change they wish to bring about'.

5. Most organisational cultures will not become more receptive to sustained and effective quality improvement without a clear and visible shift in the leadership behaviour of leaders. The requisite shift in culture also requires the judicious use of positive incentives to reward desirable attitudes and behaviour deep within the clinical and managerial domains. Commissioners in particular can play a key role in co-designing and reinforcing such positive incentive systems. Financially penalising relatively poor performers is not the route to quality improvement.

6. The new, ambitious vision of “making quality improvement the organising principle of everything we do in the NHS” may of course mean that, over time, the 'goalposts' move in terms of what makes a successful Chief Executive, Medical Director and ultimately a successful Trust. Some local leaders will find this transition easier to achieve than others. It is vital therefore that local leaders make the time to create their own effective lateral peer support mechanisms to accelerate their personal learning about what being successful now means in a re-focused NHS. Existing leadership programmes need to be refocused to reflect this need.

7. Less is better when it comes to agreeing and using a national system of metrics. When building a national set of quality metrics the NHS should start small and build incrementally, developing and agreed a more sophisticated set of metrics (with clinicians) as people learn how to measure, interpret and act. One feature therefore of a successful national Quality System will be its' ability to balance the need for a small set of consistent comparative data at the regional and national level with the dynamic of continual adjustment of meaningful metrics at more local levels.

8. All data will be interpreted. Most data can be interpreted in multiple ways. Clinicians, managers, non-executive board members, politicians, patients and members of the public will all be interpreting quality-related data. The NHS needs to ensure that, as far as is possible, useful and timely training in data interpretation is offered.

9. Data is always interpreted in context. For example, relevant patient stories, sitting alongside 'raw' data will have a significant impact on how that 'raw' data is interpreted. Some stories might 'help' the reader see the data as more positive than might be the case. Other stories could easily help create the opposite effect. Much more research needs to happen, urgently, about the psychology of data presentation, especially in relation to sharing data with the public.

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The NHS in 2009

photo by the|G|™

Here's seven personal New Year wishes for the NHS. These are not necessarily the most urgent challenges but, for me, they are some of the most important. A bit belated I know, but I've only just managed to defeat the Man flu:

1. Get serious about recruiting for attitudes and values. Let's really try to strengthen compassion, integrity, pro-activity and respect for people's wishes;

2. Develop more integrated clinical pathways AND financially incentivise acute and primary care providers, jointly, for the attainment of certain outcomes. We've made progress on the clinical recording systems, now we need to use them;

3. Find ways to 'get a grip' on what's coming down the scientific 'pipelines' and interpret and re-present this intelligence in ways that invite managers to get into dialogue with clinicians about implications for the next 5 – 7 years. Let's not wait till we hear about this stuff on the nine o'clock news!

4. Be more proactive about reshaping or investing in (new) services to ameliorate some of the probable effects of the credit crunch, especially services needed as a consequence of likely mass redundancies. Btw, do we know which areas have most jobs at risk and who the 'at risk' people are?

5. Move social marketing into a pull/push/act cycle rather than a mass broadcast push only service. A bit cryptic I know- happy to talk more about this if asked;

6. Switch revenue investment into good 3^rd sector organisations to give more 'space' for challenging official policy direction where this seems too conservative or overly centralist in nature. The NHS, at local level, will probably never have the ability to really push back hard. This just might be a better way;

7. Finally, and it won't be all that popular, don't don't don't backtrack any further about 'making markets'. The opportunities are too great. There are millions of good, talented, compassionate people out there – working beyond the NHS – who could really help to move healthcare forward. Let's use them.
   

Do any of these strike you as 'spot on'? Perhaps some suggest that I'm living on a different planet? What are your wishes for the NHS in 2009?

Oh and happy 2009.

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First Do No Harm

Salford Royal is by all accounts an excellent hospital. A few months ago the Trust was rated as ‘excellent’ for the quality of its services and the use of its resources by the independent Healthcare Commission. It also won the Patient Safety award at the HSJ awards the other week.

When you walk into entrance No 4 at Salford Royal Hospital you cannot fail to see a series of big posters that talk about Harm and the hospitals intention to reduce the amount of it people suffer in their facility. I assume that same posters are at other entrances as well. This is one of them.

Towards the bottom, in bold, the text says "at Salford Royal our harm rate of 38 (per 1000 occupied bed days) means that on average there are 850 patients that experience some harmful event each month. We plan to reduce the incidence of harm by 50%."

I was rushing to a meeting, 15 minutes late, after having to queue to get into the Trusts' not so excellent car park. But I had to stop and take some photos of the posters.

I've never seen a hospital in the UK be so transparent about it's harm rate and its' determination to make further improvements. Have you ever seen anything like this, so publicly available, in any hospital?

It may, at first sight, be an uncomfortable message but as Harriet Beecher Stowe said, "the truth is the kindest thing we can give folks in the end".

• Perhaps the pursuit of quality and patient safety is really beginning to permeate the culture in this place?
• Perhaps here clinicians and managers are, relatively speaking, more willing to openly acknowledge where they harm patients?
• Perhaps here patients and their family and friends are being treated as 'grown ups'? 
• Perhaps this Trust is on the cusp of doing great things?

Six posts that caught my eye

Prompted by my Google Reader unread count getting upto 4,000 posts I've spent a happy hour or two skimmimg through the blogosphere. Here are 6 posts that caught my eye. Hope you enjoy.

1. Worried that your ageing brain is making you look a bit pedestrian? Brain-based Business has some tips to stop your brain getting old and tired.
2. Curious about what Obama's victory might mean for healthcare in the States? The Health Wonk Review has a good selection of views from policy wonk types.
3. Are you frustrated about how busy colleagues don't give your ideas enough attention? Thinking Faster has 7 ideas that may help. The end of "NHS time" perhaps?
4. George Ambler, in the excellent The Practive of Leadership shares six skills for effective active listening that has come out of the Centre for Creative Leadership. See the list here. (Incidently, the CfCL is one of the sites in my recommended website list on my consulting site. See the full list here).
5. John Halamka, Dean for Technology at Harvard Medical School has posted an analysis of his Genome on his Life as a Healthcare CIO blog. perhaps you'd prefer not to know?
6. Finally, Michael Porter's 5 Forces model became a 'must use' strategy tool when first published in 1979. Rob Millard, on his Adventure of Strategy blog, has posted a link to a 12 minute video of Mr Porter talking about the continuing relevance of the model for today's strategy challenges. Well woth a look.

Don't React.Initiate

I've just been reading Seth Godin's latest book about leadership, called Tribes. He offers hundreds of short, really stimulating insights. The most memorable for me, so far, is his distinction between Reacting, Responding and Initiating.

Mr Godin suggests that many managers too often just react to other people's agendas. It's an instinctual, intellectually easy action and often dangerous. To my mind those NHS managers who see themselves, primarily, as local implementors of Government policy too often fall into this category.

Good managers do better than this. They respond rather than react. Responding is a more thoughtful action that seeks to take advantage of opportunities. Responders are good at 'reading' situations and can craft actions to suit a range of particular circumstances. The best managers respond rather than react.

Some people, the leaders amongst us, go further and actually initiate. These people see opportunities that others don't. They are more impatient and they help make real substantive change happen. Tribes (inside and outside the organisation) are happy to follow the initiators.

After Darling's announcement today, Government borrowing is expected to rise to £118 billion in 2009 – 8% of GDP. Spare money, generally, is now really hard to find. But the NHS, at the end of August, was reported to be heading for a surplus of £1.75 billion for this year. Now more than ever we need public service leaders who are willing to use this money to good effect. Take a deep breath and initiate some bold action that will make a lasting difference to people's lives. Follow your heart. People will follow.

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The New Second Opinion

 Edelman, a Global PR firm in the States has recently got a lot of publicity with a five-country survey of over 5000 adults (including more than 1000 in the UK) about how engaged people feel in their own healthcare. You can access the full results here. (It'sa pdf file). Highlights include:

1. People are becoming more engaged on health issues
2. People are becoming more engaged with companies and
   organizations involved in health … and want even more
3. People are becoming more engaged with health products and
   services … and want even more
4. 4 out of 5 people say they are Health Involved
5. 1 out of 3 people believe themselves to be Health Informed
6. 2 out of 5 people are health Engaged
7. 1 out of 5 people can be categorised as Health Info-entials (Edelman's term for the people who self-report to being involved, informed and engaged).

The biggest national group of Health Info-entials seem to be the Chinese (35% self-report) whilst the smallest is amongst UK respondents, where only 13% believe themselves to be involved, informed and engaged. The USA group is in the middle, coming in at 20%.

There's lots more detail about these 'leading edge' Health Info-essentials in the report, including quite a few national comparatives. 

However the finding that has really struck a chord with me concerns what Edelman calls 'The New Second Opinion'.  Perhaps not unsurprisingly, 88% of respondents agreed that  "I usually turn to my physician to validate information that I get online". But get this. Amazingly, (to me at least), the same percentage (88%), also agree with the statement "I usually turn to other sources to validate information I get from my doctor".

We live in a world where people seek to validate every professional opinion they receive. Now things start to get really interesting.

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