The Changing NHS

My friends at The Health Informatics Service  have created a new consulting site for me in return for some days of my consulting time.

Check it out here. Now what else can I barter for!

I played Scrabble on Sunday evening with my wife and youngest daughter (aged 11). I came last, with a miserable 85 points. The boss had 136 and my daughter, much to her delight had 86.

Pondering my defeat I realise that my strategy (such as it was) was wholly flawed. At one point I was very pleased with myself as I had secretly formed the word ‘ Senate’. This word appealed to me quite a bit. I thought it would impress my daughter and being an ex-politics junkie it appealed to me also. So much so in fact that I was unconcerned that each letter only scored 1 point.

I held on to Senate for 3 rounds, hoping to play it, scoring no points each time. I didn't.  Eventually, with a heavy sigh, I laid down ‘ten’ whilst telling my fellow players that I had Senate, hoping to impress daughter in any case. It didn’t. In the meantime they both had been playing away, scoring points all over the board.

I think PCTs form and implement strategy a bit like I play Scrabble! The world (like the Scrabble board) is constantly changing but they are holding onto the words they hold dear (reducing health inequalities, strengthening the patient/GP relationship etc) in the hope that some time soon the board, sorry world, will allow them to play their hand. In the meantime all sorts of opportunities for scoring points are passing by before our eyes.

For example, last week I discovered some interesting facts about our changing world, including:

1. Alternative practitioners are now more numerous than GPs;
2. The UK Governemnt has committed to spend $1.3 billion on stem cell research in the next 10 years;
3. Cancer drug launches have risen from just under 1400 in 2000 to just over 2100 in 2007;
4. In 2005 the annual spend on Complementary and Alternative Medicines was estmated to be £4.5 billion and the market has grown by 50% in the last 10 years;
5. Estimates of UK gas reserves amounted to 412 billion cubic metres in 2006 14.1% lower than the estimate in 2005.

That’s a really interesting Scrabble board for a PCT to score some serious points on, don't you think?

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strategy

primary care trust

Managers in the NHS are well aware of the policy jigsaw problem. From time to time the NHS is ‘encouraged’ to pursue what, to many people, seem like contradictory policies at the same time. Occasionally concerted efforts to stop this happening are made (the NHS Confederation’s Joining Up the Jigsaw work springs to mind), but the problem is never going to go away completely in a system where national politicians, under strong short-term pressures, are thought to be calling the shots.

I was in a couple of meetings recently when the policy jigsaw alarm bells started ringing again. Both were meetings of Clinical Pathway Groups (about 20 clinicians drawn from a fairly wide range of local NHS Trusts who had been beavering away for 5 months or so on developing recommendations for how services ought to evolve over the next 7 years or so and getting psychologically re-connected to the NHS as an important by-product of the process).

Basically all the members of both the CPGs I witnessed had really enjoyed the opportunity to exert some fairly direct influence on the future shape of services, despite the’ hoops’ that host SHAs were now making them jump through to refashion their recommendations in ways that would more easily resonate with local publics. Senior clinicians are indeed now much more engaged with the NHS than they were a year ago – hooray, a triumph for Prime Minister Brown.

However, where might this lead? The clinicians I met were, quite understandably, reluctant to ‘pack up shop’. In one case, they suggested that the SHA sponsor their continued existence – not to monitor how their recommendations were being implemented or to help smooth out ‘roadblocks’ as one might reasonably expect, but to make more recommendations in areas they simply hadn’t had time to ‘get to grips with’ and perhaps to gain direct control over certain budgets.

Great you might think. A case of influential, knowledgeable clinicians rolling up their sleeves and making a substantive contribution, rather than shouting from the sidelines. But almost all these clinicians are employed by Foundation Trusts. Organisations that are, supposedly, independent of central NHS direction and incidentally, from April 1st, free to advertise their services direct to members of trhe public.  See the DH's recent promotion of services code here.

Clearly these clinicians believe they can exert real influence on services by continuing to act together (legitimated by the Darzi process and covertly encouraged by SHAs struggling to 'make their mark strategically). These clinicians believe also, I think, that they cannot exert anywhere near as much influence by working with local colleagues, exerting influence on service strategies within their own organisations. In fact many expressed deep frustration with how little opportunity they had to exert influence by using processes within their Trusts. Perhaps the strong focus on Governance and Finance issues that occurs during 'the FT application process' has led, paradoxically, to many Trusts' taking their eye off the ball in respect of how clinicians can be supported to help shape local service strategies at the same time that senior clinicians have been welcomed into the more expansive, lateral Darzi process? 

Watch this 'space' as this policy clash becomes clearer and plays out over the next few months.

Darzi

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Given all the recent hoo-ha about the need to extend GP opening times I don't expect this will go down too well with the RCGP - but here's a primary care physician in New York City who doesn't have an office!

See Jay's site here

As Jay says; I am your easily accessible doctor. Jay focuses on serving adults aged 18-40 and offers e-visits booked direct by patients. E-visits can include use of video chating, IM and digital photos.  (You can pay also for home visits if you are registered with him).

I wonder if there are any GPs in England planning to practice in this way?

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e-visits

GPs

Last week I ran a workshop on managing change for a group of about 60 Mental Health clinicians and carers who are working in teams, throughout Scotland, as part of the Scottish Goverment's Leading Change programme in Mental Health. 

I covered the usual stuff:

i) models of change;

ii) communicating in ways to help change happen;

ii) recognising and dealing with ‘resistance to change etc.

For me the most interesting part was the last 45 minutes when we explored what might be the key attributes of successful change agents. Obviously, to some extent this is contextual but after 20 mins or so of brainstorming we had a long list of attributes including:

1. Is open to data
2. Stays enthusiastic and motivated
3. Does not let minor setbacks halt progress
4. Knows the business ‘inside –out’
5. Facilitates change rather than forces it
6. Seek outs and accepts valid criticism of their ideas
7. Communicates in ways that help others to “buy into” the change
8. Stands against status quo and takes risks when necessary
9. Copes with ambiguity well
10. Can negotiate new goals
11. Can deal effectively with the politics and influence the broader view.

I then asked the group to focus down and explore the attributes that seemed most intriguing to them. This led to 3 really interesting questions about the change agent being raised and explored in the final plenary session. The questions raised by participants included:

1. To what extent does a successful change agent need to:

a. believe in the changes being sought?

b. be an advocate for the changes being sought?

c. emotionally commit to the changes being pursued?

2. What ought change agents be accountable and responsible for:

a. getting results?

b. leading the change process? and/or

c. designing and operating an effective change process?

3. Is a change agent likely to be more effective if:

a. they personally find it very easy to adapt and make changes in their own life? or

b. they struggle with making changes,  like many of the people they are 'acting upon'?  

What do you think about these questions? Any insights greatly appreciated!  

Also, are there other important attributes that people ought to consider when seeking to identify good change agents in their organisation that aren't listed in this post?

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change agents

I'm running an Open Space training session next week for a group of mental health service users who are planning to run their own OS conference every 6 months or so.

In preparation, (yes i do prepare sometimes),  I thought I'd have a quick look on YouTube to see if anyone had posted an OS video that I could use to convey the essence of the process. Well, I found 3 great ones. What a great resource YouTube can be. Here they are:

1. 2 minute interview (in the back of a taxi) with Harrison Owen, the larger than life guy who thought up Open Space, talking about how he did it. 

2. 3min 30sec video of an Open Space process used by the Transisition Network at their inurgural conference in Stroud;

3. 30sec video showing a speeded up 1 day OS conference at the Tate Modern. Great fun to watch.

I think I'll use these next week.

Incidentally if you want to know more about OS, go to Open Space World

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Soon, nine Strategic Health Authorities will submit their visions for the future of the NHS as the formulation phase of the Darzi review process comes to a conclusion.

As outlined in an earlier post, eight clinician dominated and led review teams have been busy in each SHA area trying to articulate what various ‘service lines’ might look like in the future.

So far so good. But how does the process move on from here? That’s the tricky question. Will PCTs and Trusts embrace the recommendations made by the review teams and happily fuse these aspirations into their own commissioning plans / service strategies?

Somehow SHAs have to construct an approach to implementation that does justice to the work done by CPGs whilst also respecting the strategic independence of PCTs and Trusts.

I’ve been involved, to a limited extent, in the Darzi process in a couple of SHAs and I know that SHA strategists have been preoccupied with this question for a while now.

On the whole, despite supportive noises when necessary, most PCTs and Trusts have been content to sit on the sidelines and wait to see what ideas emerge. Meanwhile, about 200 clinicians in each SHA area have been getting all fired-up, hoping to see the changes they have asked for, come to fruition.

If implementation hits a brick wall then this clinical enthusisam may soon disipate and worse, leading clinicians might become even more disilusioned with the NHS (and managers in particuilar who will probably be seen as the problem).

There’s no easy answer of course, but in thinking a bit about this ‘adoption’ problem I’ve been reminded about Chris Huxham’s work on Collaborative Advantage. Professor Huxham identified a few traits that successful strategic partnerships exhibit. In very short summary they are:

1. Have clear, common aims
2. Build trust, start with easier issues 
3. Use collaborative leadership
4. Be very sensitive to power issues
5. Carefully construct membership structures
6. Learn together 

I was minded to think about stategic partnerships because this is , in effect, what SHAs will be trying to construct or at least encourage, between the local Darzi review groups/SHA, PCTs and provider organisations.

For me, reflecting on these successful partnership traits provides some strong clues about what an approporiate architecture for implementation of Darzi might look like at the local level – or at least it suggests some principles that all parties might agree to abide by whilst constructing such an architecture.

The seven principles that come to mind are:

1. Implementation of recommendations to be managed via PCT strategic commissioning processes wherever possible (excluding those recommendations that can be introduced easily by clinicians acting under their own steam or require formal public consultation or changes to nationally constructed policy);

2. No PCT or Trust to have to implement any recommendation that they don’t support. The choice is local;

3. SHA to act as a ‘Process Agent’ on behalf of all CPGs, seeking to get as many of their recommendations as possible 'into play';

4. All PCTs to agree which recommendations that are adopting, refining or ignoring with the SHA Process Agent - together with phasing year by year. Not everything can be done at once;

5. Each PCT to nominate an implementation lead(s) (probably but not necessarily the person who is responsible for developing and overseeing implementation of Commissioning strategy or the part of it that pertains most closely to each of the eight CPG areas of focus);

6. Each Implementation Lead to meet with the relevant CPG quarterly for no more than 1 hour to share progress on adopted recommendations and seek CPG member support to help remove ‘blockages’ to implementation - especially via informal clinician to clinician peer pressure. This update process to be orchestrated by SHA; and  

7. SHA to fund and orchestrate voluntary learning sets to encourage implementation leads and CPG Chairs to reflect and learn together about how best to implement recommendations.

What do you think? Do these seem like useful principles?

What other principles might SHAs wish to consider to encourage effective implmentation of local Darzi recommendations? 

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Darzi

implementation

I've just finished reading this book and enjoyed it a lot.  As well as helping readers to appreciate how different types of doctors think, Dr Groopman draws attention to the kinds of decision errors they are prone to make in the course of attempting to make a diagnosis.

Thinking errors  include:

Confirmation bias - the focusing of attention wholly or overwhelmingly on data that supports a presumed diagnosis and the corresponding tendency to pay less or no attention to data that contradict what is presumed;

Satisfaction of search error - the tendency to stop searching for a diagnosis once something is found;

Vertical line thinking - the constraining of diagnosis as a consequence of using cutting edge technology that must therefore point to a diagnosis

Dr Groopman believes that diagnostic accuracy will be improved if a) patients learn to help their doctors by asking questions that encourage them to think more carefully about diagnostic possibilities and b) doctors learn to welcome this prompt for more reflection.

Currently the NHS  has the expert patient programme  now led by a Community Interest Company . But this programme, as I understand it, is predominantly focused on helping patients with certain long term conditions become more confident and proficient at managing their own condition.

A 30 minute net search didn't pick up much on patients helping doctors reduce diagnostic error rates. The best thing I found was this summary article about ways in which patients might be usefully engaged in improving patient safety on the National Library for Health's site. 

One part of this short note covers how to improve the accuracy of diagnosis but it presupposes the problem is that patients don't give accurate enough information about symptoms or GPs don't listen carefully enough. There is no mention of how patients might help GPs to reduce their decision errors by asking helpful questions.

So perhaps some bright spark somewhere in the NHS ought to start or sponsor a Helpful Patient Programme (HPP)? A programme to help millions of people to become proficient at asking helpful questions to their GP to aid diagnosis.

Maybe if we labelled the Helpful Patient programme a form of social marketing it might be given a fair wind?

Maybe there are 5 or 6 really good questions to ask that often help in lots of diagnostic situations? 

Maybe intelligent articulate patients already play this 'co-producing value' role and millions more could, with just a little help?

What are you thinking (doctor)?

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Whilst I'm on a bit of an American healthcare riff I thought I'd share this with you. Kaiser Family Foundation (KFF) have supported the development of a side by side summary of the healthcare proposals of the 2008 Presidential candidates, Democrat and Republican.

You can quickly see the similarities and differences between Hillary Clinton, Barack Obama, John McCain and Mitt Romney for example.

The comparison tool is here.

 So now I know who is proposing to "provide individuals without employer-based coverage a tax deduction of up to $15,000 to make insurance more affordable". I should be popular at parties! 

usa healthcare

healthcare policies

As a rule I don't normally just pass on links to other posts but hey, it's Jan 2nd, outside it's grey and raining and yet another piece of Christmas Cake is daring me to eat it. 

Everything 2.0 has a post titled:  Health 2.0: 38 sites that can help you to stay healthy, or to improve your health, or to lighten your sickness.

Thanks to Matthew Holt at Health 2.0 for drawing this to my attention.

I haven't looked at all 38 sites yet, but I imagine they are all (currently at least) mainly focused on serving USA-based users/communities. I wonder which ones would work this side of the pond and what a more UK centric list of Web 2.0 health sites might look like? Please let me know which Web 2.0 health sites you know about. Maybe we can compile a little list and get the NHS's attention on this?

Happy 2008 to all.

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web 2.0 health