I've just finished working on a set of strategic scenarios that describe four 'edge of plausibility' possible futures for Health and Wellbeing systems. The work was commissioned by NHS North West and the detailed scenarios can be downloaded from their website.

The scenarios are titled; Corporate Cures, Community Cures, Shopping for Health and Living for Health. They have been developed, over the course of 12 months, involving nearly 400 NHS managers and clinicians, local authority senior officers and Councillors, MPs, 3^rd sector leaders, private healthcare leaders etc.

The rationale for the work, basically, is that NHS strategy making is sometimes too narrowly-focused and short-term in nature. Senior leaders (national and local) often assume that the NHS is sufficiently powerful to exert a dominant influence on its’ strategic operating environment. Unfortunately this assumption is proving less likely as a number of fundamental drivers bring stronger pressures to bear over the next 10-15 years. These drivers include:

1. Approaching the limits of the welfare state (expressed through a more solid public consensus about the ‘tax take ceiling’)
2. An explosion of new treatment and diagnostic possibilities
3. An ageing population; and
4. Increasingly sophisticated and demanding forms of consumerism

Building and using strategic scenarios is one way of helping leaders explore possible ways of coping/thriving in the light of these drivers. Hopefully NHS organisations can use the scenarios to help them improve the far-sightedness of their local strategies. Essentially by:

1) mentally immersing 'strategists' in the 4 future ‘worlds’ that depict, in differing ways, how English Healthcare and Wellbeing systems might evolve through to 2020; and

2) subsequently ‘returning to the present’ to discover a) new or sharper insights into what strategies might be appropriate over the next few years or b) new insights into how robust existing strategic intent is and what conditions might trigger it being re-thought. 

Anyway, we will see, as local Trusts and PCTs start to use them. 

nhs

strategic scenarios

Last week I facilitated a workshop for Self-Care leads working in PCTs and Trusts throughout a SHA geography. It was an enjoyable event and quite a few interesting insights were generated.

However the big bonus for me was the chance, whilst preparing, to reacquaint myself with the work of Richard Normann. Richard, who sadly died in 2003 aged 60 was, I think, the guy who first articulated termed the phrase co-production of value - where more value is created through changing the relationship between service offerer and service receiver - He suggested that this ought to be a core 'business logic' for succesful service organisations.  If you want to get into Richard's work the most accessible book is his first Service Management: Strategy and Leadership in the Service Business.

My preparation led me to one of his last books; Reframing Business: Where the Map Changes the Landscape. In a section summarising the disctinction between organisations that 'relieve' customers and those that 'enable' them, Richard has a list of useful questions that an organisation could ask itself inorder to improve the efficiency and effectiveness of the customer.

Many of these questions seem appropraiate to healthcare organisations seeking to think through how 'self-care' opportunities might be developed further. Richard's questions include:

1. Can the timing of demand be influenced?
2. Does the customer have spare time while he is waiting?
3. Do clients and contact personnel meet unnecessarily face to face?
4. Are contact personnel doing repetitive work which the customer could do himself, with customer operated machines?
5. Can the customer be given an opportunity to choose between service levels?
6. Can customers so more work for each other, or use the resopurces of third parties?
7. Do the clients sometimes try and 'get past' the contact personnel and do things themselves? Could that interest and knowledge be better utilised?

If the self-care 'movement' is to realize it's potential then it really needs to begin to affect core operational processes of Trusts and PCTs. And if this is the goal then these are exactly the kinds of questions therfore that NHS service designers and strategists need to give serious consideration too. Funnily enough, this kind of 'hard' thinking seems to be largely absent from DH self-care material.

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self care

richard normann

I facilitated a workshop last week for a PCT that was seeking to develop new insights into its' emerging strategy. One of the 5 strategic intents in the draft strategy was 'to reduce health inequalities within the local population'. No surprises there. After all, most PCTs espouse this ambition although admittedly a few do go further and articulate some goals about the extent, nature and speed of the reductions they seek to help achieve.

Things got more interesting however when the Director of Public Health reminded people that only about 20% of the local population had what most people would consider to be relatively poor health status.  Mmmmn, so what part of the PCTs new strategy spoke directly to the 80% of local people who were quite healthy?....a bit of a silence followed..... Well, perhaps the 80% would be very happy just to know that the PCT was really focused on helping the 20% 'close the gap' was one suggestion.....Mmmmn not so sure about that.

Eventually the idea of creating a PCT strategy that related, in different ways, to different segments of the local population began to take hold. We all knew this wasn't rocket science but we all also knew that, for some reason, it was not an approach to strategy making that has happened to-date.

Now we could get into some interesting questions: How best to segment? What to focus on for each segment? How to operate internally with this more layered mindset? Let the strategy making begin......

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strategy

Does your PCT/Trust have it's own brand or does it still hope to rely on the national NHS brand?

Brand tags is a great idea for a site. Just react to the brand and jot down the first word that comes into your head. Then see what other people have said.

If you're going to create a Trust/PCT micro brand what word might people jot down in the brands tag game....safe, modern, friendly, haphazard, innovative, caring, mistakes, compassionate, knowledgeable, paternalistic, informing, reassuring, helpful?

p.s. You can only have one!  

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brands

UK healthcare

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

nhs

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

open space

nhs

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)?

nhsdecision makingthinkingGPs

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.

nhs

web 2.0 health

Here’s a good 2 hour process for helping your department collectively review the year and celebrate and learn from successes. It’ll work, with a bit of tweaking, with up to about 40 people.

Set up’s very easy. You just need:

1. A bunch of post-it notes and nibbed marker pens;
2. A long wall chart, with 3 horizontal rows, about 30 cms apart. Divide the wall chart into 12 equal chunks (1 for each month of the year just gone).

The process is pretty easy too:

1. Put people in groups of 5 (as mixed as possible) and invite them to take 20 minutes to identify up to 10 key world events in 2007 and jot them down, each one on a different post-it note;
2. Get all the groups to post their ‘stickies’ at the same time on the wall chart, putting each one in the time slot in the bottom row – clearly labelled ‘World Events 2007’. Give people a few minutes to look at all the events the groups have identified;
3. Repeat the process, but this time ask the groups to identify up to 7 key work achievements in 2007. These can be achievements that people in the group feel they have been personally involved with or they can be achievements that others’ in the department have mainly brought about. Again, invite people to post in the appropriate row and give them everyone a few minutes to review all the new post-it notes;
4. Repeat the process yet again, but this time invite people to jot down one or two personal highlights each from the year, outside of work. e.g completed 10km run, moved house, son graduated etc.

Once all 3 rows of the wall-chart are populated with post-it notes, invite all groups to take 30 minutes to consider these 2 questions:

1. What, if anything, do our work achievements have in common? (Perhaps they have been led or initiated in a certain way? Maybe they all have clear deadlines? Maybe they were undertaken by teams that already existed or maybe by teams formed specifically for that purpose?).

2. How might we increse our chances of being even more successful in 2008?

Finally, have a 10 minute ‘shout-out’ where each group must make no more than 3 suggestions related only to the last question. Note the suggestions and agree how they are going to be considered further.

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review process

learning