The Changing NHS

A friend rang me today asking for a favour. She is the Chief Exec of a large public service organisation (not in the NHS) and was due to run a 3 hour session next week with her direct reports. The meeting was to 'get a fix' on what kind of organisation they want to become over the next 5 years. The vision thing if you like. Did I have any ideas?

This is what I suggested:

Imagine it’s 5 years in the future (2013) and org x has become the kind of organisation you really want it to become. It's been an incredibly successful 5 years. As a group, pick out 6 or 7 questions from the list below that appeal most and then, in turn, tell colleagues what the answers are. Capture the most salient or intriguing points made on a flipchart.

1. Who are the main stakeholders of org x in 2013?
2. How do you work with them?
   
3. How do you produce value with them?
   
4. What are the most influential trends in your industry?
   
5. What is org x's image and reputation?
   
6. How and with whom do you compete?
   
7. Who are your major customers now and how are they helping to make the organisation succesful?
   
8. What is org x's unique contribution to the world?
   
9. What is the most important impact your organisation has on the local economy ?
   
10. How do you make money?
    
11. What does org x look like?
    
12. In what ways is org x now a really great place to work?
    
13. Why do customers love org X?
    
14. What is org X's most significant contribution towards making region y a great European destination?
    
15. Why do you personally love working for org x?
    
16. When your kids ask you what you do for a living what do you tell them?

• succinct;
• unexpected;
• seen as credible; and
• has a big emotional pull

Now, return to the present and take a hard look at org x as it is now. How do you need to change? List the 5 most important changes you, collectively as a team, need to help the organisation to make.

What do you think about this process and the questions? What questions did I miss? Which ones do you really like and why?

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vision

 

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. 

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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

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