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?

nhs

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. 

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.

nhs

self care

richard normann

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?

nhs

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? 

nhs

Darzi

implementation

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.

nhs

review process

learning

I ran another 24 hour workshop last week as part of the work I’m involved in to help a bunch of NHS managers and doctors sketch out a set of ‘edge of plausibility’ scenarios for health and wellbeing systems in 2020.

I’ve talked before about this work and especially about the difficulty people often have in contemplating futures that differ from the logic of current strategic intent. That’s still the case, although the process is now better and people consequently get more help to ‘let go’ of the present’.

The starting point for constructing the scenario set is consideration of 28 ‘high impact / high uncertainty questions’ and I thought, in no particular order, you might like to see what they are:

1. What might the first 10 years of our lives be like?

2. What might the last 10 years of our lives be like?

3. What impact might new medical technologies have?

4. What impact might genetics and new pharmacological developments have?

5. What might happen if individuals became real consumers of healthcare and wellbeing services?

6. How might healthcare and wellbeing systems be paid for?

7. What might a prediction, prevention and promotion system look like?

8. How might competition and collaboration co-exist?

9. What form might leadership of healthcare and wellbeing systems take?

10. How might lower levels of social cohesion impact on healthcare and wellbeing systems?

11. How might information technology impact on healthcare and wellbeing systems?

12. What might be the ‘psychological contract’ between employers and their workforce?

13. Where might entrepreneurialism lead?

14. How might a more informed and knowledgeable society change healthcare and wellbeing systems?

15. What might happen if the search for better outcomes really drove behaviour?

16. What might happen to the balance between care and cure?

17. What might a truly efficient health and wellbeing system look like?

18. What might be different if all local stakeholders were facing ‘in the same direction’?

19. What might the future landscape for healthcare services look like?

20. How might climate change impact on healthcare and wellbeing systems?

21. What impact might the increasing globalisation of economics have?

22. What might be different if the priority was to reduce health inequalities?

23. What might be different if the priority were to maximise everyone’s health potential?

24. How might accelerating population migration impact on healthcare and wellbeing systems?

25. What key new roles might emerge?

26. What might be the impact of new diseases?

27. How might politics exert more of an influence on the nature of healthcare and wellbeing systems?

28. How might strategic commissioning evolve?

What you make of these questions? Do these seem like the best big questions to you? Am I missing some?

nhs

scenarios

healthcare

I thought I'd try out this new Sketchcast technology to show you an exercise that I sometimes use with groups of NHS managers and clinicians to open up discussion about what the future shape of healthcare might look like.

I hope it's useful to you.

nhs

change management

I had an interesting chat with a clinical psychologist the other day. We were talking about what a really successful NHS might look like in 10 years time. A lot of the conversation was about the need for people to accept more responsibility for their own health status in general and for the NHS to become much better at helping people make specific changes in relation to diet, exercise, drinking, other risky behaviours etc.

In passing the clinical psychologist said…” the trouble is the NHS has 1.3 million staff but only about 25,000 know how to change people’s behaviour.”

Do you think this is anywhere near true? And, if it is, how many of the 1.3 million ought to be competent at helping people to change their behaviour?

• All GPs, District Nurses and Health Visitors – well yes, obviously
• What about all the therapists – again almost certainly
• Well what about Ward based nurses - again yes
• Doctors? Certainly all the medics. What about surgeons, do they need to know how to change people’s behaviour? - quite possibly
• Managers? - steady on their old chap. Next thing you know managers will be dispensing drugs and ordering tests!

The model I’m most familiar with is called The Stage of Change Model. At its’ simplest, this model suggests that people could be at one of five stages in relation to changing their behaviour (and then hopefully, their attitudes).

1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

The basic idea is to first identify what stage a person is at in relation to making an important change in behaviour and then to help them move through to the next stage. Each stage requires particular support and intervention. Eventually, hopefully, they'll make it through to and remain in the final stage. There’s a bit more to it and you can learn more about this model here – but that’s the gist of it.

Hopefully, whatever the number is, over the next few years many more people will get much better at helping people change their behavior. Otherwise I guess we could ask a Government to ban every unhealthy behaviour we can think of. That might just do it!

nhs

behavior change

change model