The Changing NHS

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!  

nhs

brands

UK healthcare

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

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

Somewhat belatedly, I’ve just read the interim Darzi report, called ‘Our NHS, Our Future’, published earlier this month. The report recommends a range of actions intended to help the NHS move, during the next 10 years, from an improving system to a world class system.

The recommendations fall under 5 headings and these headings are suggested as the cornerstones of a new Vision for the NHS over the next 10 years. They are:

• A Fair NHS (improved access for disadvantaged groups, increased productivity, good outcomes for all etc)
• A Personalised NHS (more integrated care, more dignity, choice and personal control for patients, improved consumer responsiveness and access again!)
• An Effective NHS (faster adoption of new technologies / innovation, more integrated and evidence-based care pathways, a sharper focus on outcomes achieved etc)
• A Safe NHS (stronger regulatory powers to inspect and intervene, MRSA screening on admission, financial penalties and incentives linked to cleanliness of Wards etc)
• A Locally Accountable NHS (a clearer and more streamlined process for effecting big service changes, better leadership more often from clinicans and possibly a new/revised NHS consitution)

You can get hold of the interim report here (58 pages, pdf).

Stage two of the review, runs from now to June 08 and is more devolved in nature. Basically each Strategic Health Authority area has been instructed to set-up clinical review groups to make detailed recommendations about the future shape of eight areas of activity. These are:

• Maternity and newborn care
• Children’s health
• Planned care
• Mental health
• Staying healthy
• Long-term conditions
• Acute care
• End-of-life care

My guess is that given the membership and focus guidance given to the clinical review groups, the sum of all this work will add to or strengthen the recommendations associated with An Effective NHS in particular.

My initial reaction to the interim report is:

1. Overall, the report is clear and contains a number of very sensible recommendations, especially in relation to access to primary care services
2. The Locally Accountable NHS element is the weakest by far. There is nothing very exciting or visionary here with regard to the NHS’ relationship with local government or local people. Will the NHS ever be brave enough to seriously explore options and ideas in this regard?
3. The Personalised NHS element of the Vision, if pursued vigourously, is likely to conflict directly with elements associated with A Fair NHS and An Effective NHS. Under Blair I’d have expected the tensions to be resolved in favour of a more personalised NHS, but now I’d go the other way and suggest that ultimately the personalised element of the Vision will be ‘held in check’ in-order to allow the other two elements to take centre stage, especially the ideas associated with a Fair NHS. That’s what defines Brownism in my opinion.
4. Because exploration of funding options was ruled out before the review started, there are some big questions left untouched by the review process, especially in regard to how the extension of personal-budget holding might ‘play out’ over time.
5. The idea of a new/revised NHS constitution is potentially an important part of the process that could open-up a much needed national debate about the kind of health and wellbeing system that might benefit the country in future. Let's hope it does not, instead, turn into a self congratulatory 60^th birthday present.

What do you think about the interim report?

Welcome to my 3rd Words of Wisdom post -  where I share favourite posts I've seen over the last couple of months or so. The first two WoW posts are here and here. 

I hope this selection provides some ‘food for thought’. In no particular order:

Mark Wilkinson is Chief Executive of Central Lancashire Primary Care Trust (PCT). That's Preston and nearby to you and me. Mark is a new blogger! It’s good to see NHS CEOs reaching out to people / their members in such an open way. Maybe Mark will start a trend? His blog is called Mark's Blog and Banter

PauLevy is CEO of Beth Israel Deaconness Medical Center in Boston Massachusetts. A recent post that caught my eye is this one – Teamwork Wins Against VAP (ventilator associated pneumonia). Teamwork saves 96 Lives might be a better title;

Charging money for things (even at a very low rate) really does change, quite dramatically, how people perceive services and products. Seth Godin relates how IKEA started charging 10 pence for shopping bags and consumption reduced by 95%. Maybe there is a useful future for co-pays in the NHS?

ScribeMedia have put together a fantastic short video chronicling A Brief History of Medicinefrom witches and leeches to Web 2.0. health communities. Produced to show at the recent Health 2.0 - User Generated Conference in San Francisco. Treat youself and watch four minutes and 30 seconds of brilliant stuff - and no I didn't go to San Fran either!

Susan Abbott at Customer Experience Crossroads gave me a ‘aha moment’ with her post about Curves , a new fitness centre franchise, designed and run for people who hate traditional gyms and fitness centres. Now maybe this is the sort of experience that GPs ought to be 'prescribing' for people who need to lose weight? Does this kind of fitness centre experience already exist in the UK?

RateMDs , DrScore and VIMO are all sites where Americans can rate their doctors. Now how long does it take for this stuff to travel over the pond! Thanks to David E Williams at The Health Business Blog for posting about this first time around;

David Maister has a great idea. If you want to be a more agile organisation then break out of the annual cycle and review plans on a 3 monthly basis. Read it here.  

by Dr Jonathan Shapiro - Guest Blogger

Payment by Results (PbR) was introduced into the NHS to ensure that hospital activities (it was never about results, only activities!) could be linked to their costs. The idea was that hospitals would have to justify their actions to their paymasters (initially Primary Care Trusts, but ultimately Practice based Commissioning (PbC) clusters generally run by local GPs), so that the system could assure itself that expensive hospital services better matched the needs of the population, rather than the established tradition of hospital supply determining patient demand.

The system was predicated on having strong commissioners, not only at the strategic population based level (the intended role of the PCTs), but also at the more operational, individually focused level. Here clinicians (usually GPs) were intended to use their working knowledge both of individuals’ clinical needs and of local hospital providers’ strengths and foibles, to case manage their patients through the system effectively and efficiently.

So far, so sensible, but given that the notion was imposed by the Department of Health, and merely formalised the existing referral control mechanisms that had been in place since 1948, it begged the question of how to persuade the referring GPs to use the new tool, rather than ‘playing’ or simply ignoring it.

It was clearly not ‘owned’ by the GPs, and did not offer them any obvious personal or clinical advantage, but it did have the potential to introduce more control over hospital activity, itself potentially a powerful motivator.

Unfortunately, attempting to shift the locus of control over hospital activity to PbC has fuelled resistance from PCTs as well as from hospitals. A number of PCTs are resisting the introduction of effective PbC by diluting its key levers; either passively (‘PbC will work more effectively for you doctor, if we co-ordinate all your intentions’) or more actively (‘we can’t afford to let the GPs decide referral patterns, they’ll only do what’s in their own personal interests’), PCTs are finding ways of not letting go of the operational aspects of commissioning (what used to quaintly be called ‘purchasing’ in the early 1990s).

Consequently, PbC is simply not happening to any significant extent; you may argue with this point, but the reality is that PbR is still racing ahead, that hospitals are generating income by their activity, and that the intended brake on the system, PbC, is simply not strong enough or widely placed enough to slow down the express train of hospital activity.

The NHS has a tradition of muddling through (elegantly or otherwise), and in the absence of overt, clear controls, more opaque, Machiavellian, mechanisms will emerge, that are likely to reflect established patterns of power and patronage, rather than the real health needs of the population. If PbC is not clarified and strengthened quickly and radically, then the potential powerful, positive tension between PbR and PbC will be lost, to be replaced by a regression to an ineffective and unpopular mean that will help nobody, and further diminish the reputation of the public sector as a system that is capable of defining and managing its own destiny.

nhs

practice based commissioning

payment by results

If Foundation Trusts are to thrive then they need to be capable of building and sustaining a culture where clinicians and managers are confident, ambitious, competent and action-orientated. One aspect of this challenge is the extent to which Trusts can excel at spotting and nurturing potential future leaders from within their own ranks.

If a NHS hospital Trust employs, say, 4000 staff, then surely at least 100 future leaders are there somewhere? After all, that’s just 2.5% of current staff.

Does your Trust do this and if it does, do the Trust Chief Executive and the HR Director meet regularly to review how people in the ´group of 100´ are doing?, to plan what opportunities to offer people next? and to identify succession paths? 

If your Trust does invest in growing its’ own future leadership, what criteria is used to identify people? Perhaps your organisation uses the Leadership Qualities Framework, promoted by the NHS Institute for Innovation and Improvement?

Skip from Be Excellent™ has posted a list of eleven criteria for spotting future leaders, drawn from Ram Charan’s book: Know-How: The Eight Skills that Separate People Who Perform From Those Who Don’t

1. They consistently deliver ambitious results.
2. They continuously demonstrate personal growth, adaptability, and learning better and faster than their peers .
3. They seize the opportunity for challenging, bigger assignments, thereby expanding capability and capacity and improving judgment.
4. They have the ability to think through the business and take leaps of imagination to grow the business.
5. They are driven to take things to the next level.
6. Their powers of observation are very acute, forming judgments of people by focusing on their decisions, behaviors, and actions, rather than relying on initial reactions and gut instincts; they can mentally detect and construct the “DNA” of a person.
7. They come to the point succinctly, are clear thinkers, and have the courage to state a point-of-view even though listeners may react adversely.
8. They ask incisive questions that open minds and incite the imagination.
9. They perceptively judge their own direct reports, have the courage to give them honest feedback so the direct reports grow; they dig into cause and effect if a direct report is failing.
10. They know the non-negotiable criteria of the job of their direct reports and match the job with the person; or if there is a mismatch they deal with it promptly.
11. They are able to spot talent and see the “God’s gift” of other individuals.

Personally I think a list of eleven criteria is too many to ‘operationalise´ successfully. Instead I would focus on the five criteria that I’ve put in bold font. Also I’d add a sixth, along the lines of:

• They consistently demonstrate a strong sense of wanting to serve others, especially patients.

What do you think to this list? Does your Trust have a way of identifying and nurturing potential future leaders? Does it draw equally from clinical and managerial ‘gene’ pools?

Thanks to George Ambler at The Practice of Leadership for drawing my attention to this issue.

Steve

nhs

leadership

The NHS currently has 65 Foundation Trusts (FTs), employing approximately 220,000 staff. The idea is that these organisations, usually secondary care acute providers, freer from central control, will be both more effective and more active 'players' in helping to reshape the NHS provider landscape.

In an earlier post I talked about 4 strategic mindsets that FTs might hold. I’ve now 'polished this up' a bit and so I'm re-posting, as I think the mindsets, as described in this post, are more accurate.

The 4 mindsets are not all mutually exclusive but I wonder how well a FT can pursue more than one of these successfully at the same time. They are as follows:

1. Compete with ‘Look Alikes’
This mindset is often the most prominent one amongst managers at the outset of a Trusts’ journey to FT status. Usually, by the time the application process is complete, views have migrated to number 2 below, but some still retain this mindset and many may well return to it once they feel more confident. Here, the FT continues to seek to provide a comprehensive range of local services whilst also growing quickly by winning market share from neighbouring acute trusts that are believed to be in a weaker position in certain service lines. To do this well it needs to act quickly, before other Trusts get their act together and before PCTs become better at ‘market’ management.

2. Refocus on Core Business
This is the most common mindset to be adopted once a Trust becomes a FT. Driven, in large part, by fear of becoming financially unstable and thereby falling foul of Monitor, the independent regulator, this type of FT quickly decides to stop pretending that it can be good at everything and seeks to re-focus on what it is good at or can produce a surplus from. To do this well it needs to be single minded in seeking to earn a deserved reputation for providing certain services that might, ultimately, lead to higher volumes of core business, possibly via brand extension into other FT and private sector facilities.

3. Be Entrepreneurial
Here the new FT wants to get off the mark quickly by enthusiastically seeking out large numbers of opportunities for creating or contributing to new services and/or niche businesses, often beyond its current portfolio of activity. ‘Let a thousand flowers bloom’ might be the motto. Managers within this kind of FT operate within an earned autonomy regime and, even if only a few ideas are ultimately fully supported, this should quickly give the Trust an interest in several new ‘businesses’. Some of these can then be sold off as going concerns, raising significant income. Ultimately the Trust will probably become a holding company with several operating divisions or it may merge with other FTs.

4. Dive Deeper
Here, the FT believes it can use its resources and talents to help the local health and social care economy become more coherent and efficient. Accordingly, it seeks to exert more influence within the local primary and social care sectors. In its most developed form this mindset suggests a high degree of vertical integration, with groups of GP practices contractually aligned to the FT and community service staff and possibly some local authority staff employed. Ultimately this mindset suggests an FT will have an interest in investing in new sub-acute community-based services, especially those that serve older people with complex co-morbidities, perhaps in partnership with new private sector providers.

Do you recognise these mindsets? Are there others around?  To what extent do you think a FT successfully pursue more than one of these mindsets at the same time?

Steve  

nhs

hospitals

strategy

Imagine you are a newly appointed CEO of a Primary Care Trust. It’s your first CEO post and you are keen to earn a deserved reputation as being innovative, credible and far sighted.

One of the most important issues on your new To-Do list is how best to engage with the Government’s flagship White Paper ‘Our Health Our Care Our Say’. The Government clearly wishes to encourage “more effective health and social care provision outside of hospitals”. More specifically, it wishes to encourage “more personalised care, services closer to people’s homes, better co-ordination with local Councils, increased patient choice and a focus on prevention as much as cure”.

You know that the Government will initiate a lot of activity itself (too much maybe) and your organisation will need to play it’s part in helping these central initiatives take hold ‘on the ground’ – but beyond this – you're really  keen to make your own mark by initiating local change projects that succeed in bringing about concrete and welcomed changes that are in keeping with the spirit of the White Paper.

You call together a few friends and brainstorm some ideas for getting started. Ideas include:

1. Ask an acute Trust CEO to lead a planning group to identify 3 great initiatives your organisation should support?
2. Bring 25 GPs and 25 acute specialists (paediatricians, geriatricians and general physicians) together for a day and ask them to come up with at least 10 ideas before they leave the room?
3. Hold back 2% of your organisation’s contracting income and only make it available to support new or redesigned services that are proposed by joint groups of clinicians and social care professionals where at least 50% of the membership comes from social care.
4. Host a quarterly 'Innovations Breakfast' – where you advertise for / invite private and not-for- profit companies with good ideas to come along and pitch ideas informally to you and senior managers and local GPs 
5. Find 10 ‘super-patients’, give them lots of support and ask them to redesign a key service (Super-patients = articulate, knowledgeable, motivated and time rich)
6. Invite the Local Authority to nominate someone to review all Commissioning decisions and insist that they block at least 3 proposals.

So, what's next? Tell me, how did you get to win that Award?

Steve

www.stevepashley.co.uk

nhsinnovationprimary care

The Healthcare Commission recently released the results of its’ annual survey of 128,000 NHS staff across England.  According to the Guardian Society,only 42% would be happy with standards at their own establishment. A quarter said they would be definitely unhappy and 34% did not have a view. Just under half the staff in hospitals said care of patients was their trust's top priority, but 25% said it was not.
 
However, job satisfaction levels, although slightly lower than last year, remain relatively high. 68% of acute trust staff and 75% of staff in primary care trusts reporting that they were generally satisfied with their jobs.

On a related note, I recently attended a seminar where the CEO of a USA based not for profit healthcare system explained that his organisation’s mission was to ‘delight’ patients.  He claimed that a key reason why his organisation was successful in this regard was because his pay, to quite a large extent, was dependant on the Board judging that the organisation had achieved a key metric concerning patient satisfaction.  Basically every in-patient is surveyed, after discharge, and asked whether they would recommend the hospital to a friend.

That got me thinking. Currently, according to the Department of Health’s Pay Framework, (download from here) it seems English PCT Chief Executives earn a basic salary between £100k - £142k pa and have the possibility of an annual  performance bonus payment if the organisation is deemed to have met its’ financial control target and the CEO is judged to have performed above satisfactory in a four point scale. I couldn’t find the corresponding figures for Acute Trust Chief Executives – have you ever tried to search the DH website! -  though in 2005 the BBC reported on an IDS survey that claimed the average English Acute Trust Chief Executive was earning a basic salary 18% higher than a PCT Chief Executive.

Given the general direction of NHS policy, more market power in the hands of patients and more non-price related competition amongst providers, perhaps we ought to see the focus of these incentive schemes shift, away from financial control and general CEO performance, towards something more tightly focused on ‘delighting’ patients?

1. Would NHS Trusts really focus more attention and energy on ‘delighting’ patients if their CEOs had this kind of arrangement in their contracts?
2. Are CEOs sufficiently influential internally and capable of resisting other, potentially competing priorities that are externally proposed?
3. Are Chairs of Foundation Trusts likely to have more of an appetite to introduce such incentives as part of their duty to manage the performance of their CEOs?
4. If, yes, would a scheme be more effective if it meant a CEO might lose a percentage of their basic salary rather than gain a additional amount over and above a guaranteed minimal and if yes, what % of salary would need to be ‘at risk’ in-order for CEOs to make delighting all patients their number one priority? 2%, 5%? 10%?
5. Could a simple, measurable and meaningful patient-focused metric be identified, stuck with and used?
6. Should we consider introducing a similar scheme for Medical Directors?  Alan Maynard, Professor of Health Economics at York University has recently floated this idea for all GPs and Consultants.
   

You manage what you measure – hmm - you manage what you get paid for might be more accurate?

Steve
www.stevepashley.co.uk

paynhschief executives