The Changing NHS

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

by Jeanne Hardacre - Guest Blogger

The paperback version of ‘The Fight of My Life’ has just been published. It is Barbara Clark’s personal story of how she won the right for all women in the UK to receive Herceptin to treat certain types of breast cancer.

I was invited to work with Barbara Clark last week in Westminster, where dozens of women with personal experience of breast cancer met with their MPs to press for further improvements to breast cancer services and treatment. These women all form part of an advocacy and campaigning network for a national breast cancer charity called Breakthrough.

I ran workshops aimed at helping the charity’s campaigners better understand commissioning and the health economics behind why and how some treatments are funded – and others are not. Of course, NICE was in the room. So were clinical representatives, academics and health economists. Senior politicians attended. Two large pharmaceutical companies joined in the discussions.

But there were no NHS managers to be seen. Two dozen PCT Directors of Commissioning had been approached, but no replies were received.

For those of us inside the NHS, there are, of course, lots of reasons why such events are not deemed a management priority. But from the outside, for many patients and health campaigners, NHS managers often seem a faceless set of bureaucrats working behind closed doors, who are difficult to engage in dialogue or discussion.

Health lobby and campaigning groups are raising their game. People who take on the NHS, NICE and the Courts – and win – know about influencing and will only get better at it. They have shown that their work can lead to policy change, with a direct impact on PCT decision-making.

There is lots to learn from the lobbyists. They are experts in their area of interest and are eager to engage with NHS organisations. But their frustration with the NHS ‘closed door’ can lead to more negative press for NHS managers. For PCT commissioners, it could well be an hour well spent to sit and talk to local health campaigners a couple of times a year. Keeping your ear to the ground can keep you ahead of the game.

And just think, how much more civilised and productive to be influenced over tea, biscuits and conversation than through headlines in The Sun followed by a court ruling.

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herceptin

primary care trusts

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.

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practice based commissioning

payment by results

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

I was running a half-day workshop last week for a newly formed PCT. About 50 people were in the room, mostly managers but a few GPs and local Councillors as well.

We spent the first couple of hours exploring what it meant to be a ‘Strategic Commissioner’ and how we needed to act differently than we had whilst working in the 3 previous PCT organisations.

All was going well. We had generated and prioritised a list of things to do ‘more of’ and ‘less of.

The top 5 ‘mores’ were:

1. Taking difficult decisions about priorities and shifting resources accordingly
2. Identifying and addressing unacceptable provider performance
3. Listening to clinicians (primary and secondary together wherever possible)
4. Incentivising providers to address specific service aspirations
5. Creating a strong public profile

The top 5 ‘lesses’ were:

1. Trying to implement all national guidance in good faith, regardless of local priorities and workload pressures
2. Acting as if we believe we are a junior partner in the local health economy
3. Spending time in face to face meetings with colleagues within the PCT
4. Complaining about acute provider behaviour
5. Writing reports

We then put some time aside to discuss these lists. I tried to get us started by asking what I thought was a straightforward question about the ‘more of’ list. I asked “Why do you think you weren't all that successful when operating in the previous PCTs?”

We didn’t get further than item one – taking difficult decisions about priorities etc - and the answer stopped me dead in my tracks. “We don’t feel we have the legitimacy to do this”.

If true, what is to be done?

How best to create a confident, authoritative culture where people are proud to help take difficult decisions?

Steve

www.stevepashley.co.uk

According to the Health Service Journal, David Nicholson, NHS Chief Executive, recently set out 5 priorities for Primary Care Trusts(registration required to view). These are:

1. Leadership and engagement in and with the local community
2. Accountability
3. Having a more business like approach (whatever that means- answers on a postcard please!)
4. Being data driven
5. Having an ambitious strategy

This little list could keep me in posts for a month, but I was particularly struck by the first priority, because it reminded me about Open Space. I first came across Open Space when Barbara Bunker and Billie Alban included it as one of eleven Large Group Event (LGE) methodologies described in their book Large Group Interventions: Engaging the Whole System for Rapid Change

Many NHS organisations have since used Open Space Technology to help them ‘engage with stakeholders’ – though usually via  one-off events rather than as a way of democratising decision making and getting work done on an ongoing basis. If you’re thinking of using Open Space read Open Space Technology: A Users Guide. Also go to Open Space World for great resources and tips.

Within the NHS, Open Space has become the most widely used of the LGE methods. Probably because:

a) It’s relatively easy to do – for example no content preparation is necessary;

b) Participants enjoy it – people enjoy the freedom to self-organise and the energy levels are usually very high; and

c) Managers see it as an ideal method for getting something started with a ‘bang’ (we do a lot of getting things started in the NHS!).

Last week I came across a really interesting development. Gabriela Ender has created a really clever online collaboration version of Open Space that can be 'rented’ by the hour!

Initially I was sceptical, but then I took the tour (available top left of page) and was very impressed. This online version could be great for international collaboration and for ongoing collaboration when community members already have good levels of trust established.

Perhaps the online version is a tool that NHS Foundation Trusts can use to keep engaged with their members?

Perhaps PCTs can use it to help managers engage on an ongoing basis with various public and clinical communities in-order to generate and implement ambitious strategies – addressing two of Mr Nicholson’s five priorities at the same time!

Steve

www.stevepashley.co.uk

I was chatting to a PCT Chief Executive the other day. We were just ‘shooting the breeze’ really when the conversation turned to the new ("much more strategic") PCT and the design of new management arrangements

Like many I suspect, this guy had split the new PCT into 3 parts: Strategic Commissioning, Provider Services and Support Services. He readily acknowledged that the Support Services grouping was a temporary solution, buying time until larger agencies serving more PCTs could be created and he was very clear that Strategic Commissioning was to be the core focus for the new PCT. It was the Provider Services division where things were much less certain.

A Director had been appointed to lead the Division. Fair enough. But what type of brief was this person to have? What was to be their key objectives through which they could be held to account?

Until recently this was going to be fairly clear. It was to prepare the constituent services within the Division for break-up over a 2 year period? Moving services out of the PCT via a juicious mix of arrangements including the formation of a social enterprise, possibly a management ‘buy-out’ and a transfer to the local authority and possibly to a local hospital FT.

But since the Government has signalled interest in exploring the desirability of Community FTs (it starts on the bottom of page 26!) things have become more complicated and a second option now presents itself. Namely to prepare the Division, as a whole, to become a free standing Community Foundation Trust.

However, there’s a bit of a dilemma here for the new Director of Provider Services. The leadership behaviours required to accomplish brief one are, in important respects, very different from what’s necessary to accomplish the second. The ‘break-up’ brief requires a leader to constantly signal that s/he is leading a temporary organisation and foster and sustain a climate of uncertainty within which people can be supported to quickly explore and become excited about new futures. Whereas the Community FT route requires a leader to focus much more on fostering a strong single identity, a clear sense of purpose and a disciplined focus on delivering key performance metrics.

Should she try and do both things at the same time? – I doubt it. Will she try to? Quite possibly.

Steve