The Changing 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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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)?

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What do you suppose the majority of acute Trusts are doing right now? Are they preoccupied with coping with PBR and getting their finances in-order, applying for Foundation Trust status and meeting more stringent waiting time targets? Definitely.

What do you think the ‘new’ PCTs are doing right now? Are they sorting out their new structures, wondering how best to create a more diverse supply side economy and designing new decision making processes with emerging PBC clusters? Quite possibly.

Are they jointly orchestrating processes that get relevant clinical communities together in-order to explore new ways of offering medical and diagnostic services? Probably not and that’s a pity.

Despite the fact that the OHOCOS White Paper was, in large part, about having another go at encouraging the movement of some services out of hospital into lower cost and/or more accessible locations I don’t see much evidence of this starting to take place yet.

From an acute trust’s perspective this omission is also a big wasted opportunity. If an acute Trust can shift its' mindset from ‘maximizing income by maximizing activity’ to the more enlightened one of ‘creating a sustainable future for itself and the local health economy’ there are big opportunities to be grasped right now.

It will be much better to engage with PCTS now, whilst they are still in a state of uncertainty about their purpose, priorities and preferred modus operandi. In change management terms, paradoxically, this time of uncertainty is also the time when there is most opportunity for creativity and innovation to flourish. This is when people are most open to new ideas and new ways of working.

Go on, pick up the phone, call your new partner and suggest a chat. Waiting until things have ‘settled down’ may sound sensible, but delaying will only make it harder to agree processes to achieve a mutually acceptable new service landscape!

Steve

www.stevepashley.co.uk

In May, Ministers will decide on the PCT merger proposals currently out to consultation. 303 PCTs are about to be merged together to create 150 ish 'new' organisations. Presumably this is because there is a widespread and strong belief that the ‘old’ organisations cannot get us to where we want to be, or at least, not in the timescales we believe we have and the new ones can. Fair enough.

However, in all changes of this type there is a Performance Lag when the ‘new’ organisation actually performs at a lower level than the old ones. This is because people need time to adjust to the technical aspects of their new roles, to learn to trust new colleagues and bosses and to cope with any negative feelings associated with believing they have ‘won out’ at the expense of ex colleagues. It’s also because important business systems and processes will need tweaking or fundamentally redesigning etc.

If you accept this, then a key question for organisational leaders and organisation development specialists is ‘How can our new organisation be helped to get up-to speed as fast as possible?’

I believe 5 things really matter. People need to:

1. feel that ex-colleagues who have not made it into the new organisation have been treated fairly
2. clearly understand the rationale for the merger and what is intended to be different as a result
3. feel they are meaningfully involved in taking decisions about the new organisation that will affect them most directly
4. be involved in analysing the various cultures of the ‘old’ PCTs organisations and deciding what aspects need to be retained or even strengthened in the new one
5. be able to collectively articulate a new set of core values and expected behaviours that are congruent with this desirable new culture

Anything else?

Steve

www.stevepashley.co.uk

I’ve read another policy document. Well ok, technically speaking, it was a report about a policy document, in the Economist of all places – a short commentary on Our Health, Our Care, Our Say: A New Direction for Community Services - bit of a mouthful that isn't it?

Who can argue with the goals – shifting some services to more easily accessible and lower cost locations, incentivising GPs to offer more convenient access arrangements and trying to encourage people to take more responsibility for their own health status.

Policy commentators will speak about the need to reform PBR and gain greater alignment of financial incentives and acute CEOs will remind us about how they don’t necessarily want to lead bigger and bigger organisations but just organisations that are sustainable. But what will the 30,000 NHS managers do?

My guess, and this is completely understandable, is that most will probably feel too busy already to do much at all. At least until someone announces that doing something is now a priority amongst the priorities or something is done 'to them'. This may be unfair, but I wonder if we would make much more progress on this ‘strategic shift’ agenda if a) organisations required managers to spend half a day each week for protected thinking time in a conducive environment with peers and b) managers could use this time to good effect?

One really good idea that can be actioned in a way that works well is almost always worth more than a hundred of hours of endeavour focused on the wrong issue or on a process that won't actually deliver very much benefit.

Writing this has reminded me of a workshop I attended several years ago where a friend, John Harries, led a workshop on approaches to problem solving. John summarised 12 different problem solving techniques and then asked us, in small groups, to pick one and try it out on a real work problem. All the groups chose the same technique – the reversal technique – possibly the name helped! Basically, you brainstorm what would be the absolutely worst way to tackle the problem and what would be the absolutely worst outcomes you can imagine. In effect, you ask yourself “what would be the crappiest ever way to do this”. Once you have stopped laughing and acknowledging that you are already doing most of these no noes, the next step is to reverse the approach, asking yourself, “So how can I address this problem in a way that ensures that I avoid all the things I’ve just listed”. It’s not a panacea but this technique is fun and gets people, quickly, into a better frame of mind for addressing challenges and more clearly seeing ways forward that might work well.

I wonder how much more progress we could make on the 'strategic shift' agenda if managers would routinely and unapologetically protect time to think through 'the what and the how' using approaches that take us away from 'business as usual'?

Steve

www.stevepashley.co.uk