The Changing NHS

 

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

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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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? 

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Darzi

implementation

How do non –executive directors add value to strategy making in the NHS? Last week I heard two quite contrary views about this, both expressed by senior NHS managers.

1. Constructive Critics

In the first view, strategy making is seen very largely as the responsibility of executive teams. Non-execs don’t have the time or knowledge to engage in this process. Instead they can best add value by reviewing and constructively questioning the strategy (once largely formed). They might help the executives to ‘fine-tune’ around the edges but it's unlikely that they would push for a strategy that the executives were unwilling or reluctant to contemplate and in any event, by the time they are involved it's too late to have a fundamental rethink!

2. Active Shapers

In the second view, non execs are seen as central to the strategy forming process. Because they come, largely, from ‘beyond’ the NHS they can often challenge assumptions and values-led suppositions about what the strategic intent ought to be. This is especially true for non-execs who have spent time in customer facing large private businesses. In short, they can help executives to think way beyond their 'comfort zones’ and encourage the crafting of new strategies that enables the NHS to more fully enagage with the world as it is rather than how it ought to be.

So, here we have 2 quite different views about how non-executives can help NHS organisations form far-sighted and effective strategies. I suspect the first view holds sway in most places but perhaps the second is the one which holds out the prospect of creating most value.

Do you recognise the two roles I've described and what are your non-execs, constructive critics or active shapers?

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non-executives

strategy

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?

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scenarios

healthcare

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?

One feature of a new confident NHS, an NHS capable of creating its’ own future, will be organisations that are capable of making strategy for themselves.

Too often, what NHS managers see as strategy making is really a sort of meta-tactical discussion. The thing being explored will probably happen – its’ really just a question of how it gets implemented. Important yes, but not really making strategy is it?

If you don’t believe me try using the impact/uncertainity grid (shown above).

Brainstorm all the big issues that face your organisation over the next 10 years and then place the issues on the grid. My guess is that most of the issues you spend time ‘strategizing about’ are in the bottom right hand side of the grid. Yes, they are potentially very impactful but, relative to some other big issues, they also are much more likely to happen. It’s really just a question of how they are implemented.

What about the big issues in the top right hand side of the grid? The ones that are less certain to happen. Do you talk much about these issues? If not, why not? Are they in the ‘too difficult’ box? Or perhaps you think they’re in the ‘not something we can do anything about’ box?

However, if you’re going to become an organisation that really creates its’ own future then your going to have to get comfortable exploring these less certain possibilities.

Steve

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strategy