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My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Is there any evidence of the political leadership needed to transform the NHS between 2015-2020?

Filed Under (Conservative party, Health Policy, Labour Party, Reform of the NHS) by Paul on 31-03-2014

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There have been some interesting responses to this month’s posts. It’s encouraged me to think about perhaps resuming for a month in the autumn and then again in March 2015. It’s been especially interesting over the last week to gauge people’s response to my attempts to challenge the gloom being spread about the pressure on the NHS by too many of NHS leaders.

In this last post for the moment, I want to try and think through how the current political leadership – that which might be in charge of the NHS in the period after the May 2015 election – can help make the necessary transformation.

And in thinking through the possibilities I want to introduce the fact that from tomorrow there is a new CEO of NHS England – Simon Stevens. Between 2001 and 2004 he was a close colleague of mine, and is a friend, so I wish him well. But too much expectation is being placed on the ability of one person to make everything happen. He can and will achieve a great deal – but no-one can do this on their own.

When Pete Seeger died in January one of the many brilliant sayings that were attributed to him was, “Be wary of great leaders and hope that there are many many small leaders”. To succeed Simon will need many many small leaders.

And I don’t know about you but it seemed to me that there was something really odd in what his predecessor David Nicholson said in an interview last week. He said he would give NHS England “5 out of 10”. Given that he ran the transition body that set up the organisation, was responsible for the hubristic change of name to NHS England, and then ran it throughout its life one wonders, if the organisation is not very good, just why is that?

But the rest of this post concerns the interaction between political leadership and the NHS.

There is near universal agreement between the two major political parties who will either form the next Government alone or will form the larger part of any coalition. (Incidentally we don’t yet have UKIP’s NHS policy but I’m sure that if you visit any Home Counties’ saloon bar on a Sunday lunchtime you will hear it there first).

Both the Conservative and Labour parties agree that:-

  1. There will be standstill funding. Money won’t go up, but it won’t go down either. (But by 2020, even if the money is still the same for the NHS, most other areas of public expenditure will go down so the proportion of public expenditure being spent on the NHS will rise considerably).
  2. There will be no new structural reorganisation. (phew!)
  3. There will be many more older people with co-morbidities who will need different and better care than they are getting at the moment.
  4. There need to be many fewer emergency admissions.
  5. There needs to be a rapid development of integrated health and social care.
  6. This new model of care will have a radical impact upon the existing models of health and social care.

They also know that these changes need to happen quickly, need to happen across the whole of England, and that given the rise in demand they will need to reduce the amount of money spent on each patient.

Now of course we don’t know what the manifestos will bring but at the moment, given the pledge that there will be no more top down reorganisations, the levers that are available to bring about these radical changes are limited to what they have to hand at the moment.

The problem with this is that none of the political parties really agree with the current organisation of the NHS and the existing levers for change and so none are at all happy with what they have to hand.

Let’s start with the Conservatives. We know that the current Conservative Secretary of State Jeremy Hunt voted for the Health and Social Care Act on many occasions and supported the reforms in Cabinet. He was lucky enough to be in the job of Secretary of State when all the reforms he had consistently supported came into effect. Few politicians enjoy such a luxury.

But, as we know, a curious thing happened during the time between the passage of the Bill and his having the opportunity to enact the reforms.

Over the intervening year he came to disagree with the central idea of his legislation, that the NHS should be run by a series of arm’s length bodies – separated from the Secretary of State.

Instead of following the core principle of the reforms – to liberate the NHS from Whitehall – he instead runs the NHS from his office (in, er, Whitehall). Most of the time he ignores the legislation he supported (and, it might be said, much of a decade of earlier legislation.)

You would have to spend a long time searching through his speeches to find any reference to the changes that he wants being made by the actions of the 211 clinical commissioning groups that his legislation established.

Let’s look at an example of what he might do if he believed in the legislation for which he voted.

A few weeks ago the Times uncovered the fact that over 150,000 older patients are moved around our hospitals in the middle of the night. If he used the powers in the legislation that he voted for, he would read the Times and think hard about changing next year’s mandate to NHS England to cover this issue. He would in turn talk about how CCGs should commission care from hospitals that did not involve such nocturnal movement of older patients.

Instead the anxiety that the Times headline immediately raises in him leads him to try and ensure the NHS acts differently.  Since he won’t do that by using the levers his reforms gave him, he has to resort to shouting at the NHS as loudly as possible.

And this will be the problem for the NHS if the Conservatives are in charge of making the changes to bring about integrated care from 2015-2020. Since they don’t believe in the purchaser/provider split that is the keystone of their legislation, they have no other levers available to bring about these radical changes.

What they have instead is the traditional activity of shouting at the NHS to “just do it!”. Since the NHS knows that if, a week later, there is bad publicity coming from trying to create integrated care at pace, it is likely to be shouted at to do the reverse, there is little likelihood of reform taking place at the scale and pace that is necessary.

Labour of course has yet to outline the detail of its policy. But in the last month the leader of the Labour Party and the Secretary of State have both agreed that there will be no top down reorganisation of the NHS. That good news means that the levers for change contained in the current system are the only ones that will be available to a Labour Government in May 2015.

Which in turn means that commissioning at a national and local level will be the levers to bring about the move towards the integrated care outlined above. Yet the Shadow Secretary of State has made clear that the last thing he want commissioners to have at their disposal is competition. He wants to grant the existing NHS suppliers a monopoly of what health care is supplied and who supplies it.

He will therefore be asking the NHS to carry out very different integrated health and care but taking away any ability that commissioners have to challenge the monopoly of existing institutions. This reduces commissioning to an allocation mechanism with commissioners simply handing out money to existing NHS providers.

If this were to remain Labour Party policy after the next election, they too will have no levers to bring about integrated care except for the time honoured method of shouting at the NHS.

So, a year away from the next election, this is the problem.

  • We have unanimity about where the 2 main political parties think they want the NHS to get to.
  • We have agreement that there will not be a reorganisation to give the Secretary of State new levers
  • We have agreement that the current levers aren’t one they want to use.
  • They have no way of getting the NHS to move to where they want it to go.

Over the next year this may change.

I’m hoping that it has by the time I start blogging again.

Overwhelming NHS Problems #5. The money

Filed Under (Healthcare delivery, Reform of the NHS) by Paul on 28-03-2014

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All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to discuss the money.

The money is one of the main arguments that feels overwhelming. This is partly because more and more people in the NHS believe that there won’t be more and more money and that’s a bit overwhelming.

For 60 years we have all been working in a service where we have been getting a larger slice of a bigger cake. The GDP has been growing and the proportion of that GDP that has been going into the NHS has also been growing. Even in difficult times, taken over a five year period, the amount of money has gone up and up.

For the last few years it has not been going up. But many people believed that eventually normal service would be resumed and money would start going up again. Only over the last few months have more and more people begun to recognise that if we are very lucky between now and 2020, it won’t go down.

(Of course there are still some whose wishful thinking overcomes their judgment. But I hope for them that the passing of the budget last week – without a few billion extra pounds for the NHS – marked the end of that hope. The moment of maximum political pressure is the budget 14 months before an election. If the money is not found then why would it be found in the first four years of a new Parliament? No. What we have is what we will get)

As more people realise this they begin to talk about the “Graph of Doom”. This shows demand increasing every year while money stays the same. The doom comes from the growing gap – that gets bigger every year.

This gap is based upon the expectation that we will continue to do what we have done before. If demand has gone up by 20% by 2020 the expectation is that, given we will treat these new sick people in the same way as we have treated sick people before, we will need 20% more money to do it.

We heard this logic last week when the RCGP said that to meet the new demand there would need to be 10,000 extra GPs. As reported the story contained the rather odd claim that GPs might become extinct.

(That’s a very strange word to use about the future of a bit of the medical profession. Is there no little bell that goes off in people’s heads when they make these claims?)

It’s true that GPs are under great pressure from rising demand, and what some of them are doing as I discussed on Wednesday in my blog about technology, is changing the nature of their consultations with patients to utilise their time and skills in different ways.

The NHS and social care will not be treating that extra 20% of demand in the same way that we treat them now. If they (and we) are lucky we will be providing a much better service of coordinated care with much less use of emergency beds for fewer exacerbations.

The NHS is not full of people who in five years’ time will have to do what they did five years ago.

It’s not full of people who have to deliver exactly the same service that they did five years ago in five years from now.

But it is full of people, at least those over 30, who have been used to working in a service where the money goes up all the time.

What we need to do is to use the inventiveness that has been there in the past to incorporate new forms of treatment to the service for better value for money.

One of the reasons why people are not doing that is that their leadership has been talking in such gloomy doomy ways about everything – including the money.

What we need from the new leadership of the NHS is some concerted hope for the future which sees all these difficulties that have been described as “overwhelming us” as issues that provide opportunities for development.

With a bit of good leadership we won’t be overwhelmed, but will use these pressures to grow.

My last post of this month long return to the blogosphere will be about the prospects of political leadership facing these changes.

Overwhelming NHS Problems #4. Public Expectations.

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 27-03-2014

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All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to discuss what is seen as the problem of rising expectations.

I started working in public services, in London local government, in 1984. From the start, and continuously over the last 13 years of working in the NHS, I have heard leading public servants complain about the rising expectations of the public.

The argument is straightforward. If the public expect more, we can’t deliver it and it makes out job harder. So ‘rising public expectations’ over the last 30 years have consistently made our job harder.

In its own terms you know what people mean when they say this. If the public don’t complain and fit in with how we organise ourselves, (for example by not getting sick between Friday afternoon and Monday morning when we aren’t there) then the work of a health service is a lot easier.

If people are prepared to travel a few miles to what we refer to as an “outpatient clinic” (but which is in fact inside the hospital so should be called an “in-patient clinic”) and turn up with a crowd of other people at 0900 to be seen at 1215 then our organisational ability will likely meet their low expectations.

But over the last 30 years more and more people have found that in the rest of their lives they can make an appointment with, say, their hairdresser – near their home, at a set time and will probably receive a text reminder beforehand. And on nearly every occasion there will be someone ready to cut your hair at the appointed place and time.

Given that a hairdresser can organise this, the problem for the NHS is that now they now expect it to do the same.

A coda here about class.

Amongst the top 10% of the population I am not sure that expectations of public services have increased in the last 30 years. In the mid-1980s the top 10% expected to get respect, courtesy and convenience for all the services they used – public and private. And when they didn’t get it from the NHS they made a fuss.

For them expectations have always been high.

No the problem of rising expectations for the NHS is caused by the fact that ordinary people now have greater expectations of it than they had 30 years ago. From amongst a class of people who were once simply grateful more and more people have emerged with higher expectations.

This means that more and more people expect services to be organised around their lives – and not around the needs of the organisation .The main problem is not the rising expectations, the problem is that we now need to confront the way in which many of our organisations work for their own convenience.

And it’s true that people are more informed and inquiring. They are demanding a greater say.  Ordinary people are getting a taste for greater power and control in their lives.  

One of the main political points I want to make is that the very existence of mass public services raises expectations. 

Expectations of what the NHS would be had been raised, from its very creation, by the public’s experience of World War II. That generation expected more from life and from Government.  (It was just as well that that generation also had the courage to hold high expectations about beating the Nazis).

The point of mass secondary schooling was to raise the next couple of generations to want to attend university.     

If people involved in a large scale public service complain that the public want more then they don’t “get” the movement of history of which created their service in the first place.

Now there is apparently a problem because too many people are getting too much information about health and health care.

In the past people would talk to their immediate family before a visit to their GP. Now more and more will consult the internet and walk in to see their GP with printouts. In the past they would come in with bits and pieces of knowledge from their parents and grandparents, now they come in with bits and pieces of knowledge from the World Wide Web.

Of course this knowledge is not ‘correct’ but it’s there – and it’s there to be referred to when the patient has had their consultation. The doctor can’t say “don’t go on the internet” in much the same way as in the past he couldn’t say “don’t talk to your grandmother”.

So rising public expectation is seen as a problem across the whole service, from consulting room to boardroom.

Yet in other industries and services, there are attempts to raise expectations and organise to meet them.

In the hotel industry for example one can imagine that a hotel manager may feel that Trip Advisor makes their life a lot harder. I can imagine them moaning to themselves about the latest complaint on the website. But what I can’t imagine them doing is talking to their staff in their morning meeting and complaining about rising public expectations of the hotel.

Nor can I imagine a similar discussion taking place in the boardroom of the hotel chain.

In the hotel industry, and in most other services, the role of the leader of an organisation is to use those higher expectations to drive improvement. The problem for leaders in other industries is constructing a service when the public doesn’t know or demand what it wants.

The same is true for the NHS. The problem for the health service is caused by people putting up with fragmented services that don’t help their recovery.

To create a really successful health service we need, both in the consulting room and among the public, much more active engagement and we need to use that activity and demand for better health and healthcare as an asset.

This week I gave a talk at a mental health trust about these issues. I just caught the end of a patient’s story when she said that the pivotal moment for her had been when a member of staff had said to her that one day she, the patient, would get a job and go back to work. At that moment it was not imaginable, but slowly that hope of a better outcome raised her own expectation. She was then able to use that raised expectation to recover.

Recovery in mental and physical health is assisted by the raised expectation of recovery. Good medicine works with not against that expectation.

Overwhelming NHS Problems #3. Technology.

Filed Under (Health Improvement, Patient involvement, Reform of the NHS, Technology) by Paul on 26-03-2014

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All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to look at the nature of technology.

In our everyday lives technology enables. Sometimes it frustrates but mostly it makes our lives a lot easier. Modern communication is rarely a burden and mainly a boon. In our world it doesn’t feel like an overwhelming challenge.

The challenge of new technology for the NHS lies in the enormous and recognised gap between what the NHS knows it is achieving through technology – and what it knows it could. Most people, whether they be a district nurse in a patients’ home, a GP trying to find out which drugs were prescribed to their patient in hospital, or a patient just trying to find out what is going on, know that their experience of the NHS is not as “technology enabled” as it could be.

Each of them, and others beside, recognise that simple and cheap elements of new technology could transform the ways in which things work – and how they are looked after.

Indeed some of this is not new technology at all, but is old technology used to its full potential. A GP friend of mine always used to say that if doctors ever recognised that the telephone was a two-way instrument – that could be used to talk to patients as well as having them call you, the consultation process could be transformed.

And within that observation lies an important truth. New technology only really works if it enables something that the NHS already wants to do. Too often the NHS has tried to use technology as a change agent in its own right. When that happens the current way of working – the current culture – maintains its old way of working and the new technology simply bounces off it.

Its lies like a heap of junk in the corner of the room.

So the battle for modernity in the NHS needs to be won by using technology as a small part of change, rather than as its main driver.

One example would be changing the nature of the GP/patient consultation. The technology supporting telephone consultations has been around for a long while. The technology for email consultation for not so long, but few people would still refer to email as new technology.

Yet it is only in the last couple of years that the GP practice with multi-channel forms of consultation has developed with any scale. ‘Getting to see’ the doctor has become less significant than ‘talking to the doctor’. This hasn’t abolished the face to face consultation, but it has placed it in a multi-channel set of contacts.

This has not been caused by the invention of the telephone and email. It is a consequence of some GPs recognising that they have to change their core practices if they are to serve the best interests of their patients and then using ‘new’ technology to facilitate the change. Once the decision to change has been made really new technology can transform this multi-channel relationship with patients.

In the future we will see this as a significant change in one of the core relationships of medicine. Given that we know that the main site of health care is the patient’s own home, interacting with the patient there during consultations will become ever more important.

If we succeed in making the home technologically enabled – so that it can  provide a place of safety for high acuity cases – then the ‘burdens’ of both aging and non-communicable diseases (discussed over the last two days) will be transformed.

The potential here is transformative. It provides us with a real chance to address the disparity between the services that are provided – with their over-emphasis on hospital-based care – and those that are needed – for more care in the community and at home.  The opportunity is to harness technology – from big data, through patient-owned health records, to mobile health applications – to help make that transition.

And before anyone points out that the use of modern forms of communication is differentially spread around the population, this is of course true. But the relationships formed by new forms of communications are surprising and can be developed by the NHS. Many people much older than me have benefited from using Skype as they keep in contact with their family across the world. Grannies rent or buy new TVs so they can have big pictures of their grandchildren beamed in from New Zealand.

What we know about this technology is that the public will only use it if there is a point to using it. Grandchildren provide such a point.

I would suggest that the better management of health – staying out of hospital – will provide a similar powerful motivation.

New technology will be an enabler in developing the public’s motivation for better self-care. But it will not make that happen. That will need a better understanding by the NHS of what motivates people to better self-manage their own lives.

Overwhelming NHS problems #2. People are now so differently ill that the NHS can’t cope.

Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 25-03-2014

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This is the second of five posts exploring the way in which discussions about pressures on the NHS are being framed by its recent leadership and current commentators.

Yesterday I challenged the widespread assumption that the increase of the proportion of elderly in the population would from now onwards be seen as an overwhelming burden for the NHS whereas other industries see older people as possessing assets – assets that would be much more useful for a health service to work with.

I argued that characterising such problems as overwhelming does not bring about change but makes the NHS ‘hunker down’ under the status quo.

Today the second of my five posts focusses on the way we frame the argument about the fact that, in England, disease in the 21st century is different from that of the 20th.

Commentators, including myself, have said that the radical change in the nature of disease is a very big challenge for the NHS. The diseases that the NHS took on when it was founded in the last century have now been if not conquered certainly tamed and this century’s disease battle is very very different.

Health systems now have to tackle non-communicable or chronic disease.

As with the increase in the number of old people this issue is often presented using drowning metaphors – a wave, a flood or a tsunami of need is being talked of. The same enormous increase in figures used in regard to the numbers of the elderly are deployed again.

The first thing to say about this change in the nature of the diseases that the NHS has to deal with is that it is not a future thing, it is already here. Given that even today about two thirds of the NHS budget is spent on chronic diseases we must recognise that the problem has already arrived.

The fact that statistics for nearly every non-communicable disease point to a dramatic rise over the next few decades seem to ramp up the size of the problem to another one that is overwhelming.

Firstly it’s important to see that some of this is a problem of success. All of these conditions are more prevalent with age. The older the population, the more likely it will suffer with long term conditions. The fact that we are living a lot longer is partly due to the NHS, so the fact there are more people with non-communicable diseases is also partly due to its success.

In the pretty nigh unending battle between disease and human endeavour, notch one up to us in ensuring people are living longer.

Let’s take the specific of heart disease.

When I grew up in the 1950s the expectation was that when someone had a heart attack they either died or they quickly had a second heart attack – and then died. That has changed dramatically. Over the past 20 years survival rates have increased and now many more people survive heart attacks. We are now much much better at stopping the attack from destroying the heart and much better at stopping the second attack. We are also much better at diagnosing a ‘weak heart’ before an attack.

All of this means that there are now many more people with ‘heart problems’ than previously. It’s difficult to see this as anything but success.

The same is true of cancer. Go to the Macmillan’s website now and you will read a lot about survivorship as a major issue for people with cancer. Again in the battle between disease and humankind I can’t but see this as another great success. Much more to do, but so many more people surviving is a good thing.

So why is the changed nature of disease with which the NHS deals with such a problem? The main issue is caused by that word ‘change’. The NHS is shaped to do one thing and it now has to do another. It finds that change hard, but such a change does not have to be overwhelming.

The main reason it is described in this way is that the nature of the change the NHS needs to go through involves how 15 million people with long term conditions need to maintain their health. This, as a task, seems beyond the NHS – and in a literal sense they are right, it is.

The only way this new form of illness can be tackled by a health service is to recognise the importance of the people themselves in managing conditions. On its own the task lies beyond the boundaries of any health service. The service needs to find different ways of working to include and involve those people in much better maintenance of their condition.

What patients do to manage their condition – their lifestyle, diet and exercise – is as important as everything clinicians do.

A successful healthcare service needs to enhance the nation’s capacity to look after itself when it is ill.

Of course a really successful health service needs to enhance the nation’s capacity to look after itself before it is ill.

The danger is that the NHS sees itself as being overwhelmed by non-communicable diseases because it has to change to treat patients differently. They need to be seen not as passive recipients of care in a system that denies them both power and responsibility but instead as an integral part of a system that empowers them to take greater charge and more responsibility for their own health.

A model of health care that is controlling finds the necessity of this change overwhelming.

But in reality it is an opportunity is to bring patients inside the decision-making tent. An opportunity to let go of all that responsibility and let patients share the dilemmas clinicians and managers face – rather than keeping them outside.

This is only overwhelming if the NHS cannot let go of this power. What will be overwhelmed is a particular model of health care – not health care itself.

Why do we seem to need to see the pressure on the NHS as being so overwhelming that we can’t do anything about it?

Filed Under (Alan Milburn, Culture of the NHS, Health Improvement, Healthcare delivery, Reform of the NHS) by Paul on 24-03-2014

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One of the main purposes of this blog is to question some of the established orthodoxies of the NHS and how we think about it. By definition that means that I raise questions all the time about how the NHS thinks about the main issues it faces.

For the last five posts during this month of my return to the fray I want to develop a different set of arguments. These will question why so many leaders and commentators in the NHS seem to need to passionately portray the organisation as being mired deep in a many faceted crisis.

There is constant talk about ‘the graph of doom’ which has demography rising and resources flat lining.

I want to explore the nature of the psychological need that is being met by this constant return to viewing the world in this way.

Because, from the outside, all this talk of doom seems to make the job of actually achieving anything very hard indeed.

One way of looking at this is that if there are…

  • too many old people
  • too many sick people (who are also apparently the wrong sort of sick),
  • too many changes in technology
  • sky-high rising public expectations and
  • no new money

…then don’t all of these external factors create a set of drivers which argue relentlessly for the necessity of radical change?

One would think so. But then in the real world where these arguments are being made by and large radical changes of scale are not being made.

So I think we need to think of another purpose that this way of looking at things serves. If all of these external factors are coming together to create pressure for change isn’t it also the case that change on this scale can’t be achieved? So, the argument goes, this is all so overwhelming that nothing can be achieved – so let’s carry on much as we are already.

So the paradox of this week’s posts is that what should be powerful arguments leading to change have in fact become OVERWHELMING arguments resulting in people not knowing where to turn.

I am grateful to my old boss Alan Milburn for showing me how these arguments need to be turned on their head. A few weeks ago at the Guy’s and St Thomas’ Charity he gave a lecture on how all of this overpowering doom could be a set of opportunities for the service potentially leading to very different leadership activities.

Because, as with so many things, this is all about leadership. The framing of the argument is a matter for the leadership of the system. And at the moment that argument is being framed to be so overwhelming that everybody is being frightened back to the status quo.

This week I want to spend a day on each of the five areas which have been portrayed as overwhelming challenges and see what possibilities they provide the NHS.

  • Demography
  • The nature of disease
  • The nature of technology
  • Public expectations
  • The money

On demography I need declare an important interest. I am 65 – the same age as the NHS – and therefore part of the age group and generation that are being seen as the burden that will destroy it.

Personally I don’t quite see myself as a burden but I sort of get the point.

However, my generation – colloquially referred to as the “baby boomers” – has, until now, more often been seen as a generation causing problems because of too much activity – not too much passivity.

We were – just – young mods and rockers (in my case a failed rocker as I never mastered riding a motorbike); we developed and sustained several parts of pop culture; we were the first major wave of student unrest; we were an early part of the property boom; we rode a tide of divorces and changed jobs far more often than previous generations.

All of this seems very active. (For our parents, much too active.)

Apparently now that we are entering retirement we are going – for the first time in our lives – to become a passive burden, rack up several co-morbidities and spend the last 30 years of our lives bothering doctors.

Old people are not just often referred to as a ‘burden’ but we also seem to feature in a lot of ‘drowning analogies’. There is, and will be, a flood of demand which will lead to the NHS drowning under it. All of this becomes a tsunami of need.

One of the statistics used to make this case is that by 2030 a third of the population will be elderly. This is assumed to clinch the whole argument since a problem that big must be insuperable. Personally I would be 82 and be part of this flood by being ill, and passive.

I think it’s certain many of us will be ill. My aches and pains will develop into arthritis and I am pretty sure that my blood pressure will be too high. Almost certainly I will also have another morbidity.

So it’s true that there will be more of us and that many of us will be ill in complex ways.

But will we be ill in the same way as today’s 82 year olds?

When I read the Saturday and Sunday supplements many of them treat me as a very active consumer for the rest of my life. I read them as appeals to me and older generations to become ever more active. There are a whole host of organisations that are looking to me to be very active indeed when I am in my 80s.

Private sector organisations assume I will be very active.

The NHS assumes I will be very passive.

Voluntary sector organisations see me as active.

The NHS sees me as passive.

The NHS assumes that its burden (and the problem of their increasing activity) is caused in part by my passivity.

But what will be the characteristics of my activity that the NHS, if it understood me in that way, could work with?

How might my GP be encouraged to view the next 30 years of my life as a set of assets with which the NHS can work?

One of those assets would be my wish for my home to be the established and clear locus of health care. I do not want care closer to home. I want care at home.

Our care will be centred on our experience of our own homes and not designed for the convenience of the organisations that will deliver it. My generation will expect much more high acuity care in the comfort of our own homes.

This will be a challenge to the current way of working. The new generation of the old will not tolerate a system of care that tells us what to do.  We will want to tell it what to do.

But for the NHS this is also a very considerable opportunity. It will require a shift in the way in which the NHS delivers care but that shift would be based upon a recognition of our capacity to play a much bigger and active role in our own health care.

The opportunity is to re-fashion care so that it is aligned with the mind-set of this century rather than the last.

Primary care is heading in the right direction – but will it get there in time?

Filed Under (Clinical Commissioning Groups, GPs, Reform of the NHS) by Paul on 14-03-2014

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A year ago the main change happening in primary care was the move towards trying to finds ways to increase the size of the basic organisational structure.

1948 had seen Nye Bevan, for a whole range of very good reasons caused by the political reality, shy away from creating a salaried GP service. Having famously stuffed the mouths of consultants with gold, he gave GPs the right and the power to run their own businesses.

The real world of political achievement gave him little room for manoeuvre. Creating the NHS was not a matter of drafting the arrangements that you wanted. It took very hard bargaining with implacable foes running the medical trade union – the BMA.  Only commentators with no feel for the reality of political achievement could criticise Bevan for the compromises that he had to make to get the NHS show on the road.

One of those was to grant to the nation’s GPs the right to organise themselves as small businesses having control over their own organisations. Unlike other small businesses however, GPs have a guaranteed state income and a guaranteed state pension. A privilege denied to small shopkeepers and painters and decorators who have to operate in a real, competitive market to make their money and their pensions.

So in 1948 hospital consultants became workers with the right to moan about the management, and GPs became small businesses with the right to run their own organisations.

This split creates all sorts of problems for integrated care (about which I will blog next week), since the problem is not just about getting generalists and specialists to work together, but the much more difficult task of getting those who work for large organisations (consultants) to work with those who run their own show (the GPs).

So the 50th and 60th anniversaries of the NHS came and went with GPs still running their own show and the vast majority of them running very small businesses while over the previous 50 years nearly all other industries had undergone a considerable increase in the size of the unit of delivery.

Customer preference had used markets to turn small grocers into supermarkets. Customer preference had used the same markets to change nearly every industry with large numbers of small outlets into bigger organisational units.

Since consumer preference was not driving primary care to change, their organisational structure stayed where it was.

The problem was that medicine needed larger organisational structures to deliver all of its potential benefits Primary care needed to be actively involved in carrying out the many more diagnoses and interventions that at the moment take place in hospitals..

I, along with many other people, cannot get a blood test at my local GP surgery. Instead I have to go to an international hospital to get something that should be available in my street from my GP.

A year ago there was a greater recognition of the problem of size in primary care than had existed in the previous 60+ years. Most parts of the country were talking about the creation of federations and building sets of relationships between GP practices and one year on this trend has if anything accelerated.

Most people see this talk of federations coming in part because of the creation of CCGs. CCGs have brought GPs together for the purpose of commissioning, not providing. However most of the activities that GP leaders of CCGs need to talk to their fellow GPs about concern variations between the way they practice as providers of care. Therefore creating larger CCGs has inevitably raised a string of questions about scaling up GPs practices.

CCG leaders have experienced what every leader in the NHS has experienced for the last 60 years – primary care is vital but very disorganised. It will only really be able to fulfil its role if it takes on much larger organisational forms.

And it is this that is behind the strong move towards federations.

However there are two real problems with this set of changes.

Firstly because it takes on some very ‘hallowed’ experiences (the right to run their own organisation), this sizing up of primary care will not happen quickly. Taking on several thousand organisational leaders and persuading them to give up a lot of the power they have to run their own organisations will not be a speedy process.

Secondly this change is voluntary. GP practices that choose not to do this will not lose their registered lists or their income. In all other industries that have scaled up the failure to grow meant that you either had to work much longer hours to make the same amount of money (small corner stores) or be taken over – often the only way you could stay in business. These drivers have not been built into this change process in primary care.

In short GPs will do this at the pace that they want to, not the pace that their patients need. This means that it is done at the pace of the producers of the service rather than the consumers.

One other change with GP practices continues apace. As I noted above Nye Bevan failed to create a salaried GP service, resting power instead in the hands of a small business structure with partners. For 50 years Bevan’s compromise created a career path which saw GPs seeking to become partners in order to run established organisations.

This is now being changed – not by fiat from Whitehall – but from the new career choices that new GPs are making. For a variety of material reasons new GPs are not choosing to tie themselves to this old organisational structure. They are now choosing to become the very people that GPs 50 years ago did not want to become – salaried staff.

Newer GPs, instead of yearning for the long term relationship with a locality that partnership gives, are opting for the greater freedom provided by being salaried staff. This is partly caused by the change in gender of new GPs, with the larger number of women wanting to be able to shift their work patterns around prospective family responsibilities and partly because the relationship between place and security that was behind the creation and continuity of this model 60 years ago has changed radically. Professionals want to be able to move around and being tied to a locality through a particular organisational relationship does not give the freedom of movement that being salaried provides.

This means that the organisational structure of NHS GP service provision is primarily being changed by the wants of the new workforce.

The problem for patients is that they need larger scale primary care now and not in the 20 years it will take to work these changes through.

How far has the new model of local hospital provision progressed In the last year?

Filed Under (Foundation Trusts, Hospitals, Reform of the NHS) by Paul on 13-03-2014

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Truthful answer?…. not very far. In two parts of London various bits of the failure regime have sounded a death knell for the old model of the local hospital, but I wouldn’t say we are a year further on in being able to explain to the public what any new model will look like.

It’s a good 18 months since the administrator argued for the breakup of South London Healthcare offering different possible solutions for different parts of the old Trust. One part was to be taken over by Kings College Hospital FT whilst another was to become a different model of local hospital.

And in October 2013 the Secretary of State (mainly) agreed to the reconfiguration proposals in North West London which amongst other changes agreed that there needed to be a new model for local hospital care in Ealing and a part of Imperial hospital.

The main thing to say about both these developments is that progress doesn’t happen quickly. My feeling is that in both locations the local trust is trying to construct its own model of the future. Of course such local ownership is a good thing, but it’s asking a lot of failing institutions to construct their own future.

And the NHS has been discussing new models of care for local hospitals for a good 15 years. This problem is not new to the NHS, nor is it something that will happen in only three or four locations.

In September 2012, in a pamphlet called The hospital is dead, long live the hospital, I suggested that there were between 20 and 30 locations where a new model would need to be created. 18 months later I would say this was an underestimate – the number is nearer 40.

The NHS has known for some time that this is going to be a sizeable problem and whilst the main performance management organisations of the NHS are concerning themselves with very many different aspects of the organisations they manage, there is no systemic, organised development of a new hospital model.

Given these organisations are spending time and effort looking into the future, the only reason such powerful bodies are not specifically developing new models of hospital must be fear.

Developing a new model of local hospital would mean publicly entering into a debate with the public about what hospitals should look like. Generally the way in which the NHS does this is pretty awful. I have read tens of documents making a case for change that begin by saying that because there is a remorseless increase in demand for healthcare there must be radical change, and when you get to the nature of the radical changes proposed they all look like cutting hospital services.

At the bare bones level the argument seems to say “The increasing demand for services is causing us some problems, so that is why we are closing your hospital.”

This is not reassuring.

The public recognise that there is rising demand for healthcare and they need some reassurance that there will be services there to meet it. They would really like these to be run by their local hospital. But the building is just an icon for them which the NHS seems obsessed with changing.

The public really do think the reasoning is strange. “Because there is much more business for the NHS we are going to close the place that does the business.”

Why not start by saying that because there is so much more business for the NHS we will be providing more services? I would think it very likely that demand and the need for healthcare will go on growing for some time and therefore we could probably start by saying that the locations where healthcare is being provided at the moment will be providing healthcare in the future. It’s just that the nature of the healthcare being provided will change.

From the point of view of the local hospital the number of patients going through their new model of care is likely to increase. But the numbers of people going through their building may decrease.

It starts with an interesting reworking of the label ‘outpatient’. At the moment outpatients have to go into the hospital for diagnosis and treatment. It’s actually quite curious that they are referred to as “out” patients.

The new model is reworked by the idea of moving outpatients to… er… outside the hospital. For this to work of course the consultants have to recognise that the bulk of their work will be outside the hospital. And this is the rub for the real change for a new model of local hospital.

Most hospital doctors (and nurses) choose to work in a hospital and not just for it. The major change in any new hospital model is to move the bulk of their work away from the fixed building that contains a load of in-patient beds. This is a radical change in the working practices of staff and will take a lot of managing.

But in financial terms the hospital can do much more business outside of the walls of the building.

That of course brings us to what is seen as the central issue – the buildings. It’s a pity that most of the people who manage hospitals seem to end up in the real estate rather than the health business. It would appear that the rate limiting factor in terms of change in the NHS has little to do with healthcare and everything to do with the fixed costs of the buildings.

And this is where leading NHS organisations could help local hospitals change their models of care.

In terms of change most other industries are more agile than the NHS because they have moved their proportion of fixed costs into the column called variable costs. In the NHS the idea of fixed costs is treated as … well… fixed. In other industries one of the main aims of policy is to gain more flexibility by moving costs into the variable column.

Individual trusts will find this hard. But collectively the NHS could tackle this by changing policy and rules.

The NHS is often disappointed when the public become fixated on the hospital building and seem less interested in services outside of that building. Yet by failing to tackle the issue of fixed costs for local hospitals, the NHS ensures that they remain fixated on buildings and not services.

So my main point is that over the last year not a lot has happened in terms of developing a new model of local hospital for the 30-40 hospitals that need to develop one. It would be good, if this blog were to report back in another year from now, for some progress to have been made.

In March 2014 just who is responsible for the Government’s NHS reforms?

Filed Under (Accountability, Conservative party, Health and Social Care Act, Reform of the NHS, Secretary of State) by Paul on 03-03-2014

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“Victory has a thousand fathers but defeat is an orphan.” – John F Kennedy

A year ago, when I paused in my blogging, the bulk of the Health and Social Care Act was about to be implemented (on 1/04/2013). So it’s inevitable that much of the next few weeks’ posts will revolve around what has happened to the biggest set of NHS reforms since 1948. The detail of those reforms is a fascinating topic but stepping back from the minutiae, what is really interesting is how the Government takes no ownership at all for this enormous set of changes.

In reviewing their work over the last 4 years government ministers have established a litany to describe what the Coalition has achieved. Three things are mentioned again and again.

“We have succeeded in getting on top of the deficit, and have successfully reformed education and welfare.” 

But there is no mention of NHS reform.

That enormous Bill, the famous pause in the legislative timetable, the subsequent reworking of the Bill, the many, many changes in the Lords, and all of the political capital spent ramming it through against a high level of opposition.

All of that effort has resulted in …………………silence.

As we will see in subsequent posts this silence on reform is reflected in the way in which the current Secretary of State does his job, but today I want to explore the implications of no-one taking responsibility for the implementation of the actual implementation.

Of course it is wrong to say no-one takes responsibility for implementation. The Department of Health has a timetable of things it needs to do to keep the new show on the road – and of course the technical implementation continues.

But the problem is that the impetus for these reforms did not come from a set of technical problems. They were created from a new vision for the organisation of the NHS.

Andrew Lansley began work as the new Secretary of State in late May 2010 and within a month had abolished the 4 hour waiting target for A and E. (Incidentally those seeking to understand why the NHS is having difficulty meeting this target will find at least part of the answer in a letter sent out by the Conservative Secretary of State abolishing it).

Then within 8 weeks of taking up his post he published a White Paper intent upon “liberating” the NHS from the control of an overbearing centre. Within a few months the largest Health Bill ever was published and as it progressed through Parliament it became clear that it was intended to change everything.

The legislation was passed (as all legislation is) through a process of ruthless party political whipping. Again and again the two Government parties voted for radical change and presumably did so with some kind of vision of what they wanted to achieve.

Of course that Secretary of State moved on, but the vision of the cabinet, several hundred peers, and MPs was realised in this enormous piece of legislation.

And all of that politics has led to…………………..silence.

A process of change that was essentially political now has no political champion to explain what was being attempted and why any of this happened.

The only explanations we hear are the technical ones from the civil servants whose job it is to implement it.

Up until the passing of the legislation if you asked the question “why is all of this happening?” Andrew Lansley would give some sort of reply about decentralising power to clinicians in localities.

Now if you ask the question you get the reply that “we are carrying out the will of Parliament and these are technical implementation issues”.

The problem is that the implementation of technical issues actually needs an overall vision to make sense of them. And no-one is owning that at all.

We had 27 months of intense political noise and row, but since the passing of Andrew Lansley we have had 18 months of prolonged silence about why all this is happening.

In part this can be explained by my opening aphorism from John F Kennedy. The Government was successful in passing its legislation, but the moment it was passed this success was recognised as being a failure. Andrew Lansley was moved partly because he kept on banging on about it as if it were a success. But given that it’s a failure no-one wants to own it.

This is not just a political matter – it goes into the depths of all of the detail of the implementation of the reform.

Take one example – the detail of what organisational form a Commissioning Support Unit should take is a technical issue. But it would be best if that technical issue should in some way fit within the overall architecture of the NHS. If no-one is looking after that larger vision, then the answer to what happens to each bit of the structure is only answered in relationship to those bits….. The overall architecture then gets dragged apart by the answers to each small technical question.

One of the main real cries of anguish you will hear within the NHS in March 2014 is that no-one really knows how all these bits fit together. It looks as if each bit is plying its own trade with little relationship to the whole.

And my point is that there is not a single politician looking after the overall architecture.

For me this is something I can’t forgive.

Throwing the whole of the NHS up in the air has caused everyone a lot of difficulty.

Walking very quietly away from the results and pretending “it’s nothing to do with me guv” is much, much more irresponsible.

Reflections on the Nuffield Summit

Filed Under (Economics, Narrative of reform, Reform of the NHS) by Paul on 13-03-2013

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The first day of last week’s Nuffield Health summit concentrated on the linked issues of quality and finance. We are going to have to improve the former whilst having less of the latter. I will return to this issue.

Throughout my time at the Summit I couldn’t shake off the nagging idea that, here we are in the spring of 2013 – and right now would have been a great time to launch a Government NHS reform programme. Read the rest of this entry »

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