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.

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A discussion with diabetes clinicians about NHS reforms

Filed Under (Health and Social Care Bill, Narrative of reform) by Paul on 16-09-2011

This week I attended the European Conference on Diabetes in Lisbon where I talked to a group of British diabetes clinicians. As is usual in these events they had spent the day talking with European colleagues about the latest clinical developments and were now spending the evening looking at the much more organisational issue of NHS reform.

The first very significant thing about their understanding of the reforms, and one which has been something of a theme over the last year, was that no-one had spoken to them to explain why the changes are needed and what they are meant to achieve. They had been left to themselves and their employing organisations to make sense of the enormous changes. From the questions and discussion it seemed that they did not know the detail of what was going to happen.

(There were several questions about the governance of CCGs which were very detailed. Where will the clinical commissioning groups get their nurse and hospital doctor non-execs if they cannot get them from the localities? If the CCGs are meant to be local organisations isn’t banning local nurses and hospital doctors from their boards an odd thing to do?)

But no one had made any overall sense of the reforms for them. No-one, to return to the themes of the past year, had developed a narrative for change with them. This meant that whilst they might like or dislike some parts of the detail, each clinician had made their own overall sense of what was going on within their own political and moral world view. So those that were passionate about the NHS as a public provider, felt that this was all a scheme to privatise the NHS. Nurses felt that the late addition of a nurse to the CCG board was a continuation of the usual tokenism that they had come to expect, and those that were simply pragmatic were getting on with the bits and pieces that made sense.

But nobody had bothered, even with a committed and interested group of clinicians, to explain why all this was happening and what it was all about. Now admittedly, as this is partly what happened to me, if you turn up with an explanation that people don’t like you are likely to have a row about it, but it’s very important not to be frightened of that row just to know it is going to happen. Clinicians hold their world views very strongly and if you turn up with an overarching narrative about change that they don’t like, there will be an argument.

But as I have said again and again if you want to reform the NHS in any way, you have to have that argument.

Another issue is that most clinicians in this group ‘get’ the long term financial issue. Above all they, as experts in diabetes, know that there will be a growing imbalance between the increased demand for health care and the much smaller increases in resources. They know that they have to increase health care outcomes with the same levels of resource. They are worried about this but recognise that if this is the world they must face for the next decade then at least it is better that they are heavily involved rather than it being left to abstract management.

They recognised that if you walked up and down the diabetes patient pathway there was a lot of waste to be saved that could then be much better spent on increased demand for diabetes care.

But the most interesting issue for me was that whilst nearly everyone in the room was employed by a primary or secondary care organisation, they nearly all knew that the answer – the overall answer – could not be found from within their organisation. There was a strong recognition that the successful future pathway would cross all sorts of organisations.

This led to some of the discussions centring on what they could achieve themselves. I felt strongly that if they could be given permission – for some within the NHS, for others across the NHS private sector – to form their own local and national organisations that provided care, they would do so.

So the really interesting thing is that this group of clinicians who were clearly driven by the necessity of creating clinical improvement for people with diabetes within a very tight resource budget did not feel either before or after the reforms that they were empowered to set up and develop new organisations of provision. In discussion, time and again the arguments about working together – that could have been solved by developing a new organisation to deliver across the existing organisations – appeared insurmountable.

You felt that if a fraction of the organisational and political capital expended by the Government in their reforms – and their reforms of their reforms – had gone into providing a simple explanation of how you could have organisational fluidity of approach, we would have secured a lot more of the change that we need.

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  1. […] first posted about this in September 2010. My worry about the lack of a narrative grew out of personal experience of having had to explain to […]

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