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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The development of integrated services for patients may be being adversely affected by the passion that many feel for the forces that fragment NHS care.

Filed Under (Health Improvement, Integration) by Paul on 07-01-2013

2012 was the year when every part of the NHS that came under the powers of the new Health and Social Care Act had the duty to integrate services added to their statutory powers. In addition to the deluge of instructions to integrate, November’s mandate from the Secretary of State to the National Commissioning Board made it clear that he wanted the public’s money spent on the development of integrated services for NHS patients.

Given this one might expect that 2013 would be the year when, for the first time, extensive services for NHS patients would be commissioned and provided in a truly integrated way.

Yet most people don’t really expect this to happen. Whilst there will be some heroic and important new services commissioned in some local areas, (which I look forward to highlighting), most people I talk to in the NHS expect that, in a year’s time when we turn the page to January 2014, we will have substantially the same fragmented expensive provision for NHS patients that we have at the beginning of 2013.

This is curious since intellectually everyone ‘gets it’.

Everyone knows that fragmented services are an enormous problem for most patients – especially those with long-term conditions.

Equally we all know that this is an enormous problem wasting NHS resources. (The Public Accounts Committee report that 80% of NHS resources spent on diabetes were spent on complications correctly characterises that as funding failures resulting from other interventions).

There is also a great deal of intellectual agreement that if we commissioned and provided integrated services they would provide better outcomes and more value than the current fragmented services.

But even given all this agreement no one really expects 2013 to see a step change.

So no-one is really anticipating that by this time next year 10% of £110 billion NHS spending will be integrated (or say 25% by 2015, and 40% by 2016). Yet if we want to change NHS patient experience this is the level and pace of change required.

(Of course most people in the NHS would find such change of pace impossible since it would ‘destabilise’ the system. This worry about the impact of speedy change seems to rather ignore the fact that while we may, at the moment, have a stable system, it is stable and broken).

So I thought it might be useful to blog this month about why the NHS might find integration of services so very hard.

Today I want to explore the NHS’ passion for fragmentation.

Now of course, given fragmentation is a ‘baddy’ word, no one actually goes to work every day passionately arguing that they want to fragment the NHS. But many many people go to work every day very passionate about their bit of the service and with very little interest in the bits of service outside of their passion.

Medical science, in most of its manifestations, advances each year because those at the forefront of knowledge move it forward in their small area of theory and practice. As science progresses, specialisms, break down into sub-specialisms.  Colleagues interested in these sub-specialism read about breakthroughs in their area and meet to talk about how to improve things.

And, let’s be clear, this specialist form of knowledge and practice development has improved and saved many lives. Moving science forward in this way is not of itself a bad thing.

Putting it into an even broader historical perspective, the division of labour in medicine, as in most other industries, is a good thing. It doesn’t just improve knowledge, it improves practice and outcomes.

The division of labour in medicine means that we need healthcare professionals to specialise and understand more and more about very specific areas of healthcare. With the current paradigm of medicine it is very difficult to see how this might change (and given its success I am sure we would not want to try and construct a health service which came out against the division of labour).

There is however a big difference in other industries. All successful industries improve by developing and improving specific bits of that division of labour. They improve precisely by dividing specialisms into smaller specialisms.

However in those other industries there is an overarching unity resulting from a larger vision built around overall production. The smaller parts recognise that they can only really work together and influence the world as part of the bigger and wider supply chain that unites them.

I am sure that Apple has a whole team of people who are passionate about the way in which they have reduced the size of the recharging mechanism for their products. I am sure this will have involved more and more specific and detailed aspects of a wide variety of sciences and technologies. I suspect that Apple has a whole set of sciences developing into more and more specific divisions.  Modern technology needs the division of labour every bit as much as modern medicine.

The difference for Apple is that all of that work is a part of a wider value chain – brought together into products. These smaller, different aspects of very different sciences are part of something much bigger.

In medicine the problem is that there is usually insufficient power doing that for patients.

With medicine the ‘ologys’, and the sub-divisions of the ‘ologys’, feel that they have a right and a duty to run their own bit of developing value for patients. The rest of the patient pathway – if it is thought of at all – is felt to be something that could mess up the very specific work that they do.

Whilst they are usually correct that their very specific inputs can reduce distress and save lives, they would achieve much more for the patient if they gave up some of that ‘specialness’ to be part of the much longer supply chain that is the patient pathway.

This is what we mean when we talk about the importance of the patient pathway. It is this that patients complain about when they say that while the ‘bits’ of treatment may be fine, overall they don’t feel that they, as patients, get much consideration (“Why do I have to tell my story four or five times in every visit? It’s as if they don’t talk to each other.” …Well, actually, often they don’t.)

So I am not, and never have been, a hippy who doesn’t appreciate the importance of the division of labour. I really am all in favour of the specialisms that drive medicine forward as they do in other industries.

Passion for these specialisms matter.

But they need to be placed into the context of the patient journey – where specialisms recognise the need to work together for patient benefit.

Integration requires a passion for the patient – not just the science.


One Response to “The development of integrated services for patients may be being adversely affected by the passion that many feel for the forces that fragment NHS care.”

  1. Integrated care is the only way to assure the future of healthcare delivery.
    The Integration of the organisations and the data in real time is essential.

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