What is success?

First posted on April 20th 2012

This might seem to be a silly question, but in the current climate, when most stories are reported with a mix of suspicion and negativity, will we recognise success if it hits us in the face? Those twinges of doubt have started to crowd out some of my own optimism.

Let’s ask some hypothetical questions and play a gedanken experiment.

Let’s start with a typical frail elderly population receiving a mix of services across the health and care spectrum. Now let us suppose that we can allocate each individual to one of three groups.

The first group of stalwarts grew up to be very grateful for whatever services they have received. Their biggest fear is to be seen to be a burden on those around them, and they will soldier on through thick and thin. They are proud of the way they have managed to struggle through adversity and have to be on the verge of death’s door before they will seek out care. As they have aged and become more frail, their resolute spirit still drives them to put off that call for help, even when in their heart of hearts, they know they should.

Our second group are the worriers. Their fear is of being struck down so that they become dependent on others. They worry that each croak and ache might be the first step along a slippery road. In their heyday, they may have been the “worried well”. Seeking reassurance from the experts. Not necessarily hypochondriacs, but still watching out for unexpected signs. As this group becomes more frail, their anxiety levels may be rising. They will be in and out of the GP’s surgery walking out with something more important than a prescription – they will have a sense of ease, at least for a while. As the loneliness of age bites, they may find that the health system becomes a gateway to basic human contact, not just provision of care.

Then we have a third group who are neither the worriers, nor the stoics. Those with good, strong family and neighbour networks will often come in this camp. They have a sense of when to get reassurance from within their own networks and when to seek professional help. When they need to consult a professional, help is often at hand to smooth over the difficulties of navigation. As they become more frail, their frequency of turning to professionals increases, but only proportionate to their frailty.

Now, we experts in the strengths and shortcomings of the care system, observe how our fragmentary care system could be improved through a more unified, seamless approach to services, with a bit of help on navigation, more sharing of information and all the clever stuff we build in to oil the wheels from our perspective as professionals. So we decide to run a new model of joined-up care. But, being the intelligent folk we are, we decide that we need to control for variability where we can. We choose to divide our trial population into our three respective groups, so that we can compare the results between them.

I just know you’ve already made the mental leap, but, please, stay with me!

In our wonderful. integrated care pilot, group 1 makes more use of the services because the new model we have put in place does precisely what it is meant to do – it captures the need at the right time, rather than late. For this group, integrated care should reduce risk, improve both mortality and morbidity. By capturing the need early, it should reduce length of stay, but might very well increase admissions. Rightly! So integration increases demand!

But group number 2 receives reassurance in a more appropriate way, reducing the demand that we experts think is inappropriate. They probably make less use of the service, but with a better level of targeting. By providing more appropriate reassurance, they reach the front doors only when there is a higher risk. Integration reduces overall demand, but leads to a higher conversion rate of admission per attendance!

Quelle surprise? Demand from group 3 is relatively unaffected by our carefully developed improved service, though the better joining up will reduce levels of frustration.

So, which of our three trials succeeds in giving us a definitive picture of the effectiveness of integrated care? Group 1 makes more use, and is likely to be happy. Group 2 makes less use – equally happy. Group 3’s demand unaffected, but still happy.

Now let’s leave this hypothetical construct behind and return to reality. What can we really learn from the evaluation of integrated care pilots which is widely trumpeted as showing that integration doesn’t work? Has it helped us to define success? Nick Goodwin, in commenting for the King’s Fund, has gone a long way to putting the work more carefully into context, avoiding the simplistic solutions which have been too prevalent in other headlines. Now can we move this debate along to a more productive consideration of just what we should be doing to design care around the patient, and therefore what we need to know to evaluate whether we have achieved success or not?

There is one single, unequivocal message. The effects of integration are unpredictable and unmeasurable, UNLESS defined by the effect on the individual. Success is defined by the patient or service user, not by the service provider.

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So, the golden bullet appears to have gone rusty

First published March 28th 2012

So many hopes have been built on the expectation that integration is a silver bullet for the woes of the health system, that we really should see it as a golden bullet – far more than a mere silver one.

Well!  The reporting of the evaluation of the DH funded integrated care pilots would have you believe that we are doomed!  The headlines suggest that patients did not experience greater continuity of care, reduction in emergency admission has not materialised, and there is little, if any, overall financial benefit.

More of a rusty bullet than a golden one!

But the only gold items that rust are fakes – still built of base metal but painted over to make it look like gold.

And we should surely conclude that there is an element of dressing up and pretence about the integrated care pilots.  If only we had looked for the evidence before clasping the pyrites to our bosoms.

We know from most industry sectors, that all the case study reviews of transformation teach us that success needs to begin with transformation of the business model.  Which of the pilots did this?

We know from our own studies (which will be published in May) that what marks out good leadership of whole systems, demands new characteristics of our leaders: that are currently in short supply amongst the NHS top leaders.  Were the leaders of our pilots selected for their fit to these new styles?

We know from the very basics of engineering, that failures occur at boundaries, so our integration design should do three very specific things: reduce the number of boundaries; reduce the risk of failure at boundaries; and, reduce the impact of those failures which do occur at the boundaries.  Which of our pilots have used these as design criteria?

We know that for any system to work smoothly and efficiently, we must align the driving forces – i.e. incentives – to make sure that each part of the system is acting in harmony with every other.  What dispensations have our pilots been given to devise a new locally fit-for-purpose system of incentives, rather than the conflicting set currently in play?

We know that at times of disruption, attention naturally and easily focuses inwardly to deal with the consequences of change, diverting away from the attention which should be on the relationship with the cared-for.  What investments have the pilots made into genuine engagement with and involvement of patients in the redesign, or better still in co-design?

We know that sharing the right, high quality information across the whole system is the only way to reduce some of the risks, build a common purpose and enable all players to feel part of a single solution.  Which of the pilots has moved beyond temporary lash-ups between data sets?

Let’s hope that we can now read the small print of the evaluation report, not just the headlines.  The small print suggests we’ve got to work harder to get it right.  I suggest we just need to work smarter!  Integration is not the right answer, especially if most of what we do puts fixes around the current system weaknesses and boundaries.  The smart answer lies in understanding how to use the principles of integration to achieve a clear vision of patient centred, seamless care, and then to use that to drive investment in a purpose designed business model, that has all the characteristics to make it work.

Just because we have a pot of gold paint doesn’t turn us into successful alchemists.

From forlorn despair to hope – in one day!

First published 26th Jan 2012

Those of us involved in any way with the care ecosystem need to keep our mums and grannies and kids in mind.  Whether we are commentating or deeply involved in delivery, commissioning or education.  Yesterday provided one such opportunity – a hospital appointment for my mum.  It was always going to be difficult!

I had mentally taken that extra beta blocker as preparation, but I hadn’t reckoned on the real cause of the stress.  There is no better word than primitive!  Mum’s record was only about 3 cm of paper in a tattered and torn green folder with an elastic band round it and containing her previous two addresses, but not the current one.  The scheduling system was determined by where this folder rested in a large pile of similar folders, few less than 2 cm and some up to 8 or 9 cm thick.

The first check with the nurse took 5 or 10 minutes longer than it needed, because the part of the record she needed had only been added as a comment at the foot of one page somewhere in this stack of inaccessible information.  She kept overlooking it in the search for a more substantial and carefully constructed account of a previous treatment cycle.

For the next half an hour, I watched as this teetering pile of information was shuffled and inspected each time another patient completed the pre-assessment to begin their wait for one of the three doctors in that clinic.  Goodness knows what the glancing look proved, but it was a ritual which clearly provided some satisfaction to the nurses amidst this forlorn process.  Perhaps I dreamed the papyrus scroll sitting there next to the ink-well and the neatly clipped feather!  At least one patient appeared to be missing that vital folder, but maybe it turned up.  I couldn’t keep up my excitment levels to notice!

I’ve been working with IT systems for so long, I had forgotten that life can still be so primitive and processes inexcusably mismanaged!

And this is the point to ask: “how could we get the National Programme for IT so badly wrong?”  The potential for improvement in safety, quality, efficiency and outcomes is just so obvious.  Any engineer will tell you that weaknesses, failures and poor quality happen at boundaries between systems and processes and organisations.  And here, in these fat, green, scruffy folders are a series of broken boundaries on show for everyone to see!  This is not a technology issue.  This is a basic fact that, following the command to do no harm, the next most important rule for every clinician must be to keep an accurate, reliable record of every aspect of the intervention, which is communicated effectively to anyone else involved in delivering care.

And then later that afternoon, as I sat in recovery mode with steaming towel round the forehead to dissipate the stress, in through my inbox came the report from the working party of clinicians seeking to establish a basic standard of clinical record keeping.  As I mused on the way this was reported, it read just like a repeat attempt to reinvent the technology mistakes of NPfIT.  But I had been privileged to engage with one of the leaders of this work at the beginning of the month.

This is different!

It has the potential to be revolutionary!

It is the work of each Royal College and other luminaries, stating that the solution to better outcomes, greater efficiency and more inclusive working with patients and carers must begin with these clinicians focusing on transforming the way clinical records are defined and kept.  Defining and adopting structure and standards which will later lend themselves to better use of technology, intelligent mining, and ease of sharing!

This is the first real sign I have seen that the kind of monumental change we need to see right across care, must begin with the experts in the care processes powering it forwards by driving the development of appropriate tools.  This is real clinical leadership in action!  Don’t be confused by the way it is reported!  This is good stuff!

I continue to be fascinated by the juxtaposition of apparently different streams of intelligence and observations.  Sometimes the light bulb moments are genuine and uplifting.

Folks!  There is hope!

Just how do we define the priorities in health?

First published 20th December 2011

’m not usually slow to understand, but I’ve just been forced to think hard about what I am missing.

I am under the impression that we are deeply in the economic mire, and that everyone is grasping at straws to try and find some savings from their budget simply to break even, let alone contribute to the £20bn savings required to offset the growing pressures of the demographic challenge, most of which comes from increasing demand of more people needing to manage their chronic condition for a longer time.

I am also still of a mind to think that the NHS remains firmly wedded to the aims of improving patient experience, improving quality outcomes, and helping people to enjoy a greater sense of wellbeing – that pithy little adage about years to life and life to years which still does it for me!

I keep seeing policy statements about localism, and devolved responsibility, and nudging closer to our partners in local authorities, and latching into their long-standing skills in commissioning.  I keep reading how desperately we need to engender a spirit which thrives on innovation, and that we absolutely must find and plant the magic beans which will automatically sprout into widespread adoption of proven ideas.  I keep hearing people talk about using technology more effectively.  I keep working with clinicians who are regularly patted on the shoulder and told how important it is that they take a stronger lead in decision making, because, after all, they are the experts.  I talk to experts on corporate governance and leadership, observing the profound wisdom that leaders need to balance effective processes, with good judgement and a dose of personal accountability.

But then, I read the topic headlines from the Department of Health, and I am confused.  The last week or so, has seen 41 pages of detail preparing the transfer of public health to local authorities, 86 pages of command to Aspirant Foundation Trusts to demonstrate that they are sufficiently on the ball to look after themselves, plus goodness knows how many memoranda instructing doctors precisely how to configure their CCGs.  Rank this alongside a staggering 4 pages of passing comment on the Whole System Demonstrator evidence of just what telecare and telehealth can achieve.  Evidence from 6000 patients, supported by 240 GP practices, showing a 45% reduction in mortality, a 15% reduction in visits to A&E, a 20% reduction in emergency admissions and an 8% reduction in bed days.

These findings merely put substance behind the intuitively obvious: that technology is just as capable of changing our business models in healthcare as it has been for every other service industry.  They suggest that we don’t need to wait another three years, for any more studying.  We don’t need to have another document from the DH micromanaging innovation, or bemoaning lack of adoption.

I am sure I must have my priorities wrong somewhere.  I still can’t reconcile why policy is measured in kilograms of report, when some of the best evidence for policy change appears to be defined by improved outcomes, more stable health and some pretty impressive efficiency numbers.  Ah well!

Too many buses?

First published Nov 3rd 2011

With a spate of bad publicity about the apparently rapid vanishing sense of caring from the world of care it was bound to happen.  The kind of fight back reminiscent of the queue of buses clogging up the roads just after it has stopped raining!

With the anticipation of a white paper on social care in the Spring: first in the queue was the minister himself.  Paul Burstow speaks about the importance of care with a degree of sincerity and authenticity that is compelling.  He has established a series of working groups under the title Caring for our Future with the specific aim of consulting with key groups before the white paper is published in Spring.  Whether he has seen the value of the Future Forum process led by Steve Field for the Health bill is open to speculation, but if this consultation process can get in touch with the real issues, rather than rely too heavily on the rather less connected view from Richmond House than it has my vote.

Then, this morning, a press release crossed my desk from the Care Provider Alliance – a body setup to represent the vast majority of social care provision inEngland.  They have just published a vision document to stimulate debate about the nature of regulation and inspection.  In it they suggest an approach to the co-production of the regulation regime, encouraging CQC to tap into the knowledge and experience of the members, most of whom admit they are seeking re-establish credibility and shrug of the tainted image left by Southern Cross.

Lo and behold, this afternoon, I bumped into another press release, this time from Dignity and Care Partnership, an alliance launched in July between the NHS Confederation, the Local Government Association and Age UK.  This worthy group has just launched a Commission, to gather evidence from all interested parties to help improve dignity in the care provided to older people whether that be in hospitals or residential care.

Together this constitutes a chorus saying enough is enough.  I applaud it, but can we have some degree of joining up to avoid dissipation of effort to get this right.

Now I leave it to you to decide whether the Centre has just allowed another bus to leave the depot, or is offering a suitable interchange station at which those on the buses may meet up for the next leg of their own particular journey.  In responding to Caring the Future, we have already billed one of the Centre’s seminars on 28th November as a forum to support its work and bring academic and practitioners together around the quality and workforce topics.  One of our planned speakers from that working group is also a leading player in CPA, and we will continue our quest to be truly interdisciplinary in our approach as we plan out that seminar.  Do help this important debate – contribute, follow and maybe even join us.

Report from the Centre for Health Enterprise annual debate

First published Oct 31st 2011

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition.

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident.

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend.

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough.

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

  • defines the basis on which professionals make their decisions about treatment;
    sets a clear expectation for patients and carers to make their choices;
  • defines the benchmark performance against which different providers will be compared;
  • enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed.

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests.

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

Trust them with the numbers

First published on Oct 28th 2011

In 1972, Archie Cochrane launched the new phase of healthcare, when he observed an almost random level of variation in successful outcomes of supposedly similar treatments at different hospitals.  The seeds were sown for evidence-based medicine, and application of scholarship to discover what constituted best known practice for medical treatments and interventions.  His name is immortalised through the work of the Cochrane Collaborative which relies on the collective efforts of many scholars critically reviewing and synthesising published research to establish gold standards for all to see – doctors and public alike.

So, nearly 40 years down this road,  some of the best minds have been pressured into agreeing a new indicator which seeks to predict what levels of mortality are to be expected at each hospital in the country.  If you have been following the debate, you will be aware how much this has led to intense deliberation, argument, counter-argument and near rebellion on occasions.

No-one is claiming that this is an easy task.  We know, for instance that there are direct links between disease and socioeconomic status, geography, gender, ethnicity and lifestyle factors such as smoking.  We also know that different treatments and interventions carry different risks.  We aren’t surprised therefore, to realise that the predicted mortality rate for a hospital will be affected by the complexity of care it provides and the characteristics of the population it serves.

So you would expect it to be difficult to predict accurately how many people are likely to die within 30 days of being treated in hospital.  That is what standardisation is all about, and why the indicator is called standardised hospital mortality indicator (SHMI).  No-one has ever pretended that delivering healthcare is easy.  Doctors have to do difficult things  most days.  Nurses do different things, equally difficult.  Managers too have their share of difficult things, but, despite being politicians’ favourite targets for abuse, they contribute to the success or otherwise through their planning and management of resources to keep the healthcare system running.

So it is right to expect people who do difficult things to be accountable to the public whom they serve.  You would expect someone to be accountable for predicting the likely number of deaths a hospital can expect.  You would expect the publication of such information to be contentious because it takes away some of that air of mystery that professionals can generally get away with creating.

Two surgeons with the same mortality rate can in reality be at the opposite end of performance – the very best and the very worst sharing the same raw number.  The one who takes on all the cases that are too risky for anyone else to consider, and in so doing saves many lives, offers a completely different level of care from that of the incompetent surgeon who fails on even the easy cases, and ends up taking lives that didn’t need to be lost.

And raw numbers can indeed tell such a tale.  Unfortunately, within a society where most people run scared of numbers, our first reaction is more likely to be to worry about how people will misuse such raw figures, instead of concentrating on helping overcome their fear so that they do know what to do with them.  I always say that the data rarely provides answers, its power is in helping you to understand what questions to ask.  And asking the right questions in the above example very quickly leads to a clear understanding of what is happening.  Only the incompetent in our example has something to fear amongst an educated population, and rightly so!

So, when we look for the evidence on mortality, we expect clever people to work their magic in such a way that they can help Joe and Miranda Public to see whether their local care services are doing a good job or not.  The experts need to put twice as much energy into educating people how to interpret those numbers, than they do in producing the right values in the first place.  The sort of good job Archie Cochrane was worried about back in 1972.

So when the Information Centre published its new evidence exposing the considerable variation in performance between hospitals, we expected transparency on the numbers, supported by meaningful education to allow people to make sense of it for themselves.  Instead of this, energy seems to have been spent on building the smoke screen behind which the hospitals and clinicians can continue hiding from the ongoing and horrific reality of unwarranted  variation.

Of course we want all hospitals to offer the same high quality outcomes, but we aren’t there yet, and until we reach such a utopia, we should each have the chance to make the personal choice of how much inconvenience we will accept so that we can get to the very best, if we so wish.  Alternatively, we might choose the extra risk so that we have minimum disruption.  And that trade-off is not as obvious as you might think.  People diagnosed with cancer in the Isle of Wight frequently choose a regime with an inferior prognosis so that they can stay at home on the island, rather than choosing a much more intensive treatment regime away from family and friends in Southampton. That is what choice is about, and why it is so important.

But sadly, those clever people in the Information Centre have determined that the data on mortality is far too complex to translate into an accessible form for the public to digest. Instead it is presented, buried in complex, highly caveated reports aimed at fellow statisticians.

Now I know a thing or two about statistics.  I know that most people do indeed have more legs than the average person!  So I’ve looked at the data with interest.

I live in Ipswich, and I know that no relative of mine has had a good experience from my local hospital, and that its leaders only ever face the light of day defensively.  I was pleasantly surprised to discover that its performance is pretty close to the centre of the band you would expect it to be in.  I was even more surprised to discover that the hospital local to Cass is predicted to have a similar number of deaths each year, despite providing much more specialist care as well as facing the more complex health demand of its east- end population.  But instead of the same number of deaths as predicted, it positively glows at number two in the country for lowest mortality.  It only had around 68% of its predicted number of deaths.  Well done Barts and the London!  But if I got off the train in Colchester by mistake, then instead of a similar number again, this time I would have found data pointing to worse mortality: 5 deaths for every 3 at Barts and the London.

We may be delivering more sophisticated treatments, and calculating some pretty clever stuff to produce these figures compared with Archie’s day.  Like him, we know that we must avoid ascribing too great a precision to our findings because the statistical significance of each of the standardised mortality figures is never better than 5-10% or so.  But even though these subtle niceties may be lost in translation for many people, we have to trust the public with such serious trade-off as 5 versus 3.  After all, this isn’t 5 tins of beans from Morrismart for the price of 3 from Markrose.  This is about lives.  Shorter than necessary lives.  Well and truly short-changed!