Monday, 17 August 2009

Revised Inverse Care Law


Tudor Hart's Inverse Care Law was formulated in 1971, and probably is due for an overhall. Instead of "good medical care varies inversely with the need in the population served", I'd like to propose
Those who need most, ask least

Tudor Hart's Inverse Care Law[1] states
"The availability of good medical care tends to vary inversely with the need for it in the population served. This ... operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced."

This was certainly the case in 1971, to the extent that a minister for health even as late as 2001 thanked the Asian doctors and GPs that work in so many of our deprived areas, where white doctors were unwilling to work.
I believe that there is much better provision of health care services in deprived areas. Yes it's far from perfect, but we're a long way forwards from where we were in 1971.

However the poor aren't getting healthier.

There could be any number of reasons for this. Cheap food of dubious nutritional value. Lower expectation of health. Lower self-responsibility for exercise and activity. others?

A revised Inverse Care Law

I'd like to propose an alternative Inverse Care Law.
Simply stated:

"Those who need most, ask least"

Those who have the greatest need of health care and support, are also the ones with the lowest expectation that they are entitled to it.
The rich and middle-class make full use of the health services available, including GP, A&E, urgent care centres, hospital, NHS Direct; health activities that may not be vital for continuing life but that make them feel better. The 'worried well' and 'only slightly sick'.
Whereas some in deprived areas assume that it is normal to take time off work due to sickness every month, to have irritable bowel, to be tired the whole time, to get old. They don't ask for help, because they don't believe help is available


See Wikipedia for Inverse Care law

Monday, 3 August 2009

Inspiration and a job well done 2

“I work hard. But the Service keeps on setting new targets and I can’t get my job done. One minute they want me to do it this way, the next a different way, and pretty soon we’re back to the first way of doing things. Why do we put up with so much change for so little progress?“
This is a common frustration in a National Health Service (NHS) driven by 689 targets [1] and with constant and never ending improvement (kaizen or CANI).

The solution isn’t, as Lewis Caroll so rightly pointed out, that we have to run like mad just to stand still [2]. A child doesn’t complain because it has to learn to walk, then ride a bike, then drive a car, to get around. It’s the human condition. The struggle comes when you can’t see the progress in any meaningful way. Ltd works with innovative teams to define the measures which will show whether they are succeeding or not. These measures need to be based around what stakeholders determine is important –

  • service user experience,
  • quality outcomes,
  • efficiency and effectiveness (more achieved with less),
  • staff impact (professional satisfaction in a job well done) and (inevitably),
  • alignment with the strategic goals of the organisation and the local health economy.

Teams decide what’s possible to measure, who will do it, how it will be reported. They tell me that it’s now easy to collect, measure and report because what’s being measured is relevant to their lives and those they care about. They do it for self-serving goals – to see if they are delivering the service and improvements that they want to see.
When the organisation is involved in setting the framework of measures, individual team contributions can be aggregated into an overall picture for a scope of care, so that team initiatives can be illustrated for the part they contribute to a strategic goal. Ownership of benefits realisation is at the most customer facing level it can be[3], and achieving the greatest possible outcome (because it takes into account the identified priorities of the stakeholders – often around the health and well being of the population).
The strategy (BMS -[4]) needs to be developed with the stakeholders, the frameworks [5] need to be developed with frontline staff as well as performance departments and executive directors; everyone wants to do the best they can and with strategy and frameworks in place they will.
I’ve used these principles to support staff to introduce strategies, frameworks and the measures for individual projects which support the continuous innovative approach. Email me to discuss how this approach can help you.


1. Blunden, F., Frances Blunden on the burden of NHS bureaucracy, in Health Service Journal. 2009,
2. Carroll, L., Alice in Wonderland. 1988, New York: H.N. Abrams 62p
3. Semler, R., Maverick : the success story behind the world's most unusual workplace. 1993, New York, NY: Warner Books. 335 p.
4. OGC, OGC Gateway™ Process Review 5: Operations review and benefits realisation, in OGC Best Practice - Gateway to Success, H.T. UK Office of Government Commerce, Editor. 2007, Crown Copyright: London, UK.

Tuesday, 21 July 2009

Inspiration and a job well done

Why did you join the caring professions?
Everyone I speak to has a story to tell – a family connection, a loss, a deep desire to help / to heal / to cure. But so often this original spark, this burning desire, lies buried under the petty annoyances and humdrum activities of day to day service.
Doctors and nurses, AHPs and social care workers, managers and support staff talk about the high points in their career in terms of single instances – the child who felt strengthened at their lowest moment, the obscure diagnosis with a straightforward cure. Moments of inspiration that are few and far between. Most days a seemingly endless and uninspiring routine.
As you know, my work is to help people involved in service delivery and service change to remember why they are doing this, to understand what a difference they are making, and if it isn’t good enough, to change their approach THEMSELVES to make it better. I do this through helping people, teams, organisations and whole health economies to define the measures that mean something (reports that people can take home and tell the kids “I made a difference today”). To record things that they put a value on, to analyse and report because THEY WANT TO, and to feel good about the outcomes.
We align the measures for new and existing services to the objectives of the workstream, the organisation, and the health economy. You can see your individual contribution, how you fit in, the difference you are making. You have a place, a significance.
This has an interesting knock-on – public sector objectives move as fast as (or faster than) local demographic change, political whim, and new understandings/ new technologies. Which is pretty fast. When teams set their own measures, they tend to align the measures with strategic objectives meaning that as these change, so the individual team measures change. And as people do what is inspected not what is expected, as we change the measures we record and report, we change what we do. No longer the need to send someone from management in to redesign services and impose the changes on people, because we’re doing it ourselves.
This theme and others on the use of measurement and Benefits Frameworks for performance improvement, alignment to strategic objectives and Recruitment and Retention, are explored further on my web site and blog Please call me to talk further