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

Thursday, 16 July 2009

The case for change - funding innovation in social care

Allan Bowman, Chair of SCIEAllan Bowman of SCIE (Social Care Institute for Excellence) points out that it’s not enough to throw money at the requirements to fund care for older people and those with a disability; we need to consider whether the capacity is there to deliver care at the right quality (reported in Guardian Public magazine [1]).

Of course this doesn’t just apply to social care for these groups – it applies to all public services where the care will be provided by a mixture of public and independent providers (ie pretty much everything).
Care is constantly evolving, getting better (whether this means more tailored to individual need, giving outcomes that meet a higher criterion of health and well being, more effective use of limited resources, or all three). However any change costs money – requires that pioneers develop the new enhanced service. The mantra at the moment is to learn lessons from overseas – but with USA trying to be like UK [2], and many other countries with no real concept of publicly funded health and social care, where will we learn these lessons?
Public sector commissioners used to rely on charities for innovation. But charities are increasingly reliant on an income from the provision of specific services[3] and have less left over for testing out new types of working[4].
There’s a vital need to invest for innovation – the funds have been made available but without the security of a funding stream many organisations are simply unable to commit to building the capacity which will provide services of appropriate quality, and enough workforce to provide the capacity, We found [4] that the expectation is smaller organisations are more agile and likely to innovate, whereas they don’t have the capacity to deliver the volumes local authority requires. An ideal solution would be to contract with a consortium of suppliers required to collaborate, so some can focus on innovation and sharing, whilst others can provide the vital services. But getting innovative organisations to share their intellectual property, and service providers to share their income, is proving tricky.
I’d be delighted to work specifically with the following groups to bring together groups of public service commissioners and existing and innovative providers to build a consensus and prepare for an innovative service:
• Charities which commission personal care and health care services
• Capacity builders and those who fund innovation
• statutory commissioners eg Local Authority, Social Care, NHS


1. Dudman, J., Social care professionals cautious over new funding plans, in Guardian Public. 2009, Internet.
2. Porter, M.E. and E.O. Teisberg, Redefining health care : creating value-based competition on results. 2006, Boston, Mass.: Harvard Business School Press. xvii, 506 p.
3. Minney, H. Innovation - Case for Investment in Social Care. Performance Improvement and Outcomes Realisation 2008 [cited 2009 16/07/09]; Skills for Care workshops in North East]. Available from:
4. Minney, H. Commissioning Innovation. Performance Improvement and Outcomes Realisation 2008 [cited 2009 16/07/09]; Available from:

Tuesday, 7 July 2009

Innovation in the NHS

Innovation, path to the future
How to improve outcomes, how to be more effective?
The Darzi reforms had their first anniversary last week - and they have been very successful over the last year, certainly in terms of brand awareness.
Quality was the theme for the year. It was a good theme - highest quality removes waste which avoids unnecessary costs (more effective), and often quality and effectiveness go hand in hand.
There's only so far you can go with improving quality and improving efficiency. The same pathway but better. 10% cheaper. As the Wanless 2002 report indicated, if we're still doing health care in the same way in 20 years as we are today, every able person will be occupied looking after the less able - we have to change.


Making a real difference comes from being prepared to start again, to go back to the drawing board. All the lessons we learnt about process mapping, about redesign with patients and front-line staff, are all appropriate here: perhaps one of the classic examples is the ECP, giving the first professional contact with the patient, the skills, competencies and authority to change the care, to refer to a more appropriate patient pathway. This makes a real difference - community care instead of hospital care, self management instead of institution.

Permission to fail

But how do you know when it's working? That's when a really strong measurement and reporting regime is needed, tied to meaningful measures designed and implemented by front-line staff, permitting staff to recognise where their own project works and where it needs modification, and the tools to make the changes themselves.


Of course it requires people to talk to each other. In a market place environment, commissioners and providers need to understand the risks and rewards of innovation and work together to achieve the much-needed benefits

All of the above projects were run by Hugo Minney and I'd be delighted to work with you on your project

'Securing our future health: taking a long-term view' April 2002, HM Treasury an independent review by Derek Wanless
Search for: INNOVATION

Monday, 6 July 2009

Quality is the new buzzword

Quality is the new buzzword (HSJ 25 June 2009).
I return to my original thesis, that all care is delivered by people and therefore innovation, and quality, is predicated on the motivation of staff, volunteers and carers.
QualityMark.jpgMeasuring becomes ever more important than ever. "People do what you inspect" is just as relevant to the self (I do what I'm measuring - I take a shower faster if I'm timing myself, I stick to speed limits if I treat that as a priority) and staff that set their own goals and have the tools to understand how they fare compared to the goals they have set are going to achieve more, with more enthusiasm, faster, than a team with an imposed goal, and feedback 6 weeks after each monitoring period.
Give people the tools to make a meaningful difference, and we'll do it!
Hugo can establish - with front-line teams - frameworks for Benefits design, planning, realisation and reporting and help align individual and team goals to the strategic objectives of the organisation or local health (and care) economy)

Sunday, 5 July 2009

Stormy Weather

Today at the supermarket we saw rather a lot of very smart convertible cars. Drop-top jaguars and mercedes, roaring porsche and TVR. I'm sure I read somewhere that there's a recession on. Isn't it interesting how the weather can reflect the times? Or do we just notice it when it does?
The weather's unpredictable. The public appears (at least from the newspapers I read) to be completely split on who is best to run the country - do we go for the party that promises everything to everyone (in the same speech promising to "cut mindless burocracy" and "provide administrative support for frontline staff"; then promising to hold down public sector spend with reductions of 10% a year, but of course the [insert audience here] department will have its budgets maintained), or the party that everyone loves to hate but rather a lot of economists and bankers are saying other countries should immitate?
The health service faces its own dichotomies. There are finite resources. There are new technologies, each more expensive than the last, each marginally better. People are definitely sicker - where did MS, ME, Fibromyalgia, CFS come from? Or did we just not diagnose them before? Why the sudden increase in diagnoses of depression, neuroses, autism? Is it really because we can diagnose them, is it really because we keep people alive who would otherwise have died, are there enough kept alive to account for these large increases?
I wonder how many of these problems come back to simple things. Take the situation in the health service: could it be that something has changed about the food we eat? And could it be that unexplained presences or absences in the food are causing all of these problems?
Makes you wonder if the same is the case for politics . . .

Exciting Writing

‘Writing to inform and persuade’ is the knub of it; but who is to say what is good and what is bad?
Two presenters
I listened to two medical talks a couple of months ago. One followed all the rules: the slides were clear and memorable, forming a continuous story with a start, middle and end. The content was relevant to the audience; the talk ran to time.
The second stood between the delegates and dinner. It consisted of 40 slides for 20 minutes, each one another case study. Many of the slides were scans of handwritten notes and Word documents. With every slide, the presenter paused, looked at the slide, said “oh yes, now this is a very interesting one” and proceeded to spend 5 minutes describing it in detail. At 20 minutes I interrupted and asked the audience if they were prepared to delay dinner to listen to more. They were fascinated at this old man, talking about his life’s work in this rambling way, and many committed to check their own patients for the same symptoms. The younger doctor who gave the first presentation left in disgust.
My lesson
I wonder if we concentrate too much on form over function. PowerPoint slides “should be this”. Rules for doing a good presentation. Dressing for power. I don’t give talks unless I have something to say – content leads, followed closely by enthusiasm (if it doesn’t excite me, why should it excite anyone else?).
It makes me wonder how many times people try to whip up enthusiasm when they are only faking it. How many talks have no real content – they just fill a 20 minute, or 90 minute slot. How many times we say what we don’t mean.
Action steps
If you want people to buy more services from you, what’s the risk in saying so? Be clear: “this is what I’m enthusiastic about, this is the difference it can make to your work, now buy from me”. Audiences are cynical and suspect that’s what you are trying to say anyway, and telling them that they were right is surely one of the most sincere forms of flattery!
If you want to reignite that enthusiasm that people had when they joined, the passion for the work, aligned to your business objectives, that’s my specialist area. Talks, workshops, implementation; make it happen, make your organisation sing again.

Monday, 22 June 2009

Treasury decides not to bail out charities who lost in Icelandic Banks

Would it be unfair to suggest a certain naivety?
Since BCCI, and probably before then, the saying "if it looks too good to be true . . ." has marked a common-sense approach to money. Putting it simply, charities should steward the money in their trust, not try to profit from it.
What has happened here could happen to anyone. Some charities (Cat Protection League and another 29) had gambled, looking for the most profitable place in which to deposit donors' money. The gamble didn't pay off.
Many of us are suffering because of this credit crunch, and because of the view in public sector that cuts will come and they had better remove people from jobs before it does. There is less money to go around, especially from government which is about to get a big unemployment bill and additional services bill. It would be a great confidence boost to dig charities out of a hole, but it was this "no pain" culture that got us into the banking crisis, and charities should see themselves as of higher probity than that.

Sunday, 14 June 2009

What I learnt from you

arrow to target - strategic alignment
I ran a break-out session at the New Types of Working Skills for Care/Skills for Health conference last week. It was very instructive – for me!
I took a 4 month programme that I’ve now run twice in different contexts ( and and again as a whole day workshop led by Ann James CBE ( For the New Types of Working conference I tried to present this as a 1 hour break-out entitled “A way forwards – aligning services with strategic objectives in Health and Care”.
Bernice McCarthy was wrong – 80% of people don’t want to discuss WHY, don’t want to know WHAT, they simply want to know HOW do we do it. Perhaps Jay Abraham was right?
Anyhow, back to the workshop. Essentially three audiences:
  • commissioners (statutory, NHS and social services; there were no charity commissioners in the audience);
  • providers (NHS, Local Authority, Independent Sector, Third Sector (not for profit); and further and
  • higher education.

We included at least a few from each.
We started discussing how to set strategic objectives (common misconceptions such as everyone understands each other and everyone shares the same language and priorities).
Then we talked about engagement – again misconceptions (everyone thinks exactly the same way that I do, and my priorities are shared).
There wasn’t time to run a strategic alignment workshop (which anyway takes around 3 hours to 1 day).
Some people wanted more (can we have this as a full day?), and others were disappointed (he didn’t answer the question). I look forward to feedback.
If you want a programme to understand your region, I’d be pleased to discuss ( it though I would suggest more than 1 hour with the stakeholders.

Tuesday, 9 June 2009

Why front line professionals get suspicious of benefits workshops (engagement and benefits)

I went to a benefits workshop on implementing a new IT service within a big organisation. We looked at the features of the solution offered, and were asked to identify benefits for each stakeholder. Over 4 hours we brainstormed, and focussed, and documented, and planned how to measure.

Then it struck me – this is all the wrong way around! Granted, I usually examine benefits in front-line (health and care) environments not in back office functions, but many of the enablers are back office.

Nobody at the event asked “didn’t we already know why we wanted this, before we designed it?”. Instead of starting with the need and creating the solution to solve it, we appear to take the solution as the fixed item and look for ways to justify it after the event. If we knew why it was wanted, the benefits design, planning, management and realisation would be simple: does it do what we want it to do?

Lightbulb moment

So start with the need. What is the problem that needs solving (insufficient resources to meet demand, waiting lists too long, costs too high, demand for different services, administration ineffective, people’s safety privacy and respect threatened)? What is the whole of the solution that IT is only a part? What about the IT solution proposed (or mandated) actually solves the original problem, in conjunction with other (workforce, service transformation, facilities change) components?

Build a benefits profile around this. IT solutions can’t deliver benefits in isolation, and nor can most of the other components of the solution. The solution is in response to a need, so the benefit is resolving the need. Monitor progress towards resolving the need, and you have your benefits realisation. Measure something specific to the IT project, and you run the risk of becoming divorced from the whole solution and benefits not realised.

Thursday, 4 June 2009

More for Less - NHS Growth Money is coming to an end

"All bets are off" as David Nicholson tells NHS to prepare for cuts (HSJ 4June). Massive investment over the last 8 years hasn't improved productivity (HSJ 28May). PCTs aren't making use of the wealth of experience and enthusiasm available through Practice Based Commissioning (PBC) (Primary Care Today May/June 09). The same old ideas are put forward as the solutions to all our problems - more care out of hospital, more innovation, more work led by nurses, more Health centres, more salaried GPs.
Why haven't these 'obvious' solutions delivered? I'm not convinced that inertia is the complete answer.
  • Changes which deliver better care, more effectively, can only occur at decision points on care pathways. Many health service staff are engaged in the delivery of care according to a protocol. Therefore we need to focus on the decision points, and necessarily on the decision-makers. For example, GPs decide which pathway to refer a patient onto; community nurses very often provide the care on that pathway, but don't change it. ECPs (Emergency Care Practitioners) make a diagnosis and a decision where to refer when they attend the scene of a fall, an accident, an emergency; advanced paramedics or alternately trained paramedics have limited protocols and limited options.
  • salaried GPs employed by PCTs are no substitute for the family doctor. A salaried GP does not become a point of trust for a doctor (70% of GP appointments result in no referral and no prescription; patients attending to be told that they can carry on as they are, or to be listened to - by an old friend or a family friend, not by a stranger); a salaried GP moves from practice to practice according to their state of life, perhaps in the big city when young, in the suburbs when the children are school age, and to the country when the children leave home
  • care needs to be given in the most APPROPRIATE location, and by the most appropriate staff, regardless of politics and organisation. For a great many patients and a great many conditions, hospital is the best place for treatment. For a lot of other health care, the hospital staff may be the best, even if care is to be delivered in the community or patient home. All the suspicions about hospital staff steering patients towards their hospital for maximum income appear to be unfounded
  • "Redefining Healthcare" by Porter & Teisberg looked at different ways of delivering healthcare across USA, and clearly concluded that the UK system of GPs as the first point of contact is not only the most cost-effective, but also delivers the highest quality health care
Healthcare is improving (although QOF rewards for process, this is resulting in for example higher proportions of those on the CHD register with low blood pressure - see HSJ 28May 2009, same article). We do need innovation, but we must not throw the baby out with the bathwater - keep what is good, find ways to encourage what will make it better.
All we are saying, is give PBC a chance.

Tuesday, 2 June 2009

Organisational Benefits Approach - request from Steve Jenner

Dear friends
Are you using a Benefits Approach? How does this compare with other organisations?
Steve Jenner (the driving force behind the development of UK Criminal Justice System IT approach to Portfolio and Benefits Management, that was referred to by Gartner, the European Commission's economics of e-Government project and by the UK Government report to the OEDC as "UK Best Practice" and which won the 2007 Civil Service award for Financial Management). Steve was described by the UK Government CIO as "the rottweiller of benefits management"
Steve is looking at how organisations approach benefits, and in the spirit of understanding properly, wants to ask organisations to rate themselves. He's created a survey on SurveyMonkey(a secure site approved by US and UK governments for surveys of this nature) and as it only takes 20 minutes or so to complete, please mouse over to the survey and have a look. If you fill in contact details we'll email you for an address to send a copy of the guidebook "Managing the Portfolio, Realising the Benefits" on the CJS IT implementation referred to above.

Have fun!

Click Here to take survey

Monday, 1 June 2009

World Class Commissioning could save PCTs £3bn over 5 years

With savings like these, NHS could become a net contributor to the Treasury!
£50,000 per QALY (Quality Adjusted Life Year - the value assigned by statisticians that an individual puts on being healthy for a year) is a reasonable figure, but lets not get mixed up - nobody gets £50,000 in their hand, least of all government (who may have to pay for statins or insulin during that extra year of life).
It's a common misconception that "savings" achieved by transforming healthcare or social care can be counted by adding up the pounds. For example, if an IT project saves 3 minutes per patient search, then how much does it save over a month? Well lets assume that the GP surgery does 100 such searches per day, sothat's 300 minutes. And of course all of the savings can be turned into money, at £10 per hour that's £50 per day. Who gets the savings? Certainly not NHS - as I said, faced with spending 5 hours per day on searches that aren't essential and are only ever used for some admin, most GP surgeries would just not do them.
QALYs are very important to NICE (National Institute for Health and Clinical Excellence) for determining whether a particular treatment represents value for money - if a course of medication extends life by 6 months, then it represents value for money if it costs less than £25,000 (6 months * the value of a QALY), and not value for money if it is more expensive. But you or I can't bank the money. If I were on death's door I would be prepared to spend everything I have for a little extra time, and that might be £50,000 or more, or it might be a lot less.

Sunday, 31 May 2009

A letter for keeping Jobs

Let's be realistic: this crunch won't last for ever. And when it ends, consumers will need new products. We're going to need innovation in financial services (after all, we can't reuse the failed products of last year and preceding decades). New delivery services (keeping food miles down, recognising more purchasing on the internet, even home delivery services from a trip down the high street so you can go on spending!). New transportation options (carbon footprint again). New eating and socialising options (when facebook and twitter take their rightful place not as substitutes for an evening out with mates, but as the enabler). New everything.
We could leave it to a few very talented inventors to come up with new ideas - but the things that catch on have a habit of being surprising.
Perhaps we should dedicate the hundreds of thousands of people who are at risk of losing their jobs, dedicate them to creating innovation. The alternative is that society has to pay for them anyway (unemployment, mental health medication, lack of confidence to contribute for decades to come) but gets nothing back. This way (ie with government paying the same amount to their employers, as long as these workers are dedicated to discovering innovation rather than business as usual) gives people their self-esteem and puts Britain in a very very strong position coming out of the recession.

Tuesday, 19 May 2009

Dr Chandy on You Tube (B12 deficiency/ Cobalamin Deficiency)

At last - found the BBC Inside Out programme from 30 October 2006 on B12 deficiency

When you think you (alone) know

Two heads are better than one, especially when they look at a problem from different perspectives.
The saying goes that if you ask 2 doctors for an opinion, you’ll get 3 different opinions. And probably each will assume that everyone agrees with him/her. This could apply to any professional, and even more so between different professions – picture a question of additional hours: someone with a responsibility for finance argues completely logically for a very different outcome from someone concerned with staff development. They haven’t understood their differences, and none understands why the initiative hasn’t gone ahead exactly the way they assume it should.
This lack of understanding of each other affects many service transformations: nobody is exploring what the blocks to delivery are; clinicians are blaming management as the key block, and of course vica versa
Facilitated sessions have unblocked similar situations in the past. In particular elucidation of what each means by their understanding of the overall goal, where there are similarities and how they can be brokered together has fostered new understandings and a common desire to achieve a common goal (exactly where you thought you’d started).
Think of the time these professionals spend in meetings and not able to make any progress. Think of the frustrations, and the mood that puts people in to obstruct future “management initiatives”, the measurement and monitoring, and service transformation. I’ve facilitated a change in awareness and appreciation of difference that breaks down barriers and aligns people, both with each other and with strategic goals.

Call to Action

Invite facilitated workshops specifically arranged around bringing different professionals together.

Tuesday, 12 May 2009

Did we really mean that?

Half-way to implementation, we have to look at the unrecognisable mish-mash of a service that’s somehow evolved from the original idea, and seriously consider whether to cut our losses or whether it can be remodelled into something functional.
There’s many a slip ‘twixt the cup and the lip. The right research, analysis and design puts forward the right solution, for example a new care pathway complete with new or adapted services and service delivery. But a service definition can only define so much, and you still need people to align with the reason WHY.

It brings to mind my report on the pilot of Payment by Results. I interviewed medics, nurses, commissioners and managers in the South Yorkshire Laboratory after PbR had been running there for 12 months and was about to be rolled out in the rest of England. I asked them “how do you see this evolving?” (and to stop them committing suicide after I left, I concluded each interview with “what are you personally doing to put things right?”). The overall conclusion was that PbR is simply a system, and its success or failure, its ultimate benefit to the health of the population and best use of resources, depended almost entirely of the will and intent of the people who work within it. It’s possible, nay easy, to game the system. It’s also possible to provide an exemplary service and to receive due reward for quality. I like to think that the current HRG4 with reward for quality was in response to my little report.


What are you trying to implement, that you haven’t explained? Worse, what are you trying to implement where you haven’t involved people in designing, ensured everyone agrees the goals and strategic directions, that you haven’t put in place inspiring markers that let people know whether they are making progress (I call them “benefits”)? Social care and health care are staffed by inspired, highly intelligent, highly motivated super people. Without a system to report progress made, to tell each and all of us what progress we are making, many become demotivated. At least if you are following an accepted protocol you can assume that you’re having the effect that usually follows from following this protocol, but when change is asked for, naturally change meets resistance. If people understand the why and the evidence for the change, they are far more likely to engage.

How do you demonstrate improvement?

Do you have a reporting system (especially on service initiatives)? Is it designed to report on things that motivate people, such as proxies for quality outcomes (better health, better quality of life, better results, even better targeting of resources) – or does it just report a table of numbers or activity?

What could you achieve by aligning all of these superpeople (supermen and superwomen)?

Tuesday, 5 May 2009

Cultural Differences

Where are you today? How much of your environment, the jargon and language you use,
the attitudes, do you take for granted? Do you sometimes find (for example at conferences, or dinner with non-work friends) that you have to explain something you thought ‘everyone knew’?

The biggest barrier is assumption

In professional circles, particularly where the training is lengthy and the regulations and license to practice onerous, one of the biggest barriers to communication is assumption. You hear a word and think you know what is meant – the other sees you nod and carries on, and 10 minutes later you realise just how far apart you really are.
What would it be like to be understood first time around? Not to win every argument, but at least to be heard, permitted to make your point? And what can you learn from your colleagues, if you take the time to recognise that they may be talking a different language (using the same words with different meanings, or different words to talk about the same thing)?
Think what you could accomplish!


Next time you’re talking with people of a different professional background (eg health and care professionals to administrators, health professionals in different environments, the next MDT meeting especially if it includes enforcement staff), listen out. Not just for the words that help you build rapport, the pace and tone of speech and representational systems used, but for the line of reasoning, for the little red flags that suggest you might have missed the point although most of it sounds familiar.
When is the next interdepartmental meeting? What could you achieve by getting this right? What do you need to prepare to achieve this?
A lot of questions, but I’m sure you’ll agree (after the event) that it transforms what used to be frustrating wastes of time into really valuable and productive meetings.
If we’d known the start point, we wouldn’t have ended up here!

Thursday, 30 April 2009

If we’d known the start point, we wouldn’t have ended up here!

If we’d known the start point, we wouldn’t have ended up here!

A tricky situation

A few years ago, my team and I were asked into a major teaching hospital to ‘run service improvement workshops’ in three directorates.

They were at very different stages of development. One directorate ran seminars every year, and enjoyed brainstorming their possibilities, selecting the best options, working up action plans and benefit reporting, and assigning the tasks. Talk in the room was about opportunity and possibility, and how much had been achieved from previous years.

One directorate failed to set a date for the workshops. The senior clinician was acting medical director and never had time to call his top team together, and the top team didn’t want to make a decision without him. Our best efforts to get them to talk about opportunities were met with talk of targets and indicators that they had to meet now.

The third was different. On the surface all seemed normal – fairly high levels of sick leave and busy shifts that nobody wanted to work; give and take and banter.

Preparation is the key

As we interviewed each of the senior team in private, in preparation for the workshop, it became apparent to us that they weren’t on speaking terms with each other beyond the minimum required to keep up the façade. To try to run a service improvement workshop with this lot would be to try to teach a hungry tiger how to perform first aid – the end might be worthy but they just weren’t ready for it.

A disaster waiting to happen – averted by careful planning

In our case, we spotted the situation and were able to change the nature of the workshops so they became much more personal, directly tackling the communication issues and the very real resentment. We got the 6 top team members to discuss (in a protected environment) how working in that situation made them feel, what they thought could be done to put it right, and their own personal responsibility for both the problem and the solution. With the top team united, many of the problems of sickness and understaffed shifts resolved themselves with substantial improvements in patient safety and patient experience.

Cost-Benefit Analysis

The key is to use facilitators who are skilled and experienced enough to identify the situation they face, and to prepare a plan to resolve it.

Can you imagine the ‘successful’ workshop that failed to address the real issue, and that perhaps resulted in humiliation for senior staff with the inevitable litigation and claims for unfair dismissal. I often meet people with the title “service improvement facilitator”, and there’s an enormously wide range of skills and experience. Some have 20 years’ of managing teams and delivering workshops, whereas others are just out of training grades (“no experience needed”).

It will pay for itself many times over to get the right outside organisation to tackle those difficult situations, and give your staff facilitators a chance to learn from example.

Thursday, 9 April 2009

The Hippocratic Oath

THIS PAGE HAS MOVED TOΔιαιτήμασί τε χρήσομαι ἐπ' ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμὴν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν.
I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone.

Further, in GMC's "Good Medical Practice (2006) - Good Doctors" Patients need good doctors. Good doctors make the care of their patients their first concern:

This focus on the individual patient and their immediate need can conflict with community welfare, conserving economic resources, supporting the criminal justice system or simply making money for the physician or his employer.
This means that a doctor is almost obliged by his/her vows as a doctor to ignore Public Health priorities or the strategic objectives of the health economy to serve the immediate needs of the patient in front of them.

What does this mean in practice?

Management of resources, and treating immediate need, are difficult bedfellows.
The bridge between them is Public Health, or a proactive attempt to prevent ill-health through resolving the environment that will ultimately (and probably already causes) cause poor health.
Actions to reduce smoking can be perceived both by physician (improved health) and the economist (reduced future cost, reduced lost production) as beneficial to society.
Finance managers can see the long-term benefits, but sadly this year's budget has to provide both for this year's clinical needs (last year's smokers), and extra resources for the proactive programme that will reduce next year's bill. It's a difficult decision and it emphasises the importance for doctors to recognise the legitimacy of public health targets and the need for planning, and of course for managers to understand the constraints under which doctors work.

Sunday, 5 April 2009

Clinical quality vs profit

They say another key difference between clinicians and managers is that managers are only interested in what will make money, whereas clinicians are only interested in delivering the highest quality.
I don't know if you've studied Lean methodology in any detail? It's a series of techniques for improving the delivery of services and products, and
NHS Institute for Innovation and Improvement has released a number of guides of its Productive series, Productive Ward, etc.
This is about getting people to question the way we do things round here, to see if there's a better way.

Community Engagement

It's about getting staff engaged locally, down to their own individual teams, and some of the techniques including management by walking around and process mapping involve everyone working together - sponsors (typically executive directors), senior doctors, consultants, nurses and AHPs, hospital staff or primary care health care staff (staff nurses, staff medical, etc) - to map out how the patient journey is done now and where are the things we do that don't add any value.
For example, the patient waiting in the waiting room doesn't add any value. The patient going home and coming back for another appointment doesn't add any value. Writing labels on blood samples going for diagnosis adds value, but is there a better way (adds more value or takes less effort). Recording the number of patients waiting only adds value if you do something with the results.

Staff Evaluation

Staff themselves are involved. We work together. We learn from each other, understand why a particular action or a particular step is necessary, and jointly evaluate and agree what isn't necessary. The service is better quality, because there's less waste. The service is lower cost/ uses less resource, because there is less waste.

Tuesday, 31 March 2009

The Manager/ Clinician Divide


Why - the Manager/ Clinician divide

There seems to be an enormous gulf, in healthcare, between those that care for patients, and those that administer. Neither side seems to trust the other – clinicians accuse managers of thinking only of costs, and in return managers complain of a refusal to recognise limited resources. This applies in other environments, eg social care, where care professionals and management also seem to struggle to bridge the communication gulf.

I was at a NAPC dinner the other evening, and met a person who was amazed I believed that it was possible to forecast. I asked the question “what is the likelihood that someone will win the lottery this week?” Of course the answer is “anybody – pretty much certain. A specific ticket – 14million to one.”

Having spent time helping teams to work together in contentious areas such as service redesign, I present my conclusions on the differences (I’m going to use the term ‘administrator’ throughout, as I believe the problem set in when administrators took on the title Manager and thought they were important):

They think differently

Administrators and clinicians have different views on the world. This reflects the kinds of people that gravitate towards each role.

Doctors, nurses and AHPs like working face to face. They have endless patience to address each individual need, but it makes it difficult to then take a helicopter view and say “how many next year?”, “what skills will be needed?”, and “what do I prioritise and what do I do with the ones who aren’t prioritised?”. Administrators provide the complementary function.

Care vs statistics

This focussed ‘one by one’ approach can lead to different responses when each looks out into a full waiting room. A natural reaction from the clinician is “I’m so busy, how will I manage?”, whereas the administrator should take the view “I need to plan to manage” – but then that is what the manager has prioritised their time for, planning ahead.

Similarly the clinician looks at the patient presenting and says “what condition do they have?”. Statistics play a relatively minor role in this process. The administrator looks at the demographics and disease prevalence, and says “what resources do I need in place to meet the likely requirements, and to provide a response in the event of something serious but rare?”. The Administrator has the phenomenally difficult task of deciding how to prioritise limited resources, and who to say “no” to. Mind you, the clinician has to look the person in the face!

Planning ahead

There is, there will always be, more need than there are resources. Demographics change over multi-year periods, eg the number of people living with long-term conditions, the numbers alive in different age decades and their changing needs. Two studies illustrate that quality care is not dependent on the amount of money spent – one done by me on World Health Organisation data shows that within a limited range more money spent = longer life, but USA spends much more than anyone else (both as % of GPD, and also because GDP is so high per head) without getting better results:

after Porter & Teisberg who quoted Friedman, Milton in "How to Cure Healthcare" pg 20

And the one below quoted in Porter & Teisberg pg 29 showing that the UK model of GPs to see all patients and refer those who need further treatment to a specialist not only gives higher quality care than the patient self-referring from one specialist to the next, but is also cheaper:

(incidentally, why are we in UK trying to imitate USA when they are trying to imitate us?)

The administrator’s task

To set the strategy, or if it is already set, to plan how to comply with the strategy in a specific situation. This means taking advice, gaining understanding of the clinical requirement, understanding the resource requirement, whether different skills or a multi-disciplinary team is required, and how.

It applies today, and it applies in short, medium and long terms.

Bridging the divide

We’re going to present specific techniques for getting working groups that work together, and illustrate with some successes (both mine and ones I’ve studied). The first step is to acknowledge the difference.

Friday, 27 March 2009

NAPC Education Event - Practice-Based Commissioning

THIS PAGE HAS MOVED TO's always fascinating to go to a national conference (as long as you don't do this often)
Speaker after speaker explained their vision for PBC (practice-based commissioning - the policy of inviting groups of GP practices to review needs for their patients and make recommendations to their Primary Care Trust for changes), all the way from "the decision-making for care should be in the hands of the GPs" (Department of Health) to "we formed a consortium representing 97% of the population of the PCT, and now we're proposing services we might run".
Same old same old. The key issues remain:
  • real figures relating to demographics (how many, what conditions would be expected) and activity (how many treatments currently provided)
  • understanding the local process for acceptance of business cases for new services, and having followed the process, having the business cases accepted
  • vertical and horizontal integration between different organisations with different priorities (we're all on the same side - how do we have different priorities?)
  • trying to build incentives which bind unlikely bedfellows, and hoping that the incentives will actually lead to better care for the population and service users
  • potential for conflict of interest when a GP refers to a service which they themselves provide
  • long-term solutions in an environment where "long-term" can only ever mean up to the next policy change - if you haven't got a return on investment within 3 years, the ground rules will have changed before you do get one
there are clearly some excellent and outstanding initiatives going on, sometimes with NHS blessing, and sometimes in spite of NHS. Real risk remains with the initiators, and as more not-for-profit organisations are created to deliver new services, this becomes one-sided leaving the initiators with all the risk and no opportunity for reward.

A frequent comment from the audience was "how can you do it that way when we aren't allowed to?". It is painfully clear that different PCTs have set different environments for PBC, and what works in one part of the country only works because of co-operation. A quick look at the World Class Commissioning (WCC) scores suggest that the PCTs with the highest scores also have the most interesting PBC initiatives.

I'm certainly going to follow up many of the presenters who have useful and valuable solutions and/or contributions. I'm going to follow up with NAPC on how to make the politics work. And I've come away with many new ideas and new things to try. Thank-you

Monday, 9 March 2009

National Voices - notice of Policy Initiatives

Week-ending 6 March 2009

1.  Personal Health Budgets update

DH is starting a pilot programme for personal health budgets, as a way of giving people greater control over the services they use. The pilots will build on experience internationally and in social care in this country. Further information on this, together with a general update on personal health budgets is available here.


2. Care and Support on Facebook

DH has recently launched a Care and Support Green Paper page on Facebook. The page is available here, providing users with the facility to watch videos, see pictures, read articles and share their thoughts in the run up to the publication of the Government’s Green Paper on the delivery and funding of care and support.


3. Government launches help for volunteers, charities and social enterprises

Government has pledged £42.5 million to help volunteers, charities and social enterprises deliver extra real help to those that need it most, during the global economic downturn. The action plan for the third sector, published by Minister for the Cabinet Office Liam Byrne, sets out a targeted package of support that includes measures to help hundreds of voluntary organizations, charities, and social enterprises step up advice, support and volunteering in the areas that need it most across the country. Further information is available here.


4. Self-management network for people with long-term conditions

The Talking Health Network is a collective of independent consultants experienced in all aspects of setting up, developing, promoting and supporting high quality, values based, lay led self-management programmes for people living with long-term conditions. Further information is available at provides more information about the Network along with details of Network members. If you are already involved in self-management interventions and would be interested in joining the Network, please email the administrator at



5. Independent review of NHS dentistry

As part of the independent review of NHS dentistry that is currently being carried out, the review team led by Professor Jimmy Steele is looking to engage as many stakeholders as possible. A page is available on the DH website which provides a background to the review and its objectives and how people can feed into the review via email.


Professor Steele is publishing his views on the review as it progresses. This information is available here:


The deadline for responses is 30 April 2009.


6. Kennedy study on valuing innovation

NICE has commissioned Professor Sir Ian Kennedy to conduct a short study on valuing innovation.  Please note that the call for written evidence has now been published on the NICE web site.  Key information about the study and the instructions for making submissions to it are available here.


7. NCT job vacancy

NCT (The National Childbirth Trust) is currently recruiting for the new position of Public Policy Officer - Transition to Parenthood. The role is responsible for developing and promoting NCT policy positions on issues concerning women and families in the transition to parenthood, specifically focussing on the health and social issues concerning pregnancy and birth and the social and emotional issues in the very early months of new parenthood, throughout the UK. The post holder will work closely with key policy representatives across the sector, and represent the NCT in discussions with central, devolved and local government bodies. The postholder will undertake a wide range of lobbying and influencing activities with the UK government to promote improvement in services and supports for parents of young babies with regards to maternity and parent and family support services.


For more information and application details visit

8. Diabetes UK opportunity

Diabetes UK is seeking a Project Manager to be responsible for user involvement in local diabetes care (2 years fixed term contract). Further information is available here.


9. Conferences & events


§  Living with a condition – Using research to identify realities

18 March 2009, London

11am- 12.30pm  

Location: Opinion Leader, 4th Floor Holborn Gate, 26 Southampton Buildings. London WC2A 1AH 

Opinion Leader and Naked Eye would like to invite you to a lunchtime seminar to share their thinking on how their latest range of innovative research methodologies are helping health charities gain a closer understanding of people’s needs and experiences.  The session will demonstrate how their bespoke methods are being used at different stages of the research process to understand different aspects of health behaviour, including exploring what people say they do and what they really do, and insight into the cultural issues that affect their day to day motivations and behaviours. The research methods are based on participatory approaches which support service users’ and carers’ identification of their key concerns and helps service providers to understand the realities of living with a health condition. Please RSVP to Simon Munro at or 020 7861 3228.


§  NSPF Learning Event - Information Governance

19 March 2009, London


DH will be running a Learning Event which will focus on Information Governance, the standards and the issues that affect organisations in the third sector. This event will be your chance to learn more about Information Governance requirements and to hear about work the Department is doing to support organisations to meet the standards. The event will take place in London on the morning of Thursday 19th March 2009 at Prospero House, Etc Venues, 241 Borough High Street, London, SE1 1GA.  Registration commences at 10.00am for a 10.30 start and the event will finish no later than 1.00 pm


A formal programme will be sent out nearer the time, however it would be useful to have your expressions of interest as soon as possible as only a limited number of places are available.  Normally only one application per organisation will be accepted however please advise if more than one person is particularly keen to attend.


Please register your interest in this event by emailing your name, organisation, email address and contact telephone number to:


§  Brave New World – The Next Decade in Health and Social Care

26   March, London


ACEVO’s Spring Conference this year focuses on what the future holds for health and social care services, exploring key issues such as world class commissioning in health, the personal budget holding agenda and the next steps for social enterprises


Further information and booking details are available here


§  Age Concern - Help The Aged Merger Conference

7 April 2009, London


One Voice:  Shaping our ageing society

This conference marks the joining together of Age Concern England and Help the Aged to form a single new charity dedicated to improving the lives of older people.  Aimed at those with an interest in public policy it will explore the issues which are shaping our ageing society. Further information is available here.




10. Members’ Activities


§  BHF Petition

The British Heart Foundation has launched its biggest ever petition and they urgently need your help to get as many signatures as possible! They are asking everyone to sign their petition for a new Government plan for heart health in England. Further information and the petition is available at or in your local BHF Shop in England.


§  Princess Royal Trust for Carers

The Princess Royal Tryst for Carers has created a document for the benefit of health commissioners and decision makers. The health case for supporting carers is available here, linked to the Action Guide for Primary Care. They are also calling for submissions of good practice in carer support in health settings – these are available here (click the “good practice” link)


§  Men’s Health Forum

MHF has just been announced as one of DH’s new Strategic Partners. Further information is available here.