Tuesday 31 March 2009

The Manager/ Clinician Divide

THIS PAGE HAS MOVED TO http://minney.org/healthcare_management

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 http://minney.org/node/136It'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 http://www.talkinghealth.org/ 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 administrator@talkinghealth.org



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 http://www.nct.org.uk/about-us/jobs/vacancies

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 smunro@opinionleader.co.uk 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: vcsmail@dh.gsi.gov.uk


§  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 newheartplan.org.uk 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.

Workshop 1 - agenda and notes

AGENDA for Workshop 1 - defining benefits, projects and engagement

ContentWhat to doWhat happenedlength of time
IcebreakerNearest + furthest holidays

What you particularly liked about your holiday

get people into a mood to discuss benefits

line everyone up in order of distance so they have to talk

allow 10 mins for this.  ALWAYS use an icebreaker
Explanation of the Portfolio Approach to BenefitsWhy - too many benefits, too difficult to measure, performance get fed up with different requests for virtually the same thing, not so easy to report, people want to get on and DO

What - three workshops, getting engagement and commitment, reporting

How - three workshops, starting today

15 mins
Benefits Dependency Network of Long-Term Conditions to includeCOPD



Weight Management/Obesity

Hospital/ Community/ GP

Identify/ engage/ treat/ step down/ maintain

Strategic goals, benefits, outcomes which will achieve those goals; projects underway inc existing services (and therefore gaps/ anachronisms)

With this range of conditions everyone can contribute. The most important is that front-line staff take ownership for the gaps and anachronisms

cluster the benefits so that you end up with distinct benefits which can be defined yet are applicable across projects

allow at least 40 mins, though you can add more to the network at a later stage in the workshop
For each benefit (identified from clustering the benefits in previous stage)How to define this benefit (work in groups so each group has 2/3 benefits to define

How to measure with some specificity

How to aggregate (some are additive, some are a single figure across whole health community, some aggregate different ways. It isn't always possible to define which project led to which result)

Who is going to measure

within a single health economy this is easier because you can name names. At SHA level we were able to identify job titles eg which measures would come from Public Health, and which from the project's front-line staff
For each project
Which benefits of those defined does this project want to be held accountable for delivering (each project may contribute to all projects, but may not be able to influence)

Any other benefits that this project would want to be held accountable for? are the benefits important enough to be reported at workstream level?

Specific measures where the definition of measurement above isn't specific enough to apply to this project, eg how to aggregate?

Any missing projects identified from this exercise?

The benefit that senior executives would like to see projects contribute to is usually Value for Money, but this is also one of the most difficult for individual projects to report on because of a myriad of other influences

The key thing to watch here is for a project to take on too many benefits for reporting - Keep It Simple - stupid!

The Y+H workshop had two independent groups identify which benefits applied to which project, and the differences were fascinating

allow at least 30 mins, and potentially up to an hour. This section may identify additional benefits that should be reported at workstream level which go through the benefits definition process
SummaryWhat was learnt - engagement, commitment, KISS, measurement as part of doing the job, benefits focus from the start
Workshop 1 - Definitions (this workshop)
Workshop 2 - Baselines
Workshop 3 - first measures and format for ongoing reporting

Portfolio Management - Benefits Framework Workshop 1

Benefits network simplified to ensure definition of Benefits and application to Projects - projects have benefits numbers attached
The workshop (3 March, at Yorks & Humber Benefits Network - agenda listed in next blog) went swimmingly - benefits identified; defined; projects linked; realism and pragmatism.  It must be emphasised that this is normally the first of three workshops.
It illustrates just how straightforward this technique is, how certain to draw people in and engage busy people (whether frontline staff who would rather spend the time delivering services, or executive directors with 101 other meetings to go to), and to create a result.  It demonstrates how common-sense the outcome is.
From the point of view of the service leader or service improvement professional, it also illustrates how to:
  • make best use of the specific skills of defining a benefit, how it will be measured and how aggregated
  • engage service delivery staff (whether clinical/ care trained or in supporting or management roles) in defining/ selecting the benefits their success will be measured by
  • encourage senior staff to use the measures and benefits defined by the services themselves, as they are easy to aggregate to report across a whole workstream (because they are all defined the same way) and clearly bring benefits to service users, clinical outcomes, staff and the financial bottom line
The previous few blogs illustrate the Why and the What of Benefits Frameworks and the Portfolio Approach.  This one gives the agenda for running Workshop 1.  The actions you need to take are:
  1. book a meeting with the workstream SRO and sponsor, and key poeple who can arrange to take this approach across the whole workstream
  2. set a date for the first workshop (this agenda), apply to me (hugo@minney.org) for more information
  3. run the workshop, get the results, and set dates for the two follow-up workshops
It's all about making service improvement happen!