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.