This Weeks News and Comment

primary_care_training_enfield_town

I visited...

Enfield in London, has a long and distinguished history, tracing its roots back to Roman times.

In the 14th Century, Edward I, granted the first market charter giving the right to hold a weekly market, and two fairs annually.  

Later in the century, the Black Death struck the parish and killed one tenth of its population.

Fast forward; with the railways came Enfield's significant contribution to industry and science. The Royal Small Arms Factory was built in 1814 and manufactured the Lee Enfield Rifle and the Sten Gun. 

Industry and population expansion continued into the 20th Century when Belling created the first infra-red electric fire, the first halogen cooker, digital telephones, enabling the first transatlantic calls, television distribution systems, man made fibres and the diode valve... all were invented in Enfield. 

Enfield was the Seattle of its day.  

Today, of the 32 boroughs of London, Enfield currently boasts the fourth highest population figure.  

77.1% of people living in Enfield speak English. 

The other top languages spoken are 6.2% Turkish, 2.0% Polish, 1.6% Greek, 1.1% Somali, 0.9% Bengali, 0.8% Gujarati, 0.8% French, 0.7% Kurdish, 0.6% Italian. 

The religious make up of Enfield is 53.6% Christian, 16.7% Muslim, 15.2% No religion, 3.5% Hindu, 1.4% Jewish, 0.6% Buddhist, 0.3% Sikh. 

Enfield is one of the 20% most deprived district authorities in England and about 28% (20,700) of children live in low income families.  

Life expectancy is 5.8 years lower for men and 4.4 years lower for women in the most deprived areas of Enfield, than in the least deprived areas.

There's not much to add to the welter of data, numbers and statistics that swirl around this part of London.  

If I were to be honest I would say; there are other parts of the country that have, similarly, been abandoned by policy, politicians and parliament and been left to get on with life.

An area once famous for its industry is now reduced to a commerce dependent on kebab shops, double glazing, tattoo parlours and Asian grocers.  Even the mini-cabs have been killed off by Uber.

This is decaying Britain, the end to industry.  Rows of houses scarred by plastic windows and ludicrous cladding.  Soldiers of wheelie-bins, line up on the pavements.

At the centre of it all, one bright moment.  A fair employer, a place of hope.  A refuge from reality that delivers a daily reality of care, community, compassions and competence.

A place where our families are fixed up, our kids can be apprentices, our doctors and nurses are free to find new ways of treating us, getting us home safely and caring for us.  

A place where the sun shines through the atrium of its front doors and on the faces of the people who work there.

The North Middlesex Hospital.  I am so pleased I visited.

Have a good weekend.

------------------------- 

I'll pay his fare...

I've been musing.  Day dreaming really.  What would it be like, if...

If the NHS managed its information by the use of technology and interrogated data to figure out what was really happening, what worked and what did it cost.  

Of course, I understand it might be a bit of a stretch!

I was thinking about maternity services.  By and large it is a discrete service and reasonably self-contained.  Documenting the whole of the maternity experience, starting with ladies being able to refer themselves... would be a fine idea.  

Linking into GP records and giving mums2B full access to all their records, all the time would be great, wouldn't it?

Maybe, like me, you probably didn't know, you can...

I wonder what would happen if there was an elective surgery management system that booked theatre time, recorded procedures, prostheses, the length of time the operation takes, schedules operations and costs each one?  

It would be mighty useful for resource management and outcome measures.

I was stunned to see one in action.

Catering is always in the spotlight.  Choice, quality, waste.  Do you know what... there is a tablet app that can be used, on the wards, to collect orders and choices of meals, tells the kitchens and the neat bit; also tells the kitchen if the patient moves and where too.  

It also gives the nutritionists a shedload of data.  Menu forecasting, planning... wow!

I've seen it... it exists.

What about the Holy Grail; interlacing primary care records with secondary care?  

Well, we know that's old hat but if you included the whole care sector?  

What about including some protocol driven permissions for referrals to come from other than a GP.

Hold on to your hat... I've seen it.

It would be nice to give patients, with long term conditions, a reliable, simple App to monitor their status, encourage compliance, access to useful stuff, manage their wellness, keep in touch... you know the sort of thing.  

Leading to electronic consultations and prescribing.

Yes... well you know what I'm going to say... I've seen it.

What would be really useful would be an electronic white board that gave the status of each patient on a ward, linked to their records, projected discharge and what needs to be done to work towards it.

Make some space on your wall, I've seen it.

All of this is really useful but population health really matters.  

A dashboard for community profiles, practice performance and outcomes.  Projections and planning, including the impact of the weather.  Drawing on data from the third sector, social care, health, primary care... everyone connected with wellness living.

Seen it.

You'd think you'd have to travel for miles to see it all and the chances of seeing it all in one place are fat chance and no chance.

You'd be wrong.  If you're thinking of doing anything that will end up on a screen, forget NHS Dodgeitall, NHSE or any of their palaver.  Go to the place that you can see it all, doing it all, making it all happen.

Forget this latest drivel from the DH.  A 'vision' for the NHS digital healthcare.  Gimme strength.  No18 has to realise he has no power to direct anything, no money to buy anything.  

If people in his department want to write something for their Boy Scout Computing Badge fair enough but if he'd like to achieve something in the few months he has left, do what I did....

Go to the magic University Hospitals of Morecambe Bay NHS Foundation Trust and see all this good stuff in action, in one place.  See what bright, innovative people can do and copy it.

I was so gobsmacked with what I saw, I want him to see it, too.   

I'll even pay his fare. 

------------------------- 

A good place to start...

Does the fact that we have a new ministerial appointment, for suicide and doctors are prescribing dance classes for the lonely elderly, tell you anything?

If you accept there are social determinants for suicide and loneliness, is it too much of a step to conclude there is something not right about the way we live, look after each other and deal with our problems.

There are three things that are universal 'wants'; a safe place to live, a job and someone to love.

Each of those, housing, work and social tolerance are all in the gift of governments.  Can we say suicide rates are a measure of the success of  governments?  If we can, the indications are, they have failed us?

International comparisons are fraught with caveats and 'yes buts', but it's worth pointing out Europe has the global-highest suicide rate.  As far as countries are concerned, the UK rates 109th.  In case you're interested Barbados has the lowest rate... 

In the UK, in 2017, there were approximately 5,821 registered deaths by suicide.  That's about 16 a day.

Suicide is the single biggest killer of men under the age of 45.  The most common method is by hanging.

In 2012, the government announced it would spend £1.5 million to develop planning and strategies on preventing suicides.  Not much came out of that.  

A week ago the PM announced the UK's first Minister for Suicide Prevention.  I'm keeping my fingers crossed but I'm not holding my breath.

A decent job, a safe place to live and a relationship to value...  that would be a better approach but it's very difficult if your only policy is austerity and your only focus is extricating the country from the EU.

Loneliness?  You can be in a crowded room and be lonely.  I met a man the other day who told me, since his wife died he only ever gets to speak to the girl on the checkout in Sainsbury's.  He goes shopping every day, just to have someone to talk to.

In the latest census survey, 2016, we reached the biggest ever total of  65.6 million people and 20.4% are above 65yrs.

If loneliness is important in your practice or services there's a book you might want to put on your reading list.  Even if it's not, it's a good read.

John T. Cacioppo's, Loneliness: Human Nature and the Need for Social Connection.

His research challenges one of the pillars of modern medicine and psychology: the focus on the individual as the unit of inquiry. 

He used brain scans, monitoring blood pressure and analysing immune function, to demonstrate the influence of social context - a factor so strong he claims it can alter DNA replication. 

He defines an unrecognised syndrome; chronic loneliness and claims it is 'the cousin of depression'.

The sense of social isolation uniquely disrupts our perceptions, behaviour, and physiology, 'becoming a trap that not only reinforces isolation but can also lead to early death'

He shows how social cooperation is, in fact, humanity's defining characteristic. Most important, he shows how we can break the trap of isolation for our benefit both as individuals and as a society.

Loneliness, depression and suicide; the three horsemen of a modern, personal apocalypse.

  • There was a time when we lived in neighbourhoods, now we live in apartments.  
  • We once had work to go to, now we have jobs to do.  
  • We once went shopping, now we buy things on line.  
  • We once enjoyed families now we have FaceBook and emails.  

We are designing social interaction out of our lives and we wonder why they go wrong.

Do we lay the failure of parts of our society at the door of government?  Will a minister for suicide make a young man think twice before he buys a rope.  Can governments make a widower happier?

I don't know.  

But, I do know they can put at the forefront of policy-making: decent, affordable housing; decent, proper jobs that pay a fair wage and policies that underpin the importance of family life and the people we love.

That would be a good place to start.

------------------------- 

The menu...

My bags are packed and I'm ready to go.

Somehow, this year has just slipped through my fingers.  In pursuit of excellence, some sun and finding out about stuff I've been to Australia, Abu Dhabi, Portugal, France, Holland, Belgium, Wales, Scotland, Northern Ireland and the length and breadth of England.  

My new management theory; 

Knowledge (k) = Distance (D)

  Time (T)

Pretty useless management theory but it's no worse than a lot of other management theory!

That's the point; theory is one thing but going and seeing the doing, is much more valuable.

Change Week has come around again.  I'm off to Magic Morecambe Bay who are hosting our launch and finish at Wonderful Whipps Cross on Friday.

First came the fabulous Hubbies with their Change Day concept, which grew into Change Week.  This year, to mark the NHS 70th, it is 'Fab Change 70'.  Unlike previous years where pledges were made and later put into action, this year it's all about changes and improvements that are already live, up-and-running.

Over three days we will feature over 200 examples of QI that is working; on the website, Twitter and our YouTube channel.

The focus has been searching for the good stuff, sharing and celebrating it.

Organisations perform around a mean.  Below that is negative deviance, above it, positive deviance.  The CQC, the press and ministers are interested in negative deviance.  I'm not.

Positive deviance occurs when people, facing the the same problems as their peers, with the same resources, find solutions and better ways of doing things.

The Academy of Fabulous Stuff and FabChange70 is all about positive deviance and sharing it.

It amazes me how we still focus on organisation's short comings, measure them against made-up standards, bully them into trying to deliver the impossible, with staff that don't exist, and money they don't have.

Then we wonder why we can't stop the NHS's endemic bullying culture.  It starts at the top.

I once had a visit to a Trust, postponed.  'Would you mind coming next month, we're busy rehearsing for a CQC visit...' 

The measures the NHS uses are around the frequency of failure, which are used to pillory or 'punish' people.  

People doing the good stuff get ignored.  

We focus on how to fail less.  When 'failure' is inevitable, we change the rules... abandon targets.  The whole system is fruitless and pointless.

Trusts and their people have no idea what success looks like, only what failure feels like.

In the real world it is 'the best' that we are interested in.  The best footballers, the best cricketers, the best bands, Oscar winning movies and top TV shows.  The stars.  At work we are forced into thinking about failure.

At The Academy of Fabulous Stuff it is the people who have done great things who are the stars.  

Making improvement is partly about mindset and a whole lot about what works.  

Companies once used inspection to verify products as they came off the line.  It did nothing to reduce the ratio of good product, versus defective product and put the focus on the defect.

That's why inspection isn't used anywhere that is interested in quality.  Wise companies focused on producing fewer defects and what makes perfect products.  They defined success, not the presence of failure.

For instance; A&E targets focus on failure.  Friendly goals work differently; concentrating on the goal of 'getting as many people as possible, through the system, safely' needs whole system management and changes the workplace climate.

Sharing the success of ever increasing through-put, and how to do it, reinforces the fact that people enjoy following their champions, watching the stars and the great performances.  

That's why an hour with ECIST is worth 50 inspections.

Lagging indicators, measurements of adopting new practice, tell us it is something the NHS is hopeless at.  The indicators improve when people can see their peers succeeding and how.  Sharing and duplicating.  Improving and doing the same.  Copying and doing it even better. 

There is a huge amount of fabulous, innovative, good practice in the NHS and you will see a lot of it later this week.

We can make failure our millstone or success our stepping stone.  

Sharing great ideas and doing them better is a proven recipe for success.  FabChange70 is about oven-ready solutions and putting success back on the menu. 

------------------------- 

The basics...

When the first old gent is found in a heap because his walking frame's collapsed, we'll understand why Trusts and social care agencies are reluctant to dish-out second-hand kit.

When the first row erupts, at the pharmacy, because the computer can't verify if a healthy looking 19 year old young woman should have a free prescription... and she has to tell everyone in the shop her mum is receiving

Income Support... we'll know why we're reluctant to verify this stuff at the point of use.

No18 hasn't got any money and no Parliamentary time to do anything important so he's trying to look busy.  Fair enough.  Clamping down on fraud and getting the walking sticks back... all good copy for the Daily Blah.

Every Trust I know has a 'giss-yer-crutches-back' scheme.  Hospitals aren't stupid.  

They know about ISO 11199-1:1999, load testing and infection control of walking aids.  

By the time an eight quid pair of crutches has been returned, signed for, documented, stored, examined, cleaned, new handles and rubbers, tested, certified safe, labeled recycled and usable, put in the inventory, bar-coded and reissued they've probably cost £50.

Expect somebody to flog the NHS a piece of software to do all this... and a bill for ten million... and it'll be as useful as a motel shower-curtain.

Stopping prescription fraud requires fully understanding the exemptions and who grants them; specific conditions, age, social status and entitlement to benefits.  

No18 says he's going to stop fraud with a computer system.  Good luck with that... call it £2bn.

All the information is in different places, different GDPR rules and there is no system to link GP records with social care and the benefits agency.  

It'll be easier to programme a computer to send a man to Mars than sort that lot out.

May I respectfully suggest to No18 that he concentrates on getting the basics right.  Because we can't do the basics we can't get our stuff back or know who is entitled to what.  So...

Start where the data starts... in the GP surgery.  Bang-heads and kick-backsides to make all GP records interoperable with hospital records, UK wide.  Give the suppliers three months to do it.  They can if they want to.

Feed in, entitlements confirmation data (not personal details) and loan equipment, (based on bar codes), and you might have half a chance to make stuff work.

Next, go to Australia and see what the man who used to do IT here is doing with IT, there.  He's got the basics soooo right.

By Xmas, every Australian who wants it will have a pin-number.  In the same way you decide who takes money from your bank account... Australians will decide who sees their health record... with a pin-number.  Granting clinicians access.

With that we could know who had a walking frame and be able to ask for it back and the girl in the chemist would be able to give the pharmacist access to her records to confirm her entitlement.

Focus on getting the basics right, not palavering around frittering money on more Apps and software to heap onto the electronic Tower of Babel we already have.

I know the basics are boring but if we use our heads for more than a hat stand, we might get somewhere. 

We're losing the knack of doing the

B.A.S.I.C.S;

Backwards; start with the patient and work backwards.  Forget wrapping existing services around what you do.  If you do that, you'll get what you've got now and mostly, it's not good enough.  Zero-base all planning.

Accept there are problems; and problems are precious... find them happily and fix them cheerfully.

Speak to everyone face-to-face; a fast and dirty listening exercise.  Ask; 'To make this good enough for your family, what two things would you change, that need no more than petty cash to do?'  Challenge yourself to deliver in 30 days.

Inspection; forget it.  Inspect and it's good... you've wasted your time.  If it's bad... it's too late.  Quality's what you do when no-one's looking.

Celebrate success; small things are big things to someone.  The little things; the building blocks that shape us and our organisations.

Solutions; share them.  You won't be the only place with 'that' problem.  Don't reinvent the wheel, ask. (go to Australia) 

Innovation is seductive but the basics are sexy.

------------------------- 

 Contact Roy - please use this e-address

roy.lilley@nhsmanagers.net 

Know something I don't - email me in confidence.

Leaving the NHS, changing jobs - you don't have to say goodbye to us! You can update your Email Address from the link you'll find right at the bottom of the page, and we'll keep mailing.

GDPR

We don't sell or give access to your email address to any third parties.

You can unsubscribe at any time.

----------
Disclaimer

Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.