NHS News and Comments by Roy Lilley

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Get busy…

Number 18 is discovering, being the Secretary of State for Health isn’t much of a job.  Oh, it’s an honour and all the rest but thanks to his predecessor, Andrey Lansley, the role is pretty emasculated.

The management of health care is through a distributed leadership model, carved up, principally between NHSE and NHSI.  The DoH role; some resource allocation plus the development of the annual Mandate.  A shopping list of things the SoS wants done.

This year it has treasures like;  the Government is committed to providing…. the highest quality, most compassionate health and care service in the world

…and seven day operation (parked), 24/7 access to MH crisis care (stalled), reduce health inequalities (not happening), balance the budget (fat chance).

No18’s latest seems to be writing the upcoming ten year plan.  If you thought it was NHSE’s job… so did they.    Anyway, planning anything for ten years?  Well, it’ll keep him occupied.

His big idea is to use a chunk of the ‘new money’ to stop people getting sick.  He’s going to have a bash at public health.

The ‘new money’ translates into 2.9% uplift next year, just over three percent in subsequent years and well under the 4% historic average.  Enough to do what we are doing and not much new or fancy.

Through primary care we get +90% of first contacts for under 11% of the budget and they’re running up the down escalator.  

A serious shift in their responsibilities means a serious robbing of Peter to pay Paul.  Who loses?

Public health?  The Health Foundation says;

‘Based on current plans, a reduction of almost a quarter in spending per person is expected between 2014/15 and 2019/20… a £700m real-terms reduction in the public health grant in that period… mortality improvements have slowed and there are large inequalities in health outcomes between local areas.’ 

So, good luck with that.

No18 aims, by 2035 to add 5 healthy years to our lives.  That’s 17 years away… he’ll be long-gone… so will I!  

Adding life to years… in 2012 the WHO identified it as ‘[the]… single health challenge with global impact’. (Interesting Slide Share here). 

The determinants of ageing include smoking, alcohol, exercise, diet, drugs, safety, home, work and access to care.  Most are modifiable but nearly all, behavioural.

Changing behaviour is tricky.  Nudging and behavioural scientists don’t have much of an impact.  The law works best.  Crash helmets on motor-bikes, seatbelts in cars, smoking in the workplace, health and safety legislation… all save lives.

The rest is up to the extent the government will interfere in our lives.

Obesity; what laws?  Governments only dance with the food industry, they don’t have the courage to give them their marching orders.  

How about… weigh-scales at the bus-stop… you’re too heavy, walk to the next stop? 

No18’s big idea is tech’.  DNA testing.  It sounds like a good idea but doesn’t mean it works.

Telomeres are the key bit of the DNA soup, that are predictors of ageing.  There are companies that charge you about a hundred quid for a home testing kit.  One test is no good.  You’ll need a baseline test that’s followed up with subsequent tests.

The tests are just a wake-up call.  Do you really need them to underline the fact that a full-fat Latte and a chocolate muffin is a bad idea?  Feeding yer kids chips will make ’em fat-n-spotty?

Technology?  How about big data?  We can use it now, to predict readmissions.  If a doctor could tell a patient that they could add 5 years to their happy life expectancy, if they altered a behaviour, they would still have to be motivated to do it.

We can aggregate what we buy in the supermarket, look at our mode of travel, work, figure out who buys trainers from Amazon, uses their credit card in Starbucks, sleep patterns.

We can do all that now but we can’t overcome privacy rules, data protection, Caldecott, GDPR and the palaver about access and the use of data.  And, we can’t join it all up.

If No18 wants to make an impact; good lifestyle choices start in the schools and access to joined-up data starts on his desk.

Better get busy. 

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Proud of what you do…

Amazon has done something amazing.  It has completely reset our expectations of price, delivery and service. 

As well as shopping for toasted cumquat seeds, from our sofa and having them delivered by tea-time, Amazon has opened the door to a whole range of products we probably never knew we could buy!

Amazon is a total recalibration of expectations.

We ‘expect’ Amazon to find our stuff, at the price we can afford and deliver it at a time of our choosing.  No high street retailer can compete with that.

I’m expecting Amazon to see-off the pharmacy chains.

Expectations met, raise expectations about what is unmet.

I wonder what the public’s true expectations are about the NHS?

Do they really expect an ambulance in eight minutes?  Do they really expected to be done and dusted in A&E, in four hours?  Do they really expect to be diagnosed, imaged, tested and treatment started in eighteen weeks?

NHS targets are expectations that were set by politicians on the basis that the quicker the better, is always better.  

Tony Blair ‘did an Amazon’ and reframed expectations.  He invented the four hour target; 100% to be seen and sorted in four hours.  It was impossible.  Other politicians reset the clock.  Today, we just do our best. 

I don’t think the public ever shared expectations beyond wanting to be seen in a timely, safe and a prioritised way, that they can attach a rationale to.  Waiting is one thing, being abandoned is another.

A&E departments take the pressure when other parts of the system aren’t working properly.  So, if A&E looks like Armageddon, we have no expectation that our cut finger will point us to the head of the queue.  

People are sensible.  

To be frank I’m not convinced the A&E target is all it’s cracked up to be. The evidence shows that performance targets can be a proxy for wider system failure or success and can have wider consequences.  (Here)

Mostly, the public have a sense of proportion.  They watch the news and know we don’t have enough nurses and a hospital is not the Hilton.  It is only the CQC that has that expectation.

(Interesting slides and international comparisons here).

Managing expectations is a vital skill for managers.

There are some basics to think about.

It starts with honesty.  When we know an expectation can’t be met, I think we should say so.  Indeed we have a duty to say so.  

Allowing expectations to fester into an assumption, is a risk they will become accepted as a right and that soon becomes and entitlement.

The NHS is in the contortion of planing a plan for the next ten years.  No one can promise anything for ten years.  When the Plan emerges it is important that where there are expectations, they are not assumptions that ignore the risk of them being unmet.

We will have to be honest and honestly… I can’t imagine meeting any expectation over ten years. 

Communication.  Yup, that word again.  In the basic day-to-day, it means reporting back, updates, keeping people in the loop.  

In a clinic that is running late, it’s about saying; ‘We are running late because XYZ, but we’ll catch up as soon as we can.  Thank you for your patience.’  

The last bit’s the most important…’thank you’.

In reality only a fool bashes on regardless.  In a service sector, like the NHS, that is demand led, we must learn a new narrative about expectations.

‘The truth is we can’t do this.  I don’t want to let you down… this is what we can do.’  

We can’t do a full fat NHS.  It’s a skinny Latte health service, now.  The public know that.  The majority of patients that come through the doors will have a great experience and be on their way before they can post how pleased they are, on FaceBook.

I bet if you asked most people about waiting targets, they couldn’t tell you what they are. 

If you told them it was waiting for treatment for a non-life threatening injury, safe, warm, pain free and in a pleasant environment, where most people would be on their way in under four hours.  They’d say that’s cool.

We’ve reframed expectations, now we have to recalibrate them and still be proud of what you do.

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Worth remembering…

When I was growing up, on the eleventh day, of the eleventh month, everything would come to a quiet, reflective halt as Big Ben announced, on the wireless, later the TV, the eleventh hour.

In the Boy Scouts, I’d proudly carry the flag on Remembrance Sunday, Church Parade.  Later, as the Mayor, it fell to me to lead the community’s reflections.

I still watch the events on the telly.  My grandad was gassed in the trenches in the First World War.  He survived and lead a miserable life.  

If I close my eyes I can still see him sitting in his rail backed chair, propped on cushions… chest rasping, gasping for air.

In the Second World War, Mum was at Cranwell, in the RAF and my Dad had a war he would never speak of.  He went on to suffer, what was then called a nervous breakdown.  Today it would be PTSD.

It’s right that we remember and it is right that we should go on remembering but I think there is something more.  Why did the world go to war in the first place?

In a sentence… in the first instance it was the rise of nationalism and in the second, the victors punished the vanquished nation into poverty and destitution.  Creating the environment for a new nationalism.

It all came down to leadership.  Students of leadership spend too much time on good leaders and in no way enough on the bad.  The power leaders such as Hitler, Stalin, Hussein, Pol Pot, bin Laden.  How did they mesmerise their nations?

Good leaders might have the best tunes but the bad ones have music to march to.

Leadership.  A complex subject.  Why we follow some people and not others.  What made a nation turn to the Nazis?  

When times are tough, a nation will look for hope.  Churchill gave people of my parent’s generation, hope, but they dumped him in the election following the war.  Obama gave a nation hope but the jury is still out on his achievements.

Trump is giving rust-bucket America hope, delivering on jobs and migration.  Merkel is on the way out.  People are fickle about their leaders.

Tough leaders, transactional, transformational, bureaucratic, servant, situational… leaders.  Academics say there are 12 types of leaders.

There is one more… gracious leadership.

Gracious leadership is not Walter Mitty leadership but it does exist with the hope that treating organisations as a friendly and hopeful place creates better results.

Gracious leadership is not about giving power away, it’s about understanding that relinquishing control creates the opportunity to gain more strength as people realise they can trust your truth.

David Brooks, the NYTimes columnist, writes about gracious leadership.  From the interviews he has conducted with blue-chip leaders, he tells of the importance of confidence and humility.  Accountability and compassion are not mutually exclusive.

Last week a Trust was put into special measures and I was asked by the BBC if that meant the DH had lost confidence in hospital bosses.

I told them no, it was the recognition that the Trust, a prisoner of its legacy, economy and geography, was going to get some much needed support and money, to get it back on its feet.

I wasted my time, ‘special measures’ is a phrase that frames it all.  Summarises NHS leadership culture that wonders why bullying is endemic.

It points a finger, sows the seed of doubt, a critique that disguises the efforts of the people trying to straighten the mess out and makes it a harder to recruit.

Trace their problems to the root-cause?  Recruitment is at the heart of it.  Remember there are 50k nurse vacancies across the NHS.  Eventually, this fact alone will plunge the NHS into ‘special measures’.

I like gracious leadership.  It comes with a narrative that says; 

‘I know you’ve done your best and thank you.  We want to help you through the tough times to come, get you back on your feet.  We are rolling up our sleeves, what can we do to help?’

Gracious leadership owns the problems and is accountable.  Is it soft?  No, it’s tough love, highly engaged, strategic and smart.

Drive people into a corner and the only way they can come out is backwards.  Stear people to a new horizon and they’ll head for it. 

It’s worth remembering.

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