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Keep up…

I wonder what the next ten years will bring?  For me… probably a funeral!  Don’t worry, I’ll leave a few quid for a party.

For the rest of you?   Here’s what I think…

Blockchain; if you’re not across this, you should be.  It’s a protocol that allows for secure, direct, (no companies or organisations involved), digital transfer of money, value and assets… and, health records.  You’ll have a passworded encrypted record. 

Just like the pin number to your bank account.  You decide who you give access to your money.  You decide who you give access to your health stuff.  You’ll be in charge.

If you think Siri is clever, you ain’t seen nothing yet.  Forget keyboards.  Think JARVIS, from Ironman.  Put that together with AI and you get perfect knowledge; harnessing all the world knows, for all the world to know.  

By 2025 you’ll be able to buy a £300 computer that will work at 10,000 cycles a second… which is the equivalent processing speed of the human brain.  Ubiquitous knowledge, boundary-less access, as fast as you can think.

Everything we know about everything, right there, for everyone.

Healthcare?  Easy, expect the rug to be pulled on everything we have now.  Technology will crush it, like it has broadcasting, banking and the high street. 

Babylon is already nibbling away primary care, segmenting it’s own market and hollowing out funding models. One NHS for us all doesn’t mean one way for everyone. 

No one can stop it, anymore than the London Gas Company stopped us switching-on electric lights in the parlour.  

Technology will eat our systems, gobble up hierarchies and spit out our funding mechanisms.

Amazon in pharmacy, is only a start.  The likes of Google and Apple with forecasting models will demolish Public Health.  

Think of the wealth of information there is about human behaviour, mood, attitude, diet, work and wellness, on social media platforms.  

All of that reimagines public health.  We will know who is going to get sick, with what and how to fix it and more important, how to prevent it.

Right now, digital printing can create individual prosthesis.  In five years combined with DNA advances, it will tailor replacement organs.  

All this is possible.  I haven’t invented a future… it’s here, right now.  We can do this stuff.

That’s why I’m worried about the idea of a Ten Year NHS Plan.  It’s barmy.  

Please, do not write a Ten Year Plan, because it will only reinvent the past.  

We need to reimagine healthcare, reboot what we are doing and synchronise how we do it.

Reimagining doesn’t take much imagination.  Re-read the above half of this eLetter.  If we have to plan the next ten years around how primary care will answer the phone in the morning and get us to an outpatient’s appointment, you just don’t get it. 

There’s a world shortage of care workers and that includes doctors.  We can’t fix it because it takes too long to train a doctor.  So, we have to do something else.

Reboot healthcare.  That means digital first.

For instance; IBM’s Watson can provide the AI for us to talk to, get advice, diagnosis, reassurance, prescription and referral.  We will have to use scarce GPs for decision assurance, complex patients and people who can’t manage a phone.

Machine learning will lead us to understand the root-cause of illness, what fixes people up, why it works, what it costs and answers the question… do we want to do it again. 

Synchronise means redefining geography and kicking down boundaries.  Patients just want care.  So, fund care.  Not organisations.  Right now we work for every NHS pound.  A better idea is to make every NHS pound work for us.

The allocation system is broken.  Fund whole-systems.  Geography will defined natural synergies and a sense of place.  Population based, capitated budgets means system leaders will have to keep people out of hospital… otherwise they’ll run out of money before they run out of patients. 

We have squandered the past with introspection, self interest and obstinate shortsightedness.  The tools to redesign healthcare exist.  They are to hand.  Technology will define a future we cannot plan for.  

Our best plan is to try and keep up.

Japanese car…

There are little bits of wispy cloud drifting across a sky that is so blue, I can’t find a way to describe it.  Other than sky-blue.  It doesn’t do it justice, but it is sky-blue.

Across the cricket green the Durant clock, on the wall of the pavilion, is clicking round to the hour when the umpire calls… ‘Play!‘  The opening bowler comes thundering in… some things are just ‘English’.

English, like strawberries, toast and Marmite, vicars on bicycles and warm beer.  Part of our culture.  The way we are, the way we always do things. 

I’ve been having a quiet chuckle at the outrage, in the papers, at our reliance on fax-machines!  No one thinks to ask, why? 

It was GPs who forced hosptials into using fax-machines, to send discharge summaries, promptly.  Before faxes discharge letters used to take weeks to arrive.  Faxed summaries didn’t always mean the problem was solved but at the time, they made a huge difference.

And, here’s the point; if faxes didn’t do the job, we wouldn’t still be using them.  People do what works for them.  Rat-run traffic hold-ups, cut corners by walking across the grass.  

If you want to change behaviour, it’s easy… give people things that make their lives easier.  Like shopping from the sofa at midnight.

We talk a lot about changing behaviour and NHS culture.  I say you can’t change culture.  Culture grows slowly like the tall trees in the forest and a coral reef in warm seas.  They grow because they are in the right climate.

We can change the climate and we going to have to.

The NHS has to find ways of doing what it does, cheaper, quicker and faster.  The alternative will be to decide what it no longer wants to do. I’m not sure there are very many of us that want to embark on that journey.

We have to move from an analogue to a digital NHS and that means climate change.  

It is a strategic paradigm shift and a major transformation I fear we are unprepared for, unfunded for and not planning for.  I detect no method, no strategy, just a half baked promises and messages for the wish list.

There is an interesting article in Boston Consulting Group’s web-magazine talking about why a digital culture is so important. 

They say it matters because; without it, is to risk a transformation failure, it speeds decision making and attracts talent.

We have to encourage a curiosity about data, moving to analysing outcome data in, as near as damn-it, realtime.  

There are four reasons.  

  1. Hitherto information derived from analogue has been used to create averages, meaning half will always be below average, to find fault, blame, condemn and shame people and organisations.  

The paradigm shift; treat data as the new oil.  It is valuable and our friend.  It can spot trends, lubricate organisations and their performance and fuel an understanding of the ‘why’.

  1. Digital redistributes power.  Data is transparent, defines what works what doesn’t.  Redefines work, speeds decision making and enables decision making closer to the action.  Decisions are made upwards, not downwards.
  1. Digital shifts the emphasis from planning to action.  Decisions underpinned by data can be made quicker and with more certainty.
  1. Digital encourages working together; information sharing across organisations and departments, it ignores boundaries.

How do we make the changes happen?  

Recognise the majority of the public are way ahead of us.  They are buying onto Babylon, in their droves and are certainly up for tele-consulting across the board.  They assume clinicians can access their data and understand research is in everyone’s best interests.

We have to stop being timid.

We have to scrap fragmented procurement.  Find out what works, buy it for everyone, plug it in and get on with the job.

We can change the climate and that changes culture – to digital first.

As a nation, culture has been slow progress; the Romans invented toast, a marmite is French stew and most strawberries come from Spain.  Cask beer is best served at 13 degrees and cricket was first played in the village of Liettres, northern France.  

Have you seen a vicar on a bike?  

More likely to be in a Japanese car.

I hope you agree…

That’s the footie done with and Wimbledon over for another year.  Dare I suggest our flights of fancy are now turning to golden beaches, swaying palms and bourgainvillea floating across an azure pool.

A rain soaked campsite… whatever!  Not long to wait.

Amongst the plans, the new bikini and the sun cream, there is the little matter of holiday reading.  You can have a freebie on your iPad here for the plane but there is nothing like a real book for the sun lounger.

I’m always reluctant to make a suggestion but here goes…

If like me, you wonder about management, wonder why it goes so wrong , I think the answer is encapsulated in a quote, right at the start of this book.

‘I wonder what my soul does all day, when I’m at work.’

Source?  Apparently, graffiti on a wall in London! No doubt, written in frustration, conceived of drudgery.  You can imagine the dead-end fruitlessness of a job that sucks the life and energy from you.

An employee with a broken spirit.  Ignored, overlooked, shut out.  Working for a bully or a klutz or both.

Is there anything like that happening down your way?

We live in a world where, as customers our views, our data, our needs and wants are respected and sought after.  Where we use the technology in our pocket that connects us to each other and world around us.  There is nothing we can’t find out, order for tomorrow, our have our say, right now.

We come to work and… we’ll, you can write the next paragraph.

What happens when we come to work?  

In this book there is an anecdote.  A failing food delivery company.  Management reached for targets, data, metrics and weekly meetings about performance, complaints and errors.

The drivers, many of whom had worked for the company for years, became resentful, you can guess the upshot.

It’s a classic example of heavy handed, top down counterproductive management.  It’s a temptation for all leaders; focus on the outcome and control.

The Tinkerman’s famous Monday morning meetings, text book wrong.  

The trick is to find a way to keep people wanting to come to work.  The way to do that… keep them energised, purposeful, motivated, listened to, respected.  

Engaged by being interested about why things go right and why they go wrong.  Ask the question; ‘how can I help you to do better’.

Sounds simple doesn’t it.  Not; ‘why aren’t you on target, delivery waits, outcomes, delayed transfers‘.  We need to acknowledge when we aren’t delivering something important and ask why.

It was this approach that actually turned around and saved the food delivery company.  The managers learned and asked the drivers; ‘How can I help you deliver excellent service.’

This is why I recommend this book, Alive at Work, is squeezed in between the sliders and the little black dress.

In a world governed and ruled by guidance and targets, exacerbated by senseless inspections, it is so easy for managers to develop a shallow repertoire of; why, come, go, do.

Asking ‘how can I help’ changes the tone and texture of the management relationships.  The book’s author, Daniel Cable calls it, The Servant Leader.  The ‘servant’ facilitating performance.  

I call it; Leaders, creating the time and space for good people to do great things.

Creating low-risk space for people to experiment, be creative, innovate and push the boundaries of their thinking and performance.  Figure out what’s wrong, what needs to be done.

The ludicrous idea that Trusts and practices will spend weeks preparing for inspectors to arrive and wait for months to be humiliated for not achieving the impossible. 

How much better it would be for colleagues to arrive and say how can we help you to do better.

Cable tells us about a boss of Standard Charted Bank; Jungkiu Choi.  He abandoned inspection visits in favour of huddles, looking for ‘pain points’.

The only connection we have, with patient safety and satisfaction is the front line.  It takes a humble manager to ask, how can I help you to do your job better, easier, safer, more happily.

For managers and leaders across the system this might be the defining question to ask today and the defining book to read this year.

I hope you agree.

Policy…

No18 is right about one thing.  A lot of NHS staff are hacked off.  He intends to fix it…

Root cause… why are staff hacked off?  

We know a lot about this as Trusts who use the Fab-O-Meter will tell you.  Getting the local working environment as good as it can be is vital.

However, there is a much bigger issue and if No18 is to fix it, he’ll have to unpick the consequences of policy. 

We don’t have enough staff.  We kid ourselves, with mumbo-jumbo about acuity, red-flags and flexibility but we really don’t do safe-staffing.  That puts an intolerable pressure on staff.

Once the joy of the job is replaced by the grind of the job… the job’s not worth doing.  

We daren’t listen; what people have to say makes management’s life more difficult… they can’t fix the root cause… policy.

That’s why people are bullied into getting the job done.

In 2010, as part of the response to the world banking crisis, government did a handbrake turn on expenditure and that had a knock-on consequence for recruitment and training.  

The direct impact of policy.

We feel the effects of being something like 40k nurses short.  Across the whole workforce it could be 100k people.  

… exacerbated by Brexit uncertainties.  Applications from EU clinicians to work here have fallen by 93%.  Applications from outside the EU are down.  

The direct impact of policy.

Ending the bursary – applications heading for a cliff-edge. 

The direct impact of policy.

There’ s a global shortage of care staff; we are closing our doors on migration and it will take too long to train reinforcements.

The direct impact of policy.

Pay… a policy gamble; balancing the nations’s books… ‘the right thing to do’.  The recommendations of the Pay Review Body, dumped.  ‘Fingers crossed the sense of vocation and staff commitment would carry us through’… all that came unstuck with the junior doctor’s strike.  The sense of grievance still reverberates.

More absurd; to try and ‘inspect’ quality into Trust’s performance by bullying boardrooms over staffing, targets and safety, knowing full-well there was neither the money, nor the staff to do the job.

Trusts ‘shamed’ for not delivering the impossible had a crushing impact on morale.

From the top, a bullying culture seeped into organisations; ‘don’t bring me bad news, just get the job done’.  Bullying down, managing up.

The direct impact of policy.

Now, targets have all-but been jettisoned but not without damage to the careers of some very good people.  The consequence; it’s getting impossible to find quality people to take on CEx roles.

The direct impact of policy.

Government’s have a unique way of handling policy.  The Behavioural Insights Team will tell you.  Groups, making decisions can learn a lot from them.

The Cabinet interprets evidence through a political lens, or ideological preferences.  Austerity and balancing the books ‘was the right thing to do’… ideology.

The Cabinet, like all groups, will conform to a majority view.  Members will be either ill-equipped to challenge data and poor decisions, have misplaced loyalty or fearful for their position.

The more the Cabinet, or any decision making group, are in favour of a policy, the more they are likely to assume that others have a similar view.  It’s called confirmation bias.

Something called Group Reinforcement follows.  This is when people self-censor and conform to the group’s majority view, without challenge.  Cabinet responsibility… 

Group-reinforced bad decisions, like balancing the books and austerity, have caused structural damage to the NHS.  Add to that the impact of Brexit policy and you have a case study.

Finally, there is what is called ‘the illusion of control‘.  In complex systems the link between policy and outcomes is not always clear.  Unexpected outcomes push control away.  

Not enough money spent in 2010, ‘

the right thing to do’;  the outcome… today, solutions pushed beyond our grasp.  

We can’t get enough staff, fast enough.  

 The result… poor morale.

Even if we start now, there is no prospect of solving the workforce crisis for the next ten years.  The answer; change the work.  

The Royal College of Physicians know this.  They’ve issued new guidelines.  They say;

“Patients must get used to nurses and other less-qualified staff doing much of the routine medical care in hospitals…’

The direct impact of policy.

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roy.lilley@nhsmanagers.net 

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