This Weeks NHS Primary Care News Roundup


Shortage of leadership…

Conferences are a waste of time, an echo chamber of the likeminded, similar interests and hopes?  Discuss…

The disciples of data meet to discuss a distant nirvana, hoping for a golden age of technology.  A communion with the latest fads and acronyms to bamboozle the unbelievers.

What I’d like is a conference of people who don’t believe technology is going to help.  Who are unconvinced that improving flow through the system will do anything other than increase demand.  

I’d like a gathering of the luddites and the don’t-give-a-stuffs.  They are the ones we need to convince.

Improving our management of information by the use of technology has a dismal record.  We imported systems from America, designed to produce bills and invoices and wondered why they added nothing to managing NHS hospitals.

Since then we have had a proprietary-fest.  No thoughts of machines talking to each other.  No idea of universal access.  We have bought more silos than flour makers.

Creating these leviathans needed software writing skills that no ordinary mortal could divine.  It was a dark art that the great unwashed couldn’t challenge.

Since then technology has become democratised, anyone with a bobble-hat and a lap-top can do it and anyone with a bit of an idea can write an App.

Yes, each is a marvel, an example of what could be achieved… if only.  We live in a world of ‘if only’.

If only… we could access our health records.

If only… this bit of kit could talk to that bit of kit.  

If only…  if only we had a leader to make it happen.

We see presentation after presentation with list of wonderful things we should be doing, that would save this and do that.  Local, un-scaleable bits and pieces.  

The curse of The Powerpoint.  Once you’ve seen it on a slide, you know it will never happen. 

My health records are my affair.  I don’t own them.  The Secretary of State does.  I can go with that.  But they are mine to determine if they are accurate and mine to decide who sees them.

My bank curates my money… I decide who shall know how much I have and with whom I spend it.  My pin number puts me in charge.

Access to my health records is largely determined by the makers of primary care software.  None gives me direct access to my records.  I have to ask the GP.  Frankly, what’s it got to do with them?

In Australia, where healthcare is slightly different, by Xmas this year, every Australian, who wants it, will be given a pin-number and it will be the patient who decides who gets access.

Here, I’m locked out of my data.

Heaven forfend I am knocked down by an early morning milk-cart on the way home from a night, clubbing (or on my way to early communion).  

The exhausted A&E person wants to figure out more about me?  More likely than not, they will crank-up and sign-in to a system that takes forever to recognise who they are and give them no help in recognising who I am, or access to my comprehensive health record.

This is not a lacuna in the system, it is the wilful neglect of the safety of my care and a two finger salute at efficiency and effectiveness in the name of market share. 

All of this is easily solved but we would rather talk about the next big idea than talk about the issue at the heart of our inefficiency and the core of our ineffectiveness.

  • Trusts are free to buy whatever they want.  
  • Practices can do what they like.
  • Community and social care are free to buy whatever they can afford.
  • Manufacturers can invent anything and persuade us to buy it.

We need someone strong enough to say; stop!

Stop… until we have clear idea of our national imperatives; what are the three things we want IT to deliver, and enforceable, interoperability.  

Make it illegal to sell or buy any kit that doesn’t speak to any other bit of kit.

Illegal?  Yes, it’s a crime that we put patient’s treatments and professional’s decisions at risk by perpetuating a national electronic Tower of Babel.

There is no shortage of software, there is a shortage of leadership.

Prospecting for success…

State of the art.  That was how we thought of it. 

In the days when mothers gave their kids cod-liver oil and we bought our shoes in a Bata shoe shop, the Roneo machine was how we copied things.

Stencil duplication.  The Rotary Neostyle duplicator was a global best-selling machine. It was brilliant at getting ink all over your hands and had a smell that anyone working in an office in the 70’s will remember.

‘Masters’ would be prepared on special paper by typing or writing on a stencil, which was wound around a drum that forced ink through the stencil and onto paper.  Winding the handle to rotate the drum, to produce the copies… a pain!

That’s how we go our management reports.  Monthly, usually sixty days in arrears.

Armed with out-of-date information we focussed on the economy of the organisation.  Later, came an interest in people.  Not much about their welfare.  More about their strategic deployment to increase productivity.  Time and motion studies that drove trade’s unions barmy.

Business started growing and became corporations.  Money was allocated, risk control and the concept of strategic, long range planning.  It worked well enough, the business environment was less volatile than it is today.

Most of today’s management training has its roots in the 70’s and 80’s.  In the 90’s not much changed to the curriculum of management but the tools improved; basic computing and software; SuperCalc, Harvard Graphics and Locomotive gave us spreadsheets, presentations and word processing.

The acceleration was dramatic when the first Microsoft suite arrived.  As information got better, management got better, more accurate, incisive but fundamentally the same decisions.

Over time the desk-top computer; spreadsheets deskilled the accounts department, MSWord finished off the typing pool and PowerPoint took away our ability to communicate.

Management skills became more refined.  Analytic skills, longer-term planning horizons as administrative capability was consumed by machines.

Computers are no longer electronic clerks, they have an intelligence we can tap into.  We are in a new era of management.  

Yes, we have to manage resources, people, skills, talent, regulation, plus we have to manage one more thing.  A vital thing.

At a time when we have long queues of people waiting for treatment, short queues of people wanting to learn how to do it and no one waiting to pay for it, we have something new to manage.

We have to manage ideas.

Ideas were once the preserve of academics and philosophers.  Today, they belong to every one.  It’s our job and our responsibility to manage them.  Ideas are a resource as valuable as money and as important as people.

The management of ideas goes beyond strategy and planning.  Ideas will make strategy more deliverable and planning more incisive. 

The problems we face; demand, resources, stifling regulation, hopeless workforce planning, efficiency gains… none of that will be solved with out ideas.

The concept of the creative organisation.  Open minded… imitating successful ideas, adapting and tailoring.  Discovering and developing.  Organising around the central concept of finding ways of doing more for less and more of it, better.

All of this requires the creation of a conduit for ideas to accelerate the speed of change.  This is today’s central focus for management attention.

How do we do ‘this’ better, safer, quicker and once we know, how do we do more of it.  Turning organisations into an ideas factory.

Look out for the inevitable organisation chart.  Clusters of functions… the performance of the organisation defined by its shape.  Where do the ideas grow?  They struggle to grow in the shadow of the trees of hierarchy and are easily stifled.  

The places not on the chart, they are too far down.

The most precious, valuable, fertile part is never on the chart.

The new management skills are are not running systems.  We can envisage they will run themselves.  If data is the new oil, today’s managers are the prospectors for the new gold… ideas.  Finding, developing and encouraging ideas. 

The skills of strategy and planning are as redundant as the Roneo.  Forecasting technological change, social change and political change… impossible.  

Our interest in the future has to be the extent we have the tactics and techniques that are nimble enough to react and have the ideas to do it. 

The ideas manager; creating the climate for success. 

How reasonable…

As it rolled to a stop, you could see the heat-haze shimmering off every part. You could smell it.

A yard or two away, behind the barriers, people were going crazy, taking pictures.

The driver unhooked the cockpit edge, designed to stop debris entering the car, hit the six point safety harness, pressed the quick release on the steering wheel and wriggled free of the custom-made seat.

The size of the cockpit exit on an F1 car; 850mm long and at its widest, 520mm.  It’s a survival cell designed to absorb direct, a +47g impact

The rear 375mm of the cockpit’s side walls rise upwards at an angle of 16 degrees, to reduce the risk of injury in the event of one car flying over the top of another.

He levered himself up, heaving on the Halo, designed to take the weight of a London bus and protect him from head injury… and was clear.  

He stood on the car and raised both hands in triumph.  Thousands in the Grandstand roared.  

Hamilton had won another Grand Prix.

During the two hour race a driver will lose 4kgs in weight and 3 litres in fluids.  It’s as hot as hell in a race car.  

He unclipped the crash helmet and HANS neck protector and pulled off the Nomex fire proof balaclava… to the ecstatic cheers from his pit team.  

The helmet, with the peel off visor strips, features a patchwork of names and logos.  Every square inch worth thousands in sponsorship.  TIBC, Petronas, Epson and Monster… the caffeine energy drink.

Next to Hamilton in Parc-Ferme, the slate-blue, Red-Bull car sits, menacingly… a 230 miles an hour advertisement for another caffeine drink.

Both drinks have about 160mg of caffeine per 16 fl oz can, and a bucket of sugar.  If you think that’s bad, Loco Moca Monster has 188mg… only available in the US.

In a 450ml cup of Costa there are 277mg of caffein.  Pick your poison.

We take super care of FI drivers.  Safety is the watch word.  Their talents are precious.  Now we are trying to decide how precious our kids are.  Do we want them drinking the stuff that fuels F1 and revs-up the youngsters.  Should any of us?

If you are sixteen you can fight for your country, but soon you may not be able to drink a Red Bull at your wedding reception.  It depends on the outcome of the HMG consultation.

FI might be looking for a new sponsor. 

Once again, Public Health is at the centre of a moral and ethical conundrum, a dilemma was first identified by Thomas McKeon, a public health doctor who hit the nail on the head.

He said, in 1969 [in terms];

‘… government has done all it can about public health; clean water, adult literacy and childhood immunisation.’  

He went on to say; 

‘…the rest depends on the extent to which government is prepared to interfere in lives of its people.’

He was right.  It’s the law that changes behaviour.  Seatbelts in cars, crash helmet on motorbikes, smoking in the work place, health and safety legislation.

The complications of tax-take, the support and donations of big business, lobbying, votes makes public health is a messy business.

F1 is broadcast to over 200 countries with estimated viewing figures of around 500 million per race.  Watched by more people than American football, athletics, golf and cycling. 

If we don’t buy Red Bull, we don’t get motor racing?  Well, they said that about cigarettes when Marlborough couldn’t sponsor Ferrari.

Restricting choices to protect the public’s health.  How far can you go?  Transparency in decision making, a publicly understood rationale, informed consent, democratic oversight, all have a part to play.

Obesity, unlike smoking, harms no one else…. but it does divert resources away from health services needed elsewhere.  Should children who are not immunised be kept from going to school, or NHS staff who refuse a flu-jab sent home?

Sports injuries are ‘self inflicted’ should we all pay for their repair?

In the end we can only fall back on the notion of justice and fairness.  Norman Daniels and James Sabin gave us the idea of ‘procedural justice’ and the ‘accountability for reasonableness’.

We can only do the greatest good for the greatest number… how reasonable do you want to be?


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Reproduced at by kind permission of Roy Lilley.