This Weeks Roundup of NHS News and Comments by Roy Lilley

primary_care_training_ambulence

Tell us how…

If we could all run as fast as Hussein Bolt, none of us would ever miss a bus.

We can’t.  If we trained seven days a week we never will.

If we all could sing like Adele… we can’t and that’s why karaoke-nights are best avoided.

If we could all be as good as the best, it would be better, but we can’t and that’s the problem with Lord Bog-Roll’s latest.  Yes, Patrick Carter has had another go.  This time it’s the ambulance service.

In a complex and forensic dissection of the ten Ambulance Trusts around England, he tells us some are quicker than others, some use more diesel than others, some do things differently from the others and the others do things differently from the rest.  It’s a mess.

Or is it?

Fighting off regulators, deficits, staffing, an abusive public and demand, it’s more of a Zugzwang

Ambulance services in country districts are very different from services in an inner city.  Carter admits; 

‘… there was no single national measure that could be used to benchmark the productivity between trusts.’

So, Carter has invented one and pinched some ideas from Australia.  

I’m not convinced.  Why he couldn’t create audit-families of similar Trusts, geography, demography and so-on and make comparisons amongst them is beyond me.  What he opted for is dividing the number of calls by the cost and then adjusting for performance over time.  It’s baloney, isn’t it?

Pages 24 and 25 describe the kernel of the problem.  Delays at handover.  The answers; put your best people at the front door, decide who needs a stretcher and who needs a chair and Boards pulling out their collective fingers… simples.

The eye-catchers are;

Paramedics fixing you up at the scene.  Without imaging and diagnostics there’s not much they can do and whilst they are suturing-up a lacerated leg, they are ‘off-the-run’ for a heart attack.

More ambulances; we need about 1,000 more ambulances but that means more than 4,000 more paramedics to staff them.  It takes 4 years to train one and we are already scouring the world for more.  Mrs May’s happy band will soon put a stop to that.

Paramedics should have on-line access to our health records.  So should I.  So should all hospitals.  It seems to me our principle health records are held hostage by the commercial interests of primary-care software providers.  And, as for downloading them, to an ambulance on a dodgy wifi signal in a city centre or the middle of a field… well, good luck with that.

Carter misses a trick; 5G is coming and we should be lobbying government to give the NHS a dedicated channel, like the army, so we wouldn’t have to pay the likes of Vodafone a fortune.

Neither does he mention the impact of Brexit.  NHSE have brought forward orders for 112 Ambulances to avoid shortages and delays in shipment. 

Carter ducks the main question and gives no good reason.  There are ten ambulance Trusts, all independent, all buying different stuff, all doing things the best they can, in their own way.  The obvious solution; an NHS Ambulance Service run on a regional basis.

Carter, limply says; 

‘I have concluded that now is not the right time to revisit this issue…’  

Why?  Dunno.  Instead he urges them to work closer together.  

Time for the Association of Chief Ambulance Executives to get cracking and do the obvious.  That would be like Turkeys voting for Christmas.

Cater and reports… well, he wrote one on pathology labs back in 2006 and I’m not too sure that very much happened.  

Since 2016 he’s been working on the model hospital but the results are a mystery.  The web-site is password protected and I’ve seen no results.  If there was something to shout about I guess he would be shouting?

Lord Bog-Roll has a familiar theme; standardise, kill-off variation and compare.  

I think we all get that but in a fragmented NHS, decimated by ill-judged political reorganisation and austerity, running on goodwill and the smell of money perhaps he’d like to write a report to tell us how.

But he IS a very nice man… have a good weekend.

Give it a try…

There is no magic.  I’m sorry to be the bearer of bad news.  After years of study, practice, meddling and messing about… I can tell you; there is no magic.

There is no magic to running a hospital, a GP practice, community services or a chip shop.  There is no spell, no enchantment and nothing super natural about it.  There is no magic leader, no wizard manager.

Disappointingly, all I can say is, there are no short cuts.  It comes down to hard work and attention to detail.

What I can tell you, with some certainty is, the best places I’ve been to, the best people I have watched, all have something in common.

They use two words.  They use them a lot.  They use them because they are curious and have a genuine desire to do things better, quicker, safer.

The two words are simple, single-syllable words but put together can; 

  • Change the whole basis of management.  
  • Change how organisations are run.  
  • Change our whole approach.  

They throw a whizz-bang into the management arena.

The words?  They are; ‘What if?’

Think about it;

‘We want to be 

the best hospital in the NHS.’

Immediately it brings to mind a predetermined view of what ‘best’ means.  Implies ‘someone’ has made a decision and handed it down.  

It invites no involvement.  ‘We want to be...’ and that’s that.  Whoever ‘we’ might be.  The management bugle at full blast.

Try this;

‘What if… we wanted to be the 

best hospital in the NHS.’

Adding ‘what if‘ energises the question, makes the goal appear inclusive and moves the fulcrum point.  

The word ‘we’ has more emphasis and implies greater engagement.  Subtly it invites us to think how and invites us to join in.  

It implies no presumption that the person asking the question has all the answers.  This is an inclusive question.

‘What if‘ these services were good enough for my Mum?’  The unspoken words that follow immediately get us into what we would have to do, not a discussion about is it possible.

What if‘ I spent his budget like it was my own money?  

Well, I’d….

‘We are going to be the best’.  It’s a simple statement and our reaction to it will be based on all the things we know we’ve done in the past.  

All the problems that were created, the reasons for failure and not doing it.  Our brain-box races to find the answers based on what has gone before.  

The warm embrace of precedent, or the icy grip of what’s gone before.  

Be the best!  We know we can’t because… let the list begin!

Be the best!  Well, good luck with that.

‘What if’ creates an entirely different response.

What if‘ … we wanted to be the best?

‘Well, I’d want to make sure…..’

‘Well, we’d have to….’

‘Well, I’d change….’

‘What if’ helps us become more creative, innovative and thoughtful.  It moves us away from conventional responses and our zone of precedent-thinking.

What if ‘ we guaranteed, to every patient, they would be tested, diagnosed and treated inside 3hours…’

‘Well, we’d have to change the registration systems, shift the flow through pathology, up-skill the nurses and HCAs, do this… move that… and… and… and…’

‘What if’ works in our private lives.  

What if‘ I was the fittest I’ve ever been?  

What if‘ I made a real effort to get home for the kid’s bed-time one night a week?

What if‘ I started a study course for a management qualification this year?

‘What if’ as well us helping us with goals, can be a friend in a time of need;

What if‘ the resource allocation is no better, how will we improve/sustain/develop what we do?’

What if‘ invites us to think, makes us open our minds to what might be possible, helps clarify what we have to do.

It’s a powerful couple of words, worth so much more that their six letters.  They punch above their weight and might help you to do it, too.

‘What if’ you gave it a try?

Get out of the way…

It’s hard not to conclude there could be an election before Christmas?

Individuals are hard to predict but in the aggregate they are pretty predictable.  The majority want to be asked ‘that’ question again.  If the Brexit-aratti are so convinced of the rightness of their arguments, they should have no concerns about testing them again.

Ignore the will of the people at your peril.

It seems obvious to me; we voted to leave the European Union because we had a genuine belief that its institutions are trespassing on our national freedoms.

No one understood the wholesale disruption to our lives and the future of our kids, that unravelling 40 years of complex cooperation would mean.  If anyone did, they didn’t tell us.  And, frankly, what they did tell us wasn’t true.

Changing the EU might have been a better option than changing the way we live.

Add to that the cold edge of austerity so many families struggle with, the astronomic costs of rail travel that commuters suffer, utility bills that hit us all, the collapse in social care so many have to work around.  Holes in the roads.  There’s a lot to have an election about.

It seems likely the Tory Party will boil over.  Look at the pollsters and more importantly, the bookmakers.  I predict a Labour win… but what do I know.

The Labour Conference is interesting.  Google have a big stand.  Even more interesting…  

Radical, fundamentally different ideas?  Well, can the government really run the trains any worse than they are now?  Could government running the utilities make water and the lecky cost any more than it does now?  Is it feasible to print money and buy our way out of PFI? 

In the days when government did run all this stuff we used to run regional health authorities with hand written spreadsheets on graph paper.  Today, we know more, have better skills and technology to guide our decisions… we are more on top of things.  Just maybe they could?

What fascinated me most; in the days of the gig-economy and zero hours contracts, Labour talking ’employee shares’ and participation in the governance of companies.

The CBI are having a conniption. 

It doesn’t seem to hamper Mercedes or BMW.  In Germany half of the members of the supervisory board must be elected by the employees.  In Sweden employees are represented on the boards of almost all companies with more than 25 employees. 

France, Austria, Denmark, Ireland and Netherlands, in one way or another, do it.  In the UK we stalled at the Nuttall Report.

If I’ve learned anything over the years it’s this; people doing the job know a lot more about the job than the Board will ever know.  Worker directors on Trust boards?  Why not.

Medical directors don’t appear to cover themselves with glory.  We still have horrible quality failures.  I doubt the engine room of Trusts, the junior doctors, know where the board room is?

Nurse directors, conflicted between safe staffing and balancing the books.  Put some staff nurses and a healthcare assistant, or two, on the Board and we might find out what one-in-eight really means.

There is a big difference between running an organisation and knowing how it runs.  Really runs.  

If the organisation’s objective is to do things better, why not ask the people doing things, how to do it better.  You can  barricade the boardroom door with a closed mind or unbolt the door with an open mind. 

Working people know better how work is done.  There is probably no better example than with self managed teams.  Buurtzorg the famous example. 

If you want authentic decision making, innovation, leaner operating costs, improve productivity and ‘customer’ satisfaction, all the evidence seems to be; self-managed teams are the answer. 

All this boils down to understanding that, like electing a government, becoming a manager is only the beginning.  

However big the majority (or not), however senior the job (or not), what matters is that we reflect the interests of the whole country and the whole enterprise.

Democracy.  For the nation and why not, for organisations.  

It’s the job of politicians to create the climate and managers to create the time and space for good people to do great things… and get out of the way.

Get on with it…

It looks like No18 has upset the applecart.

The doctors have had a go.  The editor of the HSJ had a pop.  Some of the mainstream press joined in.

What’s he done?  He told the truth.  

Usually, minsters get into trouble for dancing around their handbags, trying not to tell the truth.   Sometimes the truth is too embarrassing, too early to be told.  Too late to be referred to.  

The truth, so often the enemy of Whitehall!

No18 has got people going because he admitted he uses a particular product, finds it very satisfactory and suits him well.

It’s not his brand of trainers, breakfast cereal or bog roll.  What’s got him into trouble?  He is a user of Babylon, the doc-on-yer-phone-app.  He has confessed and admitted he finds it very satisfactory.

He was somewhat ill judged to have mentioned one product by name but as he only uses one App, it would be hard to talk about the others.  No doubt a wise comm’s voice will whisper in his ear.

I was in the audience when Number 18 visited Babylon, to celebrate the $100m investment in their English business.  I recorded what he said.  

In these days of Brexit and uncertainty, a rare piece of good news.  He was at pains to make it clear he wanted a lot more activity in this part of the technology space.  In English, not one product but competition.

The fact the Secretary of State for Health 

is unable access to primary care and he’s resorted to Babylon (other Apps are available), will come as great news to commuters (other jobs are available) who find themselves in the same predicament (other difficulties are available).  

They are hoping he might sort it out… other solutions don’t seem to be available!

If you can’t get into the surgery but you can check your symptoms with a neat bit of AI, go on to speak to a real, live GP and receive an audio recording of the consultation and get an online prescription… all on the NHS, why wouldn’t you?

That’s the issue.  Access.  In the European Consumer Index of Healthcare, the NHS drops to tenth.  We score badly on access.  Waiting lists for treatments stretching into years and waiting for a gatekeeper, for weeks.  Nowhere waits like we wait.  

The NHS might be a religion but queuing is a national pastime.

Primary care is the pinch-point in the system.  Generally… 

  • You can’t see your patient records until the GP lets you.  
  • You can’t get to see a consultant unless the GP agrees.  
  • You can’t have a scan, or a blood-test, or anything until the GP says it’s OK.  
  • You can’t get a pill until your GP signs on the line.
  • You can’t meet a midwife until the GP makes the introduction.
  • You can’t access dementia services if the GP doesn’t think you have dementia.

All of these decisions made by private contractors to the NHS.

The GP is where we all go, first.  Those first contacts make up 90% of access into the system and we get if for under 11% of the total NHS budget.

Clearly the money’s not right but…

Capacity in primary care delays access.  GPs know they are under pressure to reduce referrals, delaying access to secondary care.  The system is clogging up.  The ECIH report challenges a number of assumptions.  

The evidence would seem to suggest, admitting patients on weaker indications, earlier, is cheaper in the long-run. (Page 36).

There is also a question on the ongoing benefits of the gatekeeper role.  Outcomes are better in countries where people can access services, by-passing the gatekeeper. (Page 68).

There’s nothing easy about any of this.  Custom and practice, how we train people, preferences, expectations, risk, continuity, cost… I get all that.

Family practice has been the corner stone of the NHS but families are changing.  The cornerstone is a millstone for commuters and students and the busy-keeping-going and the working-well.  

But, the corner stone remains a stepping stone for the vulnerable, the chaotic and those who need a longterm friend to see them through.

The NHS was born into the grey of post-war austerity.  Today we still battle austerity but we see things in a colour and texture we couldn’t before.  We can do what we could never dream of doing before.

Bevan was a radical, I bet he would have 

‘done Babylon’…

No18 is an enthusiast for technologies and is only here ’till the elections and they might be nearer than we all think.  Before No 19 arrives let’s give him the time and space to do what we all know needs to be done.  

Get on with it. 

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