Slow Down: A paradoxical way to transform healthcare services

This is a response to Partha Kar’s recent blog on seven day working, in which he argues that investment in more hospital care, as a response to the demand for seven day working in the NHS is the wrong way to go http://nhssugardoc.blogspot.co.uk/2015/09/invest-wisely.html

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Dear Partha

If I understand you right, you are saying that if (big if!) there is spare health money, that a broader definition of seven day working in the healthcare system should be adopted – one that focuses more on ‘upstream’ prevention, public health and community-led solutions. Rather than investing in hospital-based activity to ‘mop up’ demand. This seems sensible. And pigs may fly.

Apart from your cynical (and possibly correct) observation that cash for whizzy initiatives is often found down the back of the sofa (aka Vanguard pump priming and various transformation initiatives), there is a more serious question – how can the system save itself? You won’t be surprised that I think it can’t, unless those in power let go, and welcome in patient, community and citizen leaders. But let me come back to that later.

Integration is not transformation

Already, as a Patient Director, I can see the temptation to focus more on ‘improving efficiency’ and making the existing system work better, rather than shifting that system to something very different.

One reason is because there is a lot going wrong with people’s experiences (and a lot of course going right) and a lot that can be done to improve things – both in terms of making the system more ‘joined up’ so people are not passed from pillar to post and in the way they are treated (clinically and as human beings).

However, it is hard enough to ensure that what gets done traditionally (and often unnecessarily) in a hospital moves into a community clinic, for example, and that we stop unnecessary and non-evidence based treatments. Even this (albeit limited) transformation requires vast effort and institutional and professional interests to change. And money to be ‘released’. This is first order change. There goes another pig. Whoosh….!

But you are talking about something more radical. Money invested ‘outside’ the system – peer to peer support; self-management programmes; better access to local swimming pools (mine has just closed); a focus, if you like, on real ‘person-centred’ outcomes (like having more friends to prevent social isolation) as well as ‘patient-centred’ ones (like feeling better after care, rather than whether I get the right drug). This is second order change. Whoosh…!

To do this, we have to recognise that integration is not necessarily transformation in this second order sense. And, it will not happen unless…

Finger-waggers stop wagging

Health Authorities, Primary Care Groups, Primary Care Trusts, Clinical Commissioning Groups, and soon Accountable Care Organisations (ACOs) whatever they are. The churn of structural change has not brought this second order change much closer. My guess is that it won’t, unless the way those with the money relate differently to those who deliver services.

There is a big difference between ‘commissioners’ I’ve met down the years who focus on how they can help and those who scrutinise and blame when things are hard and go wrong. I have worked with commissioners who, when things are tough, ask: ‘how can we support you?’, who want to work hard at fostering better relationships. Then there are those who pass their performance anxiety down the food chain and say: ‘go and write us a report on how you will hit our targets’. They are the sort who can easily demand change fast, but who blame you when change happens too fast and things go wrong. Finger-wagging is habitual in the NHS. No amount of structural change will help. This is about, dare I say it, a different form of leadership.

Unfortunately, we have a desperate, frenzied, anxiety-driven system. From government, NHS England and CQC downward; through commissioners to providers; within providers it can also be passed down the hierarchy, from managers to staff. It is striking to see it manifest now in blaming patients (for not using services 'properly'). Each of us displaces our anxiety onto those with a little less power. It’s always more convenient to tell others what to do, especially when we don’t know how to do it ourselves. I am as guilty of this as the next person.

Unfortunately, I’ve also seen patients and carers on forums and committees who also want do a bit of finger wagging and who play the blame game just as well as their professional counterparts. But that is largely because the clarity of their role is unclear, they lack support and they don’t have sufficient investment in training around how they work with professionals as partners. See for example this article on the role of the representative

What could help?

As you know, Partha, the only reason I was interested in the NHS Survival group is that I thought (and still hope) that it will carve out a route by which we all talk about all this stuff more openly – what gets done and what doesn’t. And that this happens with patients and the public properly on board.

You also know about my faith in true patient and citizen leadership. Getting second order change is not just about what gets said and how. It’s about who says it and leads it. Until patients, carers, members of the community and citizens get more of a say, little will change. Systems can’t change themselves. You can read more about these views here and here

At present, the healthcare system is like a men’s only club that listens politely (or sometimes less so) to the views of women, but will not let them in. Yet. The role of Patient Director – people like me at senior or strategic level, in local and national organisations - may be one ray of light.

Other things give me pause for hope – patients and clinicians (like you and me) having a dialogue about this sort of thing; at local level, patients and professionals working together to develop supported self-management and better shared decision-making. This can be powerful, particularly when professionals can signpost people to community-led solutions (and managers step in to fund them!). This is slow but worthwhile work.

What I call ‘In-Reach’ services will shift things too. Housing and employment workers and/or peer-to-peer support workers within clinical teams will also start to disrupt, shift and ultimately improve things. Witness the Centre for Mental Health Individual Placement Support work and St Giles Trust work with peer-to-peer support for offenders.

Disruptive solutions from outside the system will also help – patient entrepreneurs like Michael Seres (@mjseres), Denise Stephens (@enabledby) and David Festenstein (@recoveryguru) are changing the way we envisage innovation as it becomes more about designing systems around patient-led innovators.

So, there is hope.

The slow-healthcare movement

Beneath all this, there is something else that needs to happen. We need to slow down. As the crisis of healthcare becomes more acute and the perfect storm approaches (less money, changing demographics and use of services), the clamour for ‘pace and scale’ of change becomes louder.

Scale is OK I think. I am all for large scale change, in the sense that we need to transform the vision for what is done in health and healthcare – this is the second order change. I am less convinced about need for ‘pace’.

My wife is Finnish, and she is constantly surprised by how fast one public policy in this country is torn up, only to be replaced by another short term fix – we liken it to a plant that is not allowed to grow sufficiently before its roots are ripped up. There is a feeding frenzy in healthcare, and it is exacerbating the poor behaviours – the finger wagging - I have mentioned above. It is not conducive to collaboration and better relationships.

I heard recently about a leader who said it was her job to buffer her staff from the pressures above; to create the space where they could do their job well; To slow things down and take the heat out of the situation. It’s a little like a good football manager protecting their players in the harsh glare of media publicity. Now, that is leadership!

What we need are leaders at every level – patient, clinical, managerial – to do likewise. I can see already in my new job, just how hard that is to do. And I am not overly-confident that I can do it, or that many others can. But I hope so. I hope so because slowing down is often the paradoxical key to change. If we want to move things upstream – to better invest in what will make a real difference - we all need to take that deep breath. And pause.

What do you reckon?