June 17, 2004
BAMM Conference: Knaves, Knights, Pawns and Queens
The undoubted intellectual high point of the conference was reached this afternoon when Julian Le Grand gave a shameless plug for his recent book. Professor Le Grand is the Richard Titmuss Professor of Social Policy at the London School of Economics and has recently started a 6 month secondment as health policy advisor to the Prime Minister. Simon Stevens, his predecessor at Downing Street was to have presented in the morning, but stood down in the light of his recent defection to the private sector.
Julian Le Grand has a major interest is in the motivation of professionals, which he believes is the key to policy design in the public sector. His recent book asks how professionals in public services can be motivated to deliver quality:
Can we rely on the public service ethos to deliver high quality public services? Are professionals such as doctors and teachers really public-spirited altruists - knights - or self-interested egoists - knaves? And how should the recipients of those services, patients, parents and pupils, be treated? As passive recipients - pawns - or as active consumers - queens?
[He] argues that the original welfare state was designed on the assumptions that those who worked within it were basically altruists or knights and that the beneficiaries were passive recipients or pawns. In consequence services were often of low quality, delivered in a patronising fashion and inequitable in outcome. However, services designed on an opposite set of assumptions - that public service professionals are knaves and that users should be queens - also face problems: exploitation by unscrupulous professionals, and over-use by demanding consumers, especially middle class ones.
He suggests avoiding situations where ‘knightish’ and ‘knavish’ incentives work in opposite directions (e.g. private practice), and try to get them pulling in the same direction—as with GP fundholding.
BAMM Conference: Fitness for purpose... Fitness to practise
After lunch Pam Garside chaired a session in which Sir Graeme Catto, President of the General Medical Council (GMC) reminded us what the GMC is all about —To protect the health and safety of the community by ensuring proper standards in medicine,— and how revalidation will work. Later this year, registered doctors will be asked if they wish to be granted a ‘licence to practise’ (without which, one assumes, practising will be illegal). From next year, maintenance of this licence will depend on successful revalidation. Although in discussion it emerged that the actual mechanics of revalidation is anything but clear, for most of us working in managed environments this will depend on providing evidence of satiscatory appraisal, even though appraisal is meant not to be a means of performance assessment.
Alistair Scotland then presented a ‘whistle stock take’ (sic) of the National Clinical Assessment Authority (NCAA)’s recent activities. Referals od doctors with problems continues to rise [I wrote down 1.2%, but missed the denominator]. Referalls of GPs and psychiatrists are particularly on the increase, the latter perhaps reflecting the problems of a shortage specialty operating in an a poorly-managed environment beset by the disruption of multiple mergers, rather than any particular characteristic of psychiatrists. Overall, Alistair was upbeat about the impact of the NCAA, feeling that it is having a useful effect on the number of suspensions, but noting that nearly a quarter of these are ‘resolving’ by the individual concerned resigning his or her post. The age of referrals to the NCAA co-incides with what is assumed to be the peak of one’s productive life: there is no excess of newly-qualified consultants, partly allaying fears that shortened training would reduce competence.
BAMM Conference: Leadership challenges for tomorrow
One of the conference highlight’s was Hilary Thomas’s presentation on leadership. Hilary has pursued a strong career through academic clinical oncology and leading a cancer network, and is now medical director of the Royal Surrey County Hospital. This was a well-crafted presentation which though covering familiar ground, was sufficiently challenging (The NHS must change faster if it is to survive) to keep our attention at the end of a long morning.
Whilst medicine was once considered simple, ineffective and generally safe, rapid technological progress, expectations & demand, and government intervention has changed all that. The US healthcare system is now largely driven by the pharmaceutical industry, and globalization will extend this to us all. [It already has.] Tomorrow will need to be proactive rather than reactive, characterized by partnerships not paternalism, and with healthcare based around the patient, and not the institution or [professional] tribe. Honesty and integrity will be vital.
Challenges for tomorrow are education, short-termism in the NHS, its treatment of senior managers [hear hear], and combatting the growth of regulation and reorganization.
Just one minor regret: Hilary’s love of gastronomy merely served to highlight the awfulness that was to be lunch.
BAMM Conference: The deal between patients, public, professionals and managers
There then followed a panel discussion, chaired by Charles Swainson, though by now the programme was running late and time was short, limiting the session to 5 minutes per panelist and a few questions from the floor.
Peter Lees thinks that we are missing a trick with patient liaison. Until recently it never occurred to him (or I suspect most of us) to actually ask his patients what they thought about him and his service. Rather bravely he has directly recently done just that with a few patients, and found the experience very rewarding. As a result he feels that if we could only ‘let our patients in’ in this way, they could be strong advocates for us.
Steve Evans took the managerial line humourously with a Goff cartoon of a manager telling his staff “I’ll be in charge of delegating all the blame”. He commented on growing perceptions of increasing managerialism in the health service and problems with the quality of middle management. He also felt that consideration of doctors as managers was misplaced—doctors are managers.
Sîan Griffiths lauded the Wanless reports and exhorted us to take up the public health agenda in our day to day work. The burden of preventable disease is growing such that healthcare will break unless we take this seriously. We all have responsibilities for this within our Trusts, with employees, with patients and as corporate citizens.
Ken Aswani reminded us that the PECs are the professional executive committees of primary care trusts (PCTs) which have responsibility for improving health, delivery of primary care as well as commissioning all healths services for its patients. The PECs thus give professional locally a prominent role and opportunity to shape tomorrow.
BAMM Conference: The road to nowhere?
The full title of Denis Smith’s presentation was The road to nowhere? Pillars and other metaphors for changes in healthcare, but as usual his metaphors were exceedingly obscure. Denis’s BAMM presentations have become legendary for their side-splitting humour, often funny to the point of obscuring his underlying message. This time, though still very funny in places, he had a more approachable message— namely that (if I may paraphrase) every system has embedded within it the seeds of its own failure, and that in trying to compensate for this we simply add to the complexity and, ultimately, to the certainty that at some point failure will occur. When it does, unravelling the ‘root cause’ can be a nightmare. Systems work because of the people in the system, but failure often reflects system complexity rather than human error.
[This theme will be familiar to computer programmers, and is well illustrated by the repeated security failures in Microsoft’s Windows operating system. CAR (Tony) Hoare wrote about the phenomenon over 20 years ago in his Turing Award lecture The Emperor’s old clothes. The parable that ends his lecture is well worth reading, as is the full text]
Denis is a natural, gifted and entertaining presenter. His visuals are the complete antithesis of the powerpoint misery which was the butt of yesterday’s rant (probably in part because Denis uses Keynote rather than powerpoint).
BAMM Conference: 9/11 - The lessons for today and tomorrow
Eliot Lazar is the Chief Medical Officer of the New York Presbyterian Healthcare System (NYPHS) and as such was personally involved with his institution’s response to the 9/11 disaster. His absorbing, extensive and at times moving presentation led us graphically through some of the horrors of the day itself, and then some of the lessons learned and how approaches to emergency planning have evolved as a result. The NYPHS is a major provider in the city and surrounding areas, and covers two major university teaching hospitals and dozens of smaller institutions totalling some 12,000 beds: a similar scale to our old Regions, though by no means the monopoly provider. Indeed, the complexity of inter-agency interactions that come into play in a disaster such as 9/11 are truly staggering.
However carefully one plans, and in whatever detail, something will likely catch you out. Patient flows are entirely unpredictable: victims will gravitate towards hospitals wherever they find them, not ‘rescue centers’ or wherever else they have been directed. Communication is critical but communication systems may be victims of the original disaster. [I understand that in this country the police have the power to take over and if necessary shut down our mobile phone networks in such circumstances). Manpower is not an issue: there was no shortage of volunteer manpower after 9/11 and the problem was turning many away without appearing ungrateful: wanting to help in an emergency is a powerful basic urge.
Disasters on this scale do not affect a single hospital but whole health care systems. Co-ordination between hospitals themselves and with hosts of other agencies is vital, and the ability to move surplus resources from one are to another more needy is essential. This needs the ability to generate rapidly inventories of available resources and communicate the information widely. Web-based systems are excellent for this, though what happens when the network infrastructure is also damaged was not mentioned. Interestingly, in ‘desktop’ exercises since the event, nurse shortages have been highlighted as a major potential problem.
At one point, Eliot asked how many of us had had discussions with our families about what we would do if struck by disaster. None of us had. This is apparently big stuff over the pond, and what we should be doing is detailed here.
Eliot and his colleagues have clearly been profoundly affected by their experience and have worked tirelessly to develop and disseminate good practice guidelines one hopes will never be needed. My sense is that major incident planning is fairly well developed (if not rehearsed as realistically) in the UK. As Eliot pointed out, we were there first, with the Blitz, but there are still things to learn for tomorrow.
June 16, 2004
BAMM Conference: Are our hospitals ready for tomorrow's NHS?
Rising star Mark Britnell, CE of the University Hospitals Birmingham NHS Trust is clearly a visionary and strategist, as well as ambitious. He runs a major teaching hospital Trust, with a massive PFI rebuild on his books, and a likelihood (for him, certainty) that UHB will become a Foundation Trust very soon. In brief, his tenet was that since 1948 the NHS has been driven by central command and control thinking, with local ‘management’ just responding to central demands and not able to think strategically at a local level. [I had a flash of déjà vu at this point— 10 years ago when we first became a self-governing Trust we had, for a very brief period, a real opportunity to think plan and do at a local level. The problem was that few people actually wanted to play that game, and we didn’t get far before the government changes and the forces of centralization returned.]
Birmingham has always been a tough nut to crack. Medical (private practice) and local government politics never really saw eye to eye. Mark’s approach is to look to the future (it’s often easier to share a distant vision) and then work backwards to remove the obstacles. Sound good, doesn’t it? As a Foundation Trust, the full weight of the Harvard Business Review will be at his finger tips, building value chains with all manner of potential partners, and buying out those that don’t play ball.
Clearly, Mark’s hospital is ready for tomorrow. Is yours?
BAMM Conference: The primary care service of tomorrow
David Colin-Thomé took the after lunch slot but was not as stimulating and provocative as he can be. Perhaps it was because he didn’t have much new to say, perhaps also his slides were especially soporific. He laid out the familiar central market stall of improving access (capacity), personalizing care (choice), public health, chronic disease management (based in the community), etc., but there was little insight into ‘how’, and whether the good ideas and pilot projects would scale sufficiently in the real world. For those based in secondary care (most of the delegates), the world of which he spoke seemed rather remote from how it feels on the ground.
There was some discussion about the ‘gatekeeping’ role of primary care and how this has never been a formal role, but one which simply arose from the fact that when something is wrong we usually see our generalist GP first, who more often than not can deal with our problem completely. The introduction of ‘payment by results’ will, he felt, actually increase this gatekeeping role, though he was not impressed with the possibility that his PCT’s commissioning agreements might actually prevent him from referring a patient to the specialist of his (or the patient’s) choice.
BAMM Conference: Is healthcare safe?
The first morning ended with a briefer than intended panel discussion led by Denis Smith, with Carol Black (RCP), Anna Walker (HC), Nick Bishop (HC) and Doug Russell (Tower Hamlets PCT). The discussion struggled to get off the ground with the panelists philosophically prevaricating over definitions of ‘safe’ and ‘who for?’. The eventual conclusion was ‘not safe enough’.
The inevitable parallels with the aviation industry reappeared though one commenter usefully pointed out that (unlike aviation) healthcare is not a simple interaction between people and systems—there is this confounding thing called disease to consider as well. There was much bemoaning the pervasive culture of blame, and how the legal system and media push for a scapegoat at every opportunity. One questioner pointed out the errors are often multifactorial or multistep and the sometimes the least significant contributing step is the one singled out for blame. There was also concern that the culture is engendering fear and defensiveness at an early stage of training, and that organizations that have high error reporting rates are frequently assumed to be ‘bad’, when the opposite is more likely to be the case.
BAMM Conference: Inspecting, informing, improving
Anna Walker, the new chief executive of the Healthcare Commission (the new name for CHAI, previously CHI—Commission for Health Improvement) spoke for the first time at a BAMM conference. She is new to healthcare, having previously been a Director General at DEFRA and before that at the DTI), but already shows an impressive grasp of the major political, strategic and practical issues facing the Commission.
The Healthcare Commission has regulator responsibility for the whole healthcare spectrum: NHS, private healthcare and voluntary organizations, working within a framework of government standards. Like CHI, it will undertake annual provider reviews, themed reviews, and investigate problem or failing organizations. In addition, it will likely take on the second stage of the NHS complaints process. It aims to do this with substantially fewer people and resources than sister organizations such as OFSTED. It will therefore not be relying on armies of paid inspectors (though may continue to second people from within the NHS, as did CHI) and will rely on organizations submitting a detailed self-assessment which will be rigorously analyzed and screened for deviations. Detailed inspection visits will probably be confined to poor performers, and high flyers. Cross-boundary issues are likely to be an early priority.
Asked if the Commission would tackle the government if its surveys or inspections found problems arising from central policy, Anna Walker made it clear that the Commission will be feeding back regularly to the Department of Health and would be prepared to ‘say the unsayable’ if it came across such problems. The Commission will also take into account improvement (relative performance) as well as absolute performance in its assessments, and recognizes that locality commissioning poses particular problems for hospital Trusts that have to work with multiple Primary Care Trusts.
BAMM Conference: Facing the Future: what it means for the [medical] profession
Carol Black spoke on challenges facing the medical profession, mainly from her perspective as President of the London Royal College of Physicians and with the insight of a past medical director and a member of the NHS Modernization Board. She walked us through the globalization arguments and stressed the evolving demographic, epidemiological and social trends—aging population, ethnic diversification, changing patterns of disease, and consumerism. Age-related chronic disease, preservation of health and prevention of disease are becoming the main drivers, for which the traditional primary/secondary/tertiary healthcare structures are no longer. appropriate. She predicted greater emphasis on managing chronic conditions in the community (hardly an new concept) but in a planned, structured and integrated way (a bit more novel). Although she didn’t mention it as such, ‘plurality of provision’ is part of the scheme.
The RCP has clear interests in both acute and chronic care. It has recently published a working paper on Acute Medicine which aims to ensure that hospitals receiving medical emergencies are appropriately organized and staffed with physicians who are not merely competent but highly skilled in managing acutely ill medical patients, and for whom the medical ‘take’ is not a simple diversion from their specialty work but a major part of their (professional) lives. As a rheumatologist, Carol Black is particularly sensitive to chronic disease management issues, and her college is a partner in the recent publication Clinicians, services and commissioning in chronic disease management in the NHS with the Royal College of General Practitioners and the NHS Alliance. This makes recommendations on joint working, clinical leadership & governance, and service redesign.
Uniquely among the Royal Colleges, the RCP has lobbied hard over the impact of the European Working Time Directive (EWTD) and particularly the SIMAP (rest in hospital = work) and Jaeger (immediate compensatory rest periods) rulings will have on our ability to sustain a safe and effective service in all hospitals after August 2004. Shift pattern working is not universally popular, especially amongst middle grade juniors and there are concerns for continuity of care and handover. Smaller hospitals will find it particularly difficult, and consultants will be increasingly drawn to the front line: probably no bad thing for patients, if only there were enough consultants. Various hospitals have looked at different staffing patterns and cover at night with some success. A major concern is that the changes in patterns of work may reduce opportunities for learning, though some data suggests that in larger hospitals with sufficient staff, shift patterns and night schemes may actually increase the proportion of time worked in daytime shifts, when there tends to be more training opportunities.
BAMM Conference: Death by PowerPoint
The first day of the conference went smoothly, though as usual PowerPoint intruded heavily in most of the talks. We have all been guilty of it at some time: it is so easy just to write one’s talk directly into PP, format it with bullets, indents and more, and just simply read it off to the audience. It is easy too to forget that the kind of audience one is talking to can read and digest a whole slide before one has stuttered through the first bullet point: transition effects that delay each paragraph until the presenter has caught up simply frustrate. Content and delivery has to be seriously good to overcome the deadening effect of most presenters’ slides. Today we had a spectrum: some terrific, some stimulating and some, well, there you go.
Perhaps part of the problem was that Aidan Halligan (Deputy Chief Medical Officer) set such a high standard with the first presentation that following speakers were cast somewhat into the shade. Aidan is always an engaging, thought-provoking, original and entertaining presenter, and today was no exception. His slides illustrate rather than drive his talk.
Aidan’s brief was The Challenges Ahead. We all know that for him (and, as he would have it, for us as well) is implementation of the massive IT programme for the NHS. But he chose to preface this with a gentle reminder that the uniqueness of clinical encounter between doctor and patient has endured over a long period and that we should not forget the ‘unwritten’ contract patients’ and clinicians’ contracts. The IT programme will come to nothing if not fully embraced by clinical staff ‘with enthusiasm’. Aidan’s aim is to engender that enthusiasm:
Communicate as if the whole programme depends on it. (It does: how often I should communicate is how often I should kiss my wife: before someone else does.)
Identify an enable local leadership. (And train them, too)
Match and exceed the expectations of patients and clinicians.
There is no doubting Aidan’s enthusiasm and commitment to this. If anyone can communicate it to the service, he will.
[More to follow]
BAMM Conference: Welcome Dinner
Last night the conference kicked off with a dinner for delegates sandwiched between addresses from two prominent speakers. The Secretary of State John Reid was to have been one but unfortunately was unable to come at the last minute, but the helath minister John Hutton steeped into the breach. His well crafted speech was apparently his own doing, not the civil servant-authored version that John Reid would have given. He was suitably (and I think genuinely) effusive about the key role that medical managers need to (and are) playing in the NHS as it goes through change after change. There was nothing particularly new or controversial; BAMM, the Department of Health and, of course, the government all came out smelling of roses. The NHS did pretty well too, having been pulled from the jaws of disaster by knights in shining armour, and all that stuff. Well done all!
Sadly, the meal itself came a poor third in the evening’s agenda, and we were rescued eventually by our Chief Medical Officer, Sir Liam Donaldson (minus charger). Liam had wisely guessed that powerpoint would not go down well at this juncture and spoke unaided by this—and his reading glasses. He recalled Alan Langlands’ metaphor Can the elephant dance? and gave his own view of the challenges facing our favourite elephant (the NHS) as it is forced to change over and over, much of it being a rant about the dangers of devolution. He stressed 10 points:
The death of deference. The post-Bristol NHS climate together with the rise of consumerism have led to a decline in the deference which the medical profession has traditionally enjoyed from patients and public whilst, conversely, indignation about poor care standards is increasing (for example, failure to respect dignity in the elderly). Liam feels it important that the profession itself buries deference.
Can we get to grips with the safety issue, and can we match other industries in this respect? One in 10 hospital patients suffers some kind of medical error.
Will the NHS, in its re-invention of earlier policies of devolution, become too interested in outcomes of care without being able to measure them? Infrastructure is important: can we afford to do away with [central] planning? (We had similar discussions during the big devolution revolution in our own hospital 10-15 years ago, and concluded that whilst highly desirable for many reasons, devolution without a framework leads to anarchy.)
Devolution of responsibility. The government invented NICE to end ‘postcode’ prescribing. Sereral years down the line the cancer ‘tzar’ Mike Richards can demonstrate an 8-fold difffernce in presription of anti-cancer drugs.
Adaptability and the capacity to adapt. Emergency capacity, Sept 11th, terrorism etc are challanges for an NHS with devolution away from central command and control, which is crucial in emergency situations.
The IT revolution: can the NHS get it right? The stakes are high: we are embarking on the largest and most expensive infrastructure project in the history of the planet against a background of spectacular failures of previous large projects in both public and private sectors. The potential benefits are enormous. Indeed, the NHS reforms depend on it. Richard Granger is the ‘electrician’ of the project; Aidan Halligan the ‘benefits realization’ man.
Public health. The NHS is and historically has always been primarily a sickness service that is not good a prevention and education. Liam’s view (unsurprisngly) is thar public health is not an option; we must do it.
Chronic disease management. Now a buzzword, but how do we do it? This is becoming a new government priority and one which will cut accross traditional service boundaries (which is why its difficult) but has great potential to improve the lives of many, and reduce unnecessary spend.
Younger people want a different work/lofe balance than previous generations of professionals. Currently, 60% of NHS staff are from the post-war ‘baby boom’ generation and will retire in 6-7 years. Those from later generations will probably not be so workaholic. (Or be allowed to be).
How do we define ‘greatness’ in health care. Greatness is an attribute of human endeavour, not of organizations or institutions. (Nevertheless, Liam, humans work for institutions and organizations and are often inspired to greatness by them, and their history.
June 15, 2004
Blogging the BAMM Conference
The British Association of Medical Managers (BAMM) is holding its annual summer school and conference at Stratford-upon-Avon this week, with the theme Tomorrow and tomorrow and tomorrow…
As a distraction from the awfulness of the hotel I shall see if I can blog the highlights of the event. I have my trusty PowerBook, but alas no WiFi installed, which is pretty frustrating as the hotel has WiFi access. A conference exhibitor has set up an internet cafe, so if I can transfer this to one of their machines with my USB disk or figure something else, we will be in business…