Wednesday, 28 November 2012

Imagine the perfect future, and then ground it in reality

Forgive my absence. Perhaps there is nothing to forgive. But I am back now, and a whole bunch of things have happened: I have secured my first Consultant post, starting in February. I have revelled in the thrills and spills of fatherhood. And I recently got the runners up prize with @tobyhillman in the Finnamore F20 prize, which asked us to discuss what healthcare should look like in 20 years time, and how on earth we make the necessary changes.  

Toby and I thoroughly enjoyed letting our imaginations run, and then trying to work out how we could make the vision a reality. We obviously did OK, but it would appear that one other entry did better, and to them goes my heartiest congratulations. I read their piece - it was a force of reasoning and research, and rather like watching someone else win the London marathon - I was vicariously breathless and thrilled at their achievement.

But from the relatively privileged position of thinking what the future of healthcare should look like, and what we should be aiming for comes the real world challenge of continuing to deliver health care in the current climate.

One thing struck me from my thinking around the subject: I spend much of my time at work helping elderly patients recover from their acute ill health. I spend time getting to know the patients, and how their illnesses respond to treatment. I then discharge them, and have nothing to do with them until they are readmitted to hospital. Perhaps I am over-rating the input I can have in managing patients during periods of relative wellness, but it seems to me that for my input into a patient’s care to be triggered they have to get rather poorly. There seems to be some sense in having the chance to respond sooner and at lower levels of acuity - to cut the major exacerbation or relapse off at the pass.

Current structures of care do not support the kind of collaborative, cross-boundary working that make the kind of delivery of care that I allude to possible. In particular, there is a major chasm in the delivery of healthcare formed by the different contracts that GPs and consultants work under. This might at first glance appear to be a minor issue, but its impact and effect is deep-rooted, and it makes it much more difficult for consultants in particular to work across boundaries.

We also need to have the right kind of care commissioned. We are entering a new world  of commissioning, and I doubt that many people are really that confident how it will all turn out. Just as the PCTs were getting good at commissioning, they are being disbanded, and it is difficult to shake the perception that we are starting again from scratch. The idea that GPs will have a significant role in the commissioning of care has resonance, but it is also a concern. Expert commissioning is not a part time role - it is not something that doctors have trained to do, and it is not something we can expect them to able to just do without considerable training and support.

I was struck by the risk that GP commissioning potentially poses when a GP involved in one of a local CCG told me that I shouldn’t get too comfortable at home on my nights on call as a consultant, because they were planning to commission hospital consultants to be on site 24 hours a day.

Flippantly, I asked him whether he was also commissioning pigs to fly. The point is this: commissioning is not just about writing a wish list of what you would like: the reality of having consultants on site at night means paying for that time, paying for more consultants to cover the work that needs to be done in the daytime, and also makes a statement about the importance of the acute care pathways with respect to the other work that consultants are engaged in.

Acute care is important, but so is the work that we need to do in the future to reduce the demands and use of the acute pathways, by managing chronic conditions better, pre-empting deterioration, and meeting the needs of patients away from the hospital. These work flows will become impossible if your consultant body is either working the night shift, or enjoying the inevitable time off afterwards.

Ask yourself this: if the full time consultant contract is 10 PAs a week, and a night shift is 3 or 4 PAs, where are all the consultants that will be needed to fulfill the rota requirements and the daytime work going to come from?

The way we deliver healthcare needs to change, and it will change considerably. But it needs to be grounded in what is both feasible and desirable.

Sunday, 11 November 2012

Blame the system

A couple of mornings ago, George Entwistle was given a going over by Charlie Stayt on BBC Breakfast. It was nothing like the going over that he had been given by John Humphrys on the Today programme, but it made him squirm.

We’ve seem George squirm a lot in recent weeks. It hasn’t been pretty, and at times it hasn’t seemed fair. But what was interesting about this particular episode is that Charlie was attacking him for expressing the sentiment that in the light of the Newsnight fiascos, it was important to see where the systems had failed, and seek to address them.

The answer that Charlie appeared to want was that George would seek out the individuals to blame, and punish them.

I suspect that this would have been part of George’s approach, but it is clearly not his manner to approach the issue in such an overtly belligerent fashion. In fact his managerial style seems to have been much more gentle than that, and right now, that is not what people want from him. They wanted to see him rattle his sabre, and make a bloody nuisance out of himself, to create the impression that something had been done.

There is something to lament among all of this. I can’t deny that George did a poor job of painting a good picture of himself - at times it was excruciating to see. But there is something about blame that he gets, that you see very few people publicly acknowledge. He tried to maintain that the decision-making behind Newsnight was a function of the system that exists. He placed a great deal of emphasis on systems, and how they work. A lot of the answers that he gave seemed to centre on sorting out the system, rather than focusing on the individuals. He appears to have been mocked and vilified for doing that, but I think he has been treated a little harshly.

A chap called Paul Batalden is credited with the quotation, ‘every system is perfectly designed to get the results it gets.’ It’s a good one. He wasn’t trying to say that every system is perfectly designed, but rather the product of a system is never better or worse than one could have expected, providing that one has a good understanding of how the system works.

It seems that we put an awful lot of focus on personal responsibility, and in particular, on personal blame, but we rarely pay much attention to the set of circumstances that lead to people making the decisions, or taking the actions that lead to scrutiny.

This is something that affects us a great deal in healthcare. Sometimes, the price for failure is high, and sometimes people make decisions, or take actions that result in harm. It is easy to spend time reflecting on the specific decision or action, but it is much harder to spend time reflecting on the circumstances that led to the person making that decision or action.

Every time a doctor makes a mistake, there are a whole range of factors at play, and you can perhaps boil down the issue of blame to a single question: did the working environment that that doctor was working in maximise the chances that he/she would make the best possible choice for the patient he/she was treating. If the answer to that question is ‘yes’ then it is perhaps valid to focus on the decision made by the individual, but if the answer is ‘no’ (and I would expect this to be the answer most of the time) then at least some of the reflective time needs to be spent on examining how the performance of that individual could have been improved by the environment that they work in.

Personal responsibility still exists - there is no excuse for individuals being reckless, lazy or unkind, but we need to recognise that individuals will perform better if the circumstances around them support their efforts.

George Entwistle clearly understands this, which is why it is a shame he felt he had to resign. I would have been interested to watch him see through a process of rehabilitation that was not founded only on blame, but recognised the need to focus on systems.