Motorway Musings over a pasty

So it’s dark and raining and I’m sitting in some motorway services car park at 9pm, I’ve been on the road since 4am and I’ve got 2 hours to go to get home. And I’m thinking “why on earth do you do this? I hate my job”.

But then I think. Don’t be stupid – you’re lucky. You don’t hate your job. You’re just tired and grumpy. It’s a great job, nice car, nice colleagues, nice clients…and an M&S sandwich or Greggs’ pie on a motorway! (Other sandwiches and pies are available). But I do then start get to thinking “why do people work to the point of such tiredness and frustration and how could it feel better?”

The vast majority of us have to work. For some the choice of what we can do is limited. Maybe we don’t want to be in that office or supermarket, factory or call centre. Maybe we want to be getting home and out of the workplace as quickly as possible. But others seem able to go the extra mile so why are they different? What makes people do the extra hours, offer the extra services or take on other responsibilities? Several reasons I think:

• Obviously we get paid for work but sometimes the added value contributed by employees or those in high producing companies might mean we get paid for contributing or producing more.
• Socially and psychologically it’s recognised that for most of us, (not all admittedly), work is central to our lives although to get the most from our jobs the role must be fulfilling. So we know people will support their organisation and work harder if they help create what they do rather than being told what to do. Success in and appreciation for the role we carry out tends to mean happiness in the job.
• Any fans of McGregor’s X and Y theory will recall that theory X employees are typically lazy and avoid work and responsibility where they can. They inherently dislike work and need to be heavily controlled and supervised. Theory Y employees have a greater sense of accomplishment and are ambitious, self-motivated and exercise self-control. However imagine if you are a theory Y employee working for a theory X boss who rules with fear and control – maybe that’s why it’s a challenge for some people in those situations.
• Also many people want responsibility in some form. They will go to work and work harder if they are trusted, given responsibility and have access to opportunities to learn at whatever level. You don’t have to run the company to take responsibility.

But despite all that for many of us work seems a chore, something to get through, something to moan about and so how can I stay motivated when I hate my job? Well being paid a salary or even a living wage, offers a means to pay our bills, working with others helps some to escape a tough home life or loneliness, and work is still seen as respectable! But beyond that we can also help ourselves by admitting what is at the root of the problem. For me, when I feel I ‘hate my job’ I’m really saying I don’t feel very good at it, I can’t seem to deliver what’s expected, I’m tired or I’m fed up or scared of failing. So to combat that I have to think differently I guess. Do I really hate my job or do I need to make changes, behave differently, set new goals? Should I set myself targets that mean I can celebrate small wins, set myself achievable goals instead of impossible ones and yes, continually re-learn how to be better at my job. I am not defined by my job so I should stop the self-pity and try to improve instead. Seeking out courses, events, mentors, networking, and trying to develop new skills will allow me to see what my clients or users of my service really want. I’ve taken to realising that one small problem doesn’t have to ruin every part of my day. A walk, a chat, a laugh and if all fails realise that the job is paying the bills. Someone telling me I’ve done well makes a world of difference too. Mind you I’m often told I’d be even more impossible or go crazy without work so who knows!

So let’s say you work in the NHS – our main clients/partners, and you’re struggling, or life feels tough. We read the NHS is in crisis, in terminal decline, there is inherent system failure, it’s a miserable environment – its election battle ground time again. How are you supposed to feel positive in that environment?

Well one way is to embrace the opportunity and remember why we go into some jobs in the first place. Caring for the public is a privilege. I’ve been there in the NHS and it’s true. The job can be an awful lot of fun – that’s my memory. Usually others in the system are as dedicated and compassionate as you and often a great laugh too. Mostly despite the challenges faced the NHS staff enjoy what they do. And our best moments in whatever job we do are usually the shared ones. For me, the sense of success, winning bids, getting a successful deal over the line or clearly adding value works. For others sometimes, perhaps as my doctor and teacher daughters tell me, it’s the camaraderie, the team support, the ‘we’re in it together’. Conversely our worst times are when we face challenges alone. Sitting in a motorway service car park in darkness after driving for 12 hours for an hour long difficult meeting isn’t great. But instead of moaning, I should realise that I’m lucky to be doing a job I enjoy, contributing in some small way to the success of our NHS partners and my own company , building a business and learning what to do differently – like realising I could just have caught the **** train.

 

Believe what you read or read what you want to believe?

 

Another 600 mile round trip sitting in traffic leaves plenty of time to think.

The Health Select Committee has said that the NHS isn’t ‘awash with cash’ and argues that last year’s Autumn Statement provided an NHS settlement of an extra £4.5bn, not the £10bn that has been reported by Government. The £10bn is calculated in real terms once inflation has been taken into account say Ministers. The Health Select Committee however says the Government has added extra years to the spending review period and relies on cuts elsewhere in the public health or social care sectors. The Select Committee argument seems to be predicated on ‘it’s not what Simon Stevens (Head of NHS England) asked for’; therefore more money should be allocated – really? I want more so I should have it? Is that how we allocate public funds?

Other commentators say we shouldn’t throw money at the NHS because the challenge lies in funding social care (Richard Murray – King’s Fund). Then the Health Foundation Think Tank says “immediate action to support social care is needed BUT without funding growth for the health service it’s hard to see how the range and quality of care for patients will be sustained”. The BMA joins in saying the funding crisis can’t be solved through further efficiency savings and in fact the NHS community and social care system is “on the brink of collapse”. Oh and the Government say local authority social care spending has up to £3.5bn of ‘new support’.

Confused? I am.

We have a multi-agency agreement to develop  44 local Sustainability and Transformation Plans (STP) across the health and social care system designed, as Simon Stevens said, “To confront, not duck, the big local choices needed to improve health and care across England over the next five years “. Each of the “footprints” is a collaboration between all the statutory bodies in the area involved in health and social care. You would think that this offers, again as Stevens puts it, the chance for “unprecedented” cooperation between organisations. That’s a good thing, right? In Lancashire and South Cumbria for example there are 31 different statutory bodies. There are also voluntary organisations, health watch branches and local GP forums.

It ought to work and yet because behind the STPs lies the need to find £22bn of savings, inevitably what starts out as “unprecedented cooperation” turns into argument, bed reductions and as Chris Ham of the King’s Fund says, “bruising rows about ill-conceived closures”.  We’re told that this is because STP areas are bringing together agencies with different agendas, following often unpopular and challenging paths using bodies with no formal power across a wider footprint and no history of cooperation.

As a result of this cooperation we’ve seen to date many draft STPs “leaked”, seven alone by local authorities, ahead of NHS planned timetables. To what end? The Huffington Post reports that STPs are “a major threat to the continued existence of the NHS”. It will be “devastating” and plans are based on “wilful self-delusion”. Oh come on – shouldn’t we be bigger than this? Sensible contributors, for example at the NW London STP say “We all recognise that we don’t agree on everything, however this will not stop us working together to improve the health and wellbeing of our residents.”  Why do others always find ways NOT to do things? We have such wonderful examples of care and service improvement, of individual commitment and willingness to learn how to be better – and yet we also have structural and collective failure, carelessness and poor attitudes or obstinacy. I know it’s got to be hard to deliver perfect care services 24/7. It isn’t always going to be right because mistakes happen. But our senior leaders are paid well to manage these challenging issues and work together to do so. I’m lost as to why we allow egos and competition, silo management and unnecessary central reporting and rules to get in the way of what our care services do best? This isn’t about money belonging to individual Chief Executives or Council leaders. It’s the tax payer’s money designed to get the best out of our care system and if you are paid to make the best decisions you can with the money you’ve got in the interest of those who use the service then get on and do it. Don’t participate in the process and then ‘leak’ the results and say the outcome isn’t what you wanted.

We know that the poorest, the most elderly and the most vulnerable in society need our statutory services most of all. And we should protect appropriate access to our services for all including focussing on those most in need. I know it can be hard and at a personal level I don’t want my mum travelling miles to find a service that is open three mornings a week somewhere between major towns and cities. Not everyone has a car. Not everyone lives near main roads. BUT crucially, also not everyone needs an A+E because we know that good quality primary, community and social care can prevent hospital admission. We know too that specialist care might be better provided in well-resourced services supported by appropriately trained high quality experienced staff. So for most care we can and should rethink how it is offered and learn from others in this country and elsewhere that have already trodden that path.

There is a danger that we might adopt a bunker mentality perhaps being too cautious and dismissing for example the impact that technology can make on home or self-caring; we might be ignoring how we can improve health and social care’s antiquated appointment and booking systems; perhaps we are putting to one side the huge savings that can still be made from rationalising and sharing estate, back office, infrastructure and clinical process improvements and in many cases we aren’t even challenging behaviours, employment terms and conditions and the required appropriate skill levels for individual user needs.

STPs aren’t a panacea but the shared approach philosophy should help us support out of hospital care, prevent admissions, challenge the solutions for outcome based pathways of care, review cost make up of services and question why we are looking inwardly at government led administrative reporting instead of outwards towards the patient experience. Reductions in hospital bed numbers and developments in neighbourhood working through integrated care programmes with improvements in the use of ICT should change our estates capabilities and requirements leading to costs savings. Seeing health and social care providers working together SHOULD deliver real changes as envisaged by Government.

And yet the arguments instead as described above means that we are failing those same vulnerable service users we say we are there to support. The NHS of today is not the NHS of 1948. Our proud and passionate protection of the NHS is vital but we surely shouldn’t be blind to its failings.  Equally social care is able to be so much more efficient and focused on need than is currently the case.

Look at the recent headlines telling us that still only 4% of GP appointments are booked on-line. That 30% of acute and specialist trusts are engaged in merger talks or hospital chains. That cyber-attacks are threatening patient data and that continued reporting by the CQC of poor care means increasing number of services require improvements.  Our world is changing and I genuinely have no idea how much money the NHS needs but as the Chair of the Health Select Committee (back to where we started) said, “we really need clarity and if there isn’t any more money then (we) should have an honest discussion”.

Time now for that honest discussion? Because like those traffic jam signs on motorways that say “you are the traffic” surely our failure to grasp the realities and implications of REAL change mean that we are causing the traffic jam.

What do the NHS and Desert Island Discs have in common?

Let’s play a game. It’s your ‘Desert Island Discs’ challenge.

I was thinking about my playlist as I travelled on yet another 600 mile round trip. Should I include ‘Honky Tonk Women’ by the Stones, ‘Stay with me’ from the Faces (not the Sam Smith song – please no!), perhaps Otis Redding with ‘Try a little tenderness’ or Led Zeppelin’s ‘Black Dog’. Could finish with a live version of Lynyrd Skynyd’s ‘Free Bird’ – should we go Country Rock – say the Eagles or Bonnie Rait. Yes – my iPod is firmly set to the past. I know there are some popular people around currently like Drake or Rihanna or Ed Sheeran but there you go, it’s the 60’s and 70’s for me.

Which as ever, brings me to the NHS. It was obviously so much better in the past. I mean, look at the headlines again this week; “failure is the norm at some NHS Trusts”, “The NHS has no wriggle room”, “current performance suggests we’ve had 3 years of failure”, or as Dr Mark Holland (Society for Acute Medicine) says “The system is close to breaking down”.

Or how about:

“Can we cut costs any further without cutting services?”
“We can’t match resources to demand says Government”
“Too much paperwork, nurses can’t do their job, its unsafe”

Well, actually the last three quotes are headlines from the 1950’s in the nursing press and from Government reports. So just like I might feel 70’s music was incomparably better than the music my children listen to it is of course all a matter of expectation, taste, circumstances and the culture of the times we live in.

The past is not better; it’s just a different place. Expectations of music were different just as our expectations of today’s NHS and wider public services are different now. I can remember how long it took to have a telephone installed – months waiting; how horrible some of our town centres were; how violent our football matches were (both on and off the field!); how limited our range of food and clothing was in the shops; despite current problems, how awful our trains were in punctuality and condition; how impossibly dream like even the most basic of today’s cars seemed then; what a fantasy mobile computers pretending to be phones seemed and so on.

So why do we persist in bashing our public services?

We’ve failed to hit urgent response time standards or we only hit 95% of A&E four hour waiting times. We are missing some urgent cancer patients outside a two month window and our delayed transfers of care are up by 23%. Yes, we could be doing better and yes we spend billions of pounds of taxpayers’ money and have a right to see improvements. But we also have seen a rise in A&E attendances year on year. In 2003 some 14 million attendances were recorded – since then we’ve seen it rise to 22.3 million – a rise of 35% and more people are being admitted to hospital from A&E – an additional 365,000 or 10% rise.

So we moan, but we add fuel to the problem. We restrict funds to the service but we massively increase our use of it. We demand efficiencies and streamlined integrated services, but we expect more and more scrutiny and reporting at every level. This all eats up resources and even something as simple as encouraging trusts to work together to streamline back office functions becomes hijacked with oversight frameworks, template reports and reporting structures, scoring charts and response sheets. Just do it!

We over complicate a system already under stress by putting in place a false ‘market’, technical challenges about tariffs in a system already with provider deficits of £600m. We have built in system expectations that CCG budgets will be achieved because providers will be fined for failure and we continue to encourage trusts to do more on the promise of earning more income then moan because we don’t have an integrated care package based around preventing hospital admissions.

I am a passionate defender of the NHS but, I am with Lord Carter of Coles when he said: “I wrote a report 10 years ago showing how to save £300m per year and we blew it”, “we can still do it but we have to drive productivity”. The report he referred to was about pathology services whilst his most recent efficiency review flagged potential savings of up to £5bn per annum. The sad and frustrating fact is that some trusts instead of saying “OK, not sure about the accuracy of the £5bn but we can still make huge savings” would rather seek ways of not delivering savings or challenging their bit of the target.

Indeed the Royal College of Pathologists pointed out, with some justification that if decisions are based on something that is done very quickly there is a huge risk that things will go wrong. That is of course potentially true but by the same token doing nothing whilst waiting for everyone to have their queries addressed, concerns mitigated or personal issues resolved means that little change occurs and momentum is lost.

In my little world if the opportunity to make a proportion of these savings can be realised perhaps with help from other NHS partners or the private sector why aren’t we? I see today one of the Labour leadership candidates is suggesting the Government has a ‘secret plan’ to privatise the NHS because 8% of healthcare spending was bought from private providers. This is the same candidate who worked as a lobbyist for drug company Pfizer of course. The NHS needs a supply of services from a variety of sources and a mainly publically funded system free at the point of use isn’t incompatible with that set of supporting skills. So let’s not look back and say how wonderful the NHS was and knock it now. Let’s focus on why there are challenges now and ask the financial, political, structural and efficiency based questions and then be open minded about how we continue to improve it.

Still whilst I accept life wasn’t better necessarily in to 70’s, nor was the NHS, the music certainly was!

Change, does it really change anything?

We are told we’ve never seen the like in a generation…we’ll never see such change again say the media. All the talk is of how the world will never be the same again. So what changes have we seen over early summer…well I call it summer…we have had below average temperatures, above average rainfalls and fewer sunshine hours than normal…apart from that it’s been lovely. Anyway I digress. Change – that’s what is in the air. Just think what changes we’ve seen in recent days:

• The EU referendum result
• The resignation of our Prime Minister
• Resignation and sackings from Labour’s front bench
• England out of Euro16 but Wales (as I write) storming the Euros
• Chris Evans quitting Top Gear
• Stock and currency markets fall (then rise again)

Oh and bakers in Tonga are now banned from selling bread on Sundays.

Question: is any of this really ‘change’?

They may be ‘events’ or loudly expressed opinions but what defines ‘change’?

I ask because the world keeps turning, we go about our daily business; we broadly will do tomorrow what we did today. But what about the ‘EU Brexit vote’ you cry. Well if you go along with my cynical view of the world where I suggest the overarching establishment always wins and deals are done (however spun in the media) over time I suspect we will still have significant labour movement and trade tariffs will not be one way and we will still have to pay somehow into a pot somewhere to enable ‘free trade’ to happen. The world tends to work for the benefit of the richest club members be it inside or outside the EU or USA or the Far East emerging markets. I suspect deals are always done that maximise those benefits for those that control the agenda. Of course I may be wrong and the trading world may collapse, markets may seize up and investment may be put on hold…although cyclical events mean just that…markets do bounce back and new opportunities are found. Much of what is happening now is due to uncertainty and a political leadership vacuum…not because we’ve actually changed anything.

If I’m wrong however then real change for the NHS could mean for example that 50% of supplies already imported from outside the UK will no longer be available as the first choice of users adding potentially an extra £900m bill to NHS costs (HSJ 04/07/2016). It might mean our 50,000 NHS staff who joined from the EU choosing (or being forced) to return home and it will probably mean EITHER a sizeable cash injection for the NHS (say Brexit) or significant further pressures on costs (say Remain) reflecting the uncertainty of our economic future outside the EU.

In the event I doubt any of these extreme outcomes will happen and the most likely assumption is that things will stay broadly the same even if there is a general election, new PM, EU exit clause triggered and goodness knows what else.

Why am I so cynical? Because real change is about finding new ways of doing things, transforming behaviours and introducing aspects of innovative behaviour that make us stop and gasp and say “well – I never thought that would happen”. It’s not about saying ‘no’ or ‘yes’ and then simply changing the captain or manager or structure.

Definitions of change include:

• “To make or become different” or
• The “act or process through which something becomes fundamentally different”.

So when I qualified my Google search to include ‘NHS change’ and found over 21 million different results…this suggests lots of NHS change going on then. And yet there isn’t – not really.

There are undoubtedly new clinical techniques, new procedures, new safety standards, new skill sets, new approaches to treatment all of which mean we can care for more people with better outcomes than ever before. I get that. But is it fundamental change in the way we deliver care at a time of challenge, increased demand, austerity and our selfish behaviour as patients? I don’t think so. Because real change transforms our life..look at the Internet, mobile and digital technology and social media. Real change is sustainable and delivers outcomes and behavioural impact ideally for the better. In my view real change is also enabled by looking at what others do, seeking partners where skill and resource gaps exist and trying to say ‘what can I do’ not ‘ I can’t do it because..’

We have ‘change models’, ‘change management’, ‘change transitioning’, ‘sustainable change’, ‘transformative change’, ‘accelerating change’, ‘analytical change’…and many, many change managers… but there are also barriers to change as highlighted in The Health Foundation report  ‘Constructive Comfort: accelerating change in the NHS’:

• Recognition of the need to change
• Motivation to change
• Space to make change happen
• Capacity to execute change

And therein lies the problem for the NHS and others. Because we can have committed leadership, data that supports the need for change, resources set aside for change, problem solving skills and even an enabling environment for change…but if there isn’t an acceptance of the absolute requirement to change…that burning platform …then changes won’t happen. We know almost 75% of change initiatives fail to achieve their intentions…so says Helen Bevan who is Director of Service Transformation at the NHS Institute for Innovation and Improvement. She says the more things change the more they stay the same and has based her assessment on peer reviews of over 1000 healthcare initiatives.

So when we talk in the NHS about hospital chains, integrated care, accountable care organisations, single oversight frameworks, sustainability and transformation plans and forward views are we really talking about absolute and fundamental change… or just new words for repackaging care delivery, estates and cost changes and care planning in new boxes? Change means being fundamentally different and we aren’t… we are doing the same things differently, in a different order, in a different system with new names…but the outcomes are the same. I get frustrated by that set of parameters but I do try and understand all the pressures and governance challenges that limit change, limit risk taking, limit imagination and initiative and try in our partnerships to share those risks and promote innovation. And I know that working at the sharp end of care is difficult; working in a hugely public and political environment under the media spotlight is terribly hard but is the solution really more Government led structural change and name juggling? Or is it time to look at other countries, other models of care, other local solutions capable of extrapolation and see what real change might look like?

Because old chestnut although it is, there is much to recognise in the words attributed (perhaps falsely) to Gaius Petronius in AD65:

“We trained hard… but it seemed that every time we were beginning to form up in teams we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralisation.”

 

 

 

 

 

 

Jumpers for Goal Posts and the Whitehall Brand

I have daughters who play sport. Indeed one who is a PE teacher. I have fond memories from their earliest ­­­school days through university and later on watching ladies football and hockey in their sports clubs. Other dads will remember rugby or tennis, athletics or netball, cricket or swimming. I’m sure our memories are much the same as the reality of grass roots sport is played out.

Images stay with me of cold, wet Sunday afternoons or chilly Tuesday nights, windy muddy pitches or queuing for game time in pools or courts. Balls kicked between pitches, babies and toddlers crying for their mums who cast anxious glances from the pitch to the sideline, whilst partners do their best to keep the children occupied or bribed with toys or sweets. Teenagers jeering at the ‘girls’ n ‘kids’ trying to sneak onto a corner of the pitch at half time, grandparents smiling proudly wrapped up against the cold sitting on  muddy camping seats with a thermos ­­flask asking ‘which one is our Susan’. Avoiding the dogs fouling the pitch ignored by careless owners talking to other walkers, goalposts nets and pitches that have seen better days or swimmers being jostled by exuberant children throwing balls and dive-bombing.

And yet shining through is the joy, the fervour, the will to succeed, the happiness at doing something they enjoy. They may (or may not) be good at the sport they play but they share their excitement as the game or event approaches. It gives us our memories of why young people (and sometimes older out of breath and rather larger than they should be people) play the sport they love. It is what sport is about for most people and it is a million miles from the packaged glossy world of TV sport. The logos and spin and branding and identity of the Premier League  has no real connection to this world of grass roots sport and to some degree is mirrored by the controlling nature of the Government’s PR machine when reporting on public services. I’m reminded of the Department of Health PR official stopping filming when a TV reporter asked Jeremy Hunt as Secretary of State where he was going to be during the junior doctors’ strike; the NHS stopping the publication of inconvenient data and KPIs last December or the ‘line to take’ that dominates every politician’s briefing pack when talking about public services or even the price of a loaf of bread. David Laws picks this up in his new book ‘Coalition’ whilst Tom Bowers comments on NHS spin in ‘Broken Vows’

This mismatch between the reality of care services offered by hard working committed staff to millions of deserving, uncomplaining, compliant service users and the politician’s image of a well-funded, smooth, Rolls Royce of a sector that can meet everyone’s needs, can deliver huge savings and is capable of doing so despite the climate of austerity, fear of failure and excess demand over supply is really frustrating. Dr Mark Porter of the BMA says” the politicians tend to see a service that is just one major reorganisation away from being perfect” and yet things are never perfect nor should they be otherwise we never try to make things better. The NHS wants pragmatic realistic solutions, stability, less spin, and the chances to learn from experiences and to continually improve…not live in fear about saying the wrong thing, whistleblowing or making a mistake.

We know there are problems in our NHS, like any service or industry; of course there is waste; of course there is poor care; of course mistakes are made; of course there are time wasters amongst the patients; of course there are staff that just turn up and take the money… it is like every other industry or sector. But for every failure there are a million successes- for every mistake there are a million achievements and for every member of staff who doesn’t care there are many thousands who do. We’ve lost the ‘joy’ of our NHS, the celebration of what ‘real’ looks like. I’ve talked before about the billions of pounds we spend, the daily achievements of our health services and the unfair pressures we place on our staff. I’ve talked about the choices we as patients make every day, to use or not use services, and then the moans we offer when A&E is busy on a Friday night.

And yet we are still captivated by politicians who try to gloss over the warts and all reality of our daily life in the health service. The success delivered is in spite of and not because of Government Ministers, PR spins, sound bites and glossy presentations. Care is something delivered in a ward, an outpatient department, a community mental health facility, a health centre, the patient’s own home or a walk in centre- not Whitehall’s own Premier League TV show.

The reality of our grass roots services is by and large wonderful to see and yet myths are plentiful as evidenced by the Nuffield trust in 2016 ’10 NHS myths to watch out for’.

• The NHS isn’t being privatised- there has always been private providers and even now only 6% of any NHS services are delivered by the private sector
• The NHS isn’t ‘out to tender’ – only 5.5% of services are subject to competitive tender
• The public actually don’t hate the private sector and want the NHS to provide all care- as 67% of the public say they don’t mind who provides care as long as it’s free to the point of use
• A&E isn’t in meltdown and is not everyone’s first point of call because GPS work less hard than they used to- actually 90% of care is delivered in a primary care setting and GP services demand rose by 13% between 2008-2014. The primary care sector professionals like pharmacists actually saw their attendances rise by 18% in the same period.
• GPs don’t only see minor cases- actually 60% of visits are for long term conditions or complex care with over 12 visits per year per person on average.

There are many more myths from there being too many managers to junior doctors not working weekends, from ‘staff don’t care’ to ‘the NHS is performing badly’. These myths become the political football that dominates elections and ‘Question Time’ and TV political shows. It’s the Government version of BT Sport or Sky football pundits. Why don’t we instead sign up to  celebrating falling waiting times, falling smoking rates, falling infection rates, improved dietary advice, improving public health, improving cancer successes and improving patient satisfaction but still accept that there is always room to do better.

By and large as I’ve said before, our NHS delivers. By and large patients get a great deal and by and large our staff are brilliant and they do care. It’s a long way from political sound bites and ‘NHS bashing’ just like by and large our kids playing evening or weekend sport have kept hold of what makes it important- and realise that just like Whitehall the glossy, packaged, PR driven TV sports world is a  long way from reality.

Knock, Knock: Who’s there? Doctor: Doctor Who?

Driving across the Ashdown Forest on a crisp morning as the sky was starting to get light – a rosy glow over the trees and ‘The Lark Ascending’ playing on the radio – very nice (yes I know I said in a previous log I had ‘70s rock on sometimes but mix it up a bit OK), I thought “this is a nice day”.

Then I read Sir David Dalton (CE of Salford Royal NHST) suggesting in respect of the BMA Doctors dispute that Junior Doctors felt victimised and he was pleading for both Government and staff side to begin ‘respectful’ discussions. He said the ‘temperature around the BMA dispute needed lowering’, it would become a ‘long dirty war’ and that Government may have then to act to protect patient services.

I had to read that a few times to have a sense of the significance of the piece. When did our NHS become a place where people felt ‘victimised’, there was a ‘lack of respect’ and differing views could lead to ‘a long dirty war’. I know we have had the problems leading to the Francis report which were bad enough and I felt ashamed for our NHS then. But now?

I declare an interest in that my daughter is a doctor in specialist training and I make no comment on the differing views about their dispute. All I would say is that in common with, I hope, the vast majority of NHS staff, she is fiercely proud of her role and passionate about protecting patient interests. She has been reduced to tears of frustration about the way our NHS is now governed from the centre and I’m sure she’s not alone.

In our day to day working with the NHS we see so many positive examples of care, passion and innovation but sadly also often tempered by frustration, exhaustion, irritation and anger sometimes at the hurdles to jump, reports to produce and bureaucratic blockage preventing good care and a positive working environment.

Which begs the question – do people enjoy working in our health services? I hope so. We saw the Christmas single from the NHS Choir which captured the hearts of many and that was fun to see. We witness untold numbers of patients and their families expressing gratitude to the NHS for their care or support and we see acts of selflessness on a daily basis. I hope that’s fun too.

I started as a management (or actually National Administrative) trainee in the 1970s and I recall very many incidents which, looking back, were a product of a different era:

• I recall the police calling me as a very junior manager to help them with a Mortuary technician who sewed up amputated limbs and pacemakers inside bodies to be sent for cremation. Not great obviously, but I learnt a lot!
• Dead patient during a porter’s strike, moving patient in trolley…fell out in full view of visitors on busy corridor. Excuse me could you just lift…yes…thank you…no I’ve got the head can you get the legs…thanks
• Or what about the time when a machete wielding robber threw a blade at Manager’s head…stuck in ‘come to xxx hospital and we care for you’ sign…didn’t look great on the local news but we dealt with it
• On another occasion we had helicopters and armed police hovering overhead whilst chasing jewellery store robber who ran to the hospital where his partner giving was birth…gun hidden in delivery room…get down you in the suit…put your arms on the floor…”but I’m the chief executive”
• Perhaps I should reveal an episode of food poisoning of patients when out of date eggs used for 200 breakfasts during management trainee work experience day in catering…sorry
• I’ve dealt with armed robbers on cash pay-out days…Thursdays which happened three times…police…disguises…robber was deputy head porter. Should have guessed
• But I’m left thinking now of the involvement beyond belief of politicians and civil servants to ensure ministers are ‘sighted’, ‘solutions found’. They win…always

Of course all the above and many more stories happened to me in my NHS days but in essence it was fun. Sadness too with the loss of patients and staff but it was human…it felt ‘ours’ and it was the archetypal village in which we worked. We did our best to support each other, to provide care for our patients, to live within a budget and to always seek to do better. Our patients wellbeing always came first despite my being told that ‘doctors bury their mistakes’ and the ‘rules come from on high’. We had fun, we knew everyone, we smiled and we cared…is it like that now?

I thought I knew everything, all that had gone before was ‘old fashioned’ and my way was best. Of course it wasn’t and I learnt that there is value in all our past experiences good and bad that learning to learn is a vital part of our development as people and as managers.

So I hope there is enjoyment in the NHS still and I hope we never have an environment in which our staff are engaged in ‘a long dirty war’.

 

Is our NHS good or not?

So how do we know if our NHS is good or not? To read the news, to follow past ‘scandals’, to listen to commentators comparing us with other countries, you’d think we were always in crisis. How should we measure the NHS? A random search brings the following contradictory headlines:

“Do we want better healthcare or do we want to keep the NHS?”

“At its best the UK health system is both world class and worthy of public affection”

“The NHS is the best healthcare system in the world”

The NHS is no longer the envy of the world”

“Judged on outcomes our healthcare system is simply not as good as much of Western Europe”

So how are we measuring our NHS and is it possible that all the contradictory headlines can be correct?

It’s really hard because what progress we make is made through small steps. The King’s Fund report from July 2015 ‘Better Value in the NHS’ is a really good review but it also shows how difficult it is to compare services.

We could say that we are the most efficient system in the Western world but also that outcomes in some speciality areas are less encouraging. We could say we make little improvements in general productivity but in focused activity, such as day care, we do really well.

What is clear is that there isn’t a one size fits all answer. What matters to politicians may not matter to patients. What matters to managers may not matter to ward based staff. However, what should matter to everyone is the achievement of a positive patient experience, high end clinical quality and safety, good responsive services and vital care when needed.

I’m not sure that because the UK spends less than half the USA expenditure per head on healthcare that is a good thing. It is good, I think, that surveys put the NHS in top place in providing effective care, safe care, co-ordinated care and patient centred care. It may be good that access to care is high and efficient use of resources is welcome but we have a poor record of keeping people alive when they should receive timely and effective care.

So I looked at other countries and the trade-offs they make between universal coverage and timely access and we find ourselves back to square one. I’ve fortunately seen health systems in lots of countries and in common with many think by and large that the UK the best when considering system content and structure. The WHO rank US healthcare, for example, as 37^th in the world and the Commonwealth Fund ranked the USA last over 21 indicators. Yet the US senator Jeff Sessions described the US system as ‘the greatest healthcare system the world has ever known’.

Look at other systems and you’ll find universal public coverage with private insurance top up or additional tax charges such as in Australia – similar approaches apply in Sweden which focuses on use of GPs and cost efficiencies to keep the costs low. In France there is public coverage where medical costs are met publically via taxation supplemented by private insurance. The surprise echoed around the world is that the UK NHS covers preventative and mental healthcare and offers largely free prescribing (88% of prescriptions in the UK are exempt from charge). Germany has the oldest universal healthcare system in the world, publically funded too, whilst the Netherlands is different, focusing on health insurance as a statutory requirement with private insurance competing on cost and equality.

In the end, healthcare can be financed and provided by Government through tax payments (UK, Spain, Cuba, New Zealand); it can be managed through a non-profit making insurance system financed jointly by employers and employees through payroll deduction (Germany, France, Belgium, Switzerland, Japan) ; a private provider, Government paid / run insurance programme offering universal insurance (Canada, South Korea) or a system like the US where a mixture of direct insurance, pay as you go, Government aid and meeting out of pocket costs combine in a ‘system’ of sorts.

However whichever system we favour we really should note that only 40 of the world’s 200 countries have established healthcare systems. Most nations are too poor and / or disorganised to provide mass medical care. The basic rule in such countries is that the rich get medical care, the poor stay ill or die. If they have nothing, there is no real medical care. Let’s remember that on our Friday night in A+E as the drunks hit each other and we moan about waiting four hours, shall we?