Never Let a Good Crisis Go to Waste

So, the NHS is in another winter crisis.

The Oxford English Dictionary defines a crisis  as:

1 A time of intense difficulty or danger.
‘the current economic crisis’

Mass noun ‘the monarchy was in crisis’

1.1 A time when a difficult or important decision must be made. As modifier ‘the situation has reached crisis point’
1.2 The turning point of a disease when an important change takes place, indicating either recovery or death.
Origin
Late Middle English (denoting the turning point of a disease): medical Latin, from Greek krisis ‘decision’, from krinein ‘decide’. The general sense ‘decisive point’ dates from the early 17th century.

 

A crisis is still a crisis, even if you see it coming. What is vital, as per Winston Churchill, is that a) we don’t waste this moment, but allow it to be a true tuning point and b) we don’t rush prematurely to actions to try and solve it, but ensure we look deep enough and far enough and then move towards collective steps for an altogether different kind of future.

 

I think there are some difficult and inconvenient truths that we need to face up to together. If we can do so, then we can move beyond sensational news cycles into co-producing something really exciting. Here are my incomplete thoughts about where we might want to think about starting:

 

  1. We need to get some perspective! One of the dangers of believing everything is bad is that we start to believe that the NHS is over. It is not over. It is 70 years old and it is transitioning, but it is not over! In the crisis we find ourselves in, let’s remember why the NHS is such an incredible thing and why its integration with social care is so vital. The Commonwealth Fund rates the NHS as the BEST healthcare system in the world, when it comes to equity, care and accessibility. However, our outcomes are significantly worse than that of our peers – there are some really important reasons for this, which we need to understand better. One of the major reasons is that our goals are so short term, that we cannot bring the long term changes to the health and wellbeing that we need – and this is caused by the way the NHS is run and the nature of our political cycles.
  2. We need to stop the boring, binary, partisan nonsense that is the political boxing match. It really is grow-up time when it comes to our arguments. There are some very different perspectives on why we’re in the crisis we’re in, what we might do about it and how we should go about those things. However, shouting our perspectives ever more loudly, whilst never encountering or deeply listening to the other perspectives in the room make it impossible for us to find an effective 3rd way forward together. We are well versed in the blue vs red options, but let us be honest, please. Neither the reds nor the blues are wholly right, and neither is wholly wrong! It is absolutely OK to hold different perspectives, but the manner of our arguments is astoundingly pathetic. Whilst all this shouting goes on, there are several perspectives that are not being heard, important voices, those of the patient, the carer, the poor etc. We need to stop our reactionary, swing left, swing right steering of this great ship (and that’s not to say a centrist approach is best either!) and learn to have some humility. Humility starts with listening and being willing to change. This is being so beautifully demonstrated by the Rose Castle Foundation and Cambridge University through their work with the vastly differing world views of Conservative Islam, Judaism and Christianity and offers us much learning and hope for the NHS and indeed any other of our deeply held belief systems. Anyone willing to have better conversations and find a way forward?
  3. The maths simply doesn’t add up. We need some honesty.  A few weeks ago, the head of NHSI Jim Mackey, said that by April the NHS will be in around £2.2billion of debt. That is a very conservative estimate. It is a mathematical impossibility to close wards and scale down the size of our hospitals at a time when district nursing numbers have reduced by 28% over the last 5 years and social care is on its knees AND sort out the deficit! We know what the direction of travel needs to be, but the equation is simply unworkable, due to time and workforce pressures.We need to understand the true scale of the problems we’re facing and be real about how much money is going into health and social care spending compared to what is actually needed.
  4. The reason for this is that health and social care funding is becoming more costly and more complex. Our population is growing in size and people are living longer – this is great, on many levels (although we still need a much better conversation about death and why sometimes we keep people alive, when we could allow them to die well and peacefully). However, as we grow older, we develop more health conditions, and social needs, which require more costly treatments and packages of care, which we’re simply not accounting for, especially when we know the predictions of how our population will grow and age over the next 20 years.
  5. We therefore need to have a long term vision of how we want to build the most safe, excellent, effective, equitable, efficient, compassionate and kind health and social care system in the world whilst recognising in order to so, we will HAVE to make some upfront, BIG investments. It is simply impossible to have double austerity on health and social care and then believe we can do the transformational work necessary for the future change we need. Austerity has woken us up to the fact that there are some inefficient ways of working and some things we could definitely do more effectively in partnership. We’ve learnt that now. However, as a philosophy it is now defunct for where we need to go.
  6. This means, we have to put significantly more money into the system now. Once we have done some more work on the vision and plans for the future (the 5 year forward view is too short and although sets us up a good trajectory, is not ambitious enough), we need to ensure there is a sufficient injection of cash (not removal of it) to make this possible. So, we have some options available to us. A) We could increase tax for everyone – something that 67% of our population seem to be willing to pay. B) We could close tax loopholes and ensure that companies like Amazon and Google pay the tax that is owed. C) We could also increase our GDP % spend on health and social care – remember, currently, we have one of the lowest % spend of any of the other OECD nations. Perhaps a combination of all of these things is necessary.
  7. Creating long term health and social care solutions means that we have to put population and public health as the foundation of the system. We know that prevention is better than cure. We know that if we promote health and wellbeing, disease will be far from us. The disinvestment in these areas and the over reliance on a very stretched and struggling community-voluntary-faith sector is a recipe for disaster. There is huge work to be done in deeply listening to and working with our communities to improve the health and wellbeing of everyone, using the best research, evidence and data available to us through our public health bodies in order to make this shift.
  8. This means we need to continue to tackle the wider determinants of health and think radically about these things as being serious public health issues. This is how the city of Glasgow has gone about tackling knife crime and London has much to learn. We need to apply wisdom and learning to things like smoking, sugar, alcohol, pollution, drugs, road traffic accidents, domestic violence, suicide and adverse childhood experiences. We also need to develop a radically generous philosophy to the areas of job creation, housing, land rights and the care of the environment of which we are stewards not lords.
  9. We have to take greater responsibility and care of the health and wellbeing of ourselves and of those around us. It is not possible for us to have a national health and social care system that is sustainable if we think we can live exactly how we want whilst thinking someone else will simply mop up the mess or pay the tab. Our sugar, food and alcohol consumption, lack of exercise, driving, smoking and drug habits are all areas where we do have to take greater responsibility. NHS staff need to lead by example here. They are also areas where government give those lobbies far too much power and where we need better legislation to help bring about change. It is a both/and not an either/or approach.
  10. We need to create a much more shared-care approach with patients, co-partner with patients to enable them to understand the conditions they live with so that they are able to self-manage/self-care more effectively and create community support groups.
  11. We need to use digital solutions to full effect. We need to widen the access to patients having their own online records, the sharing of data across the system and getting savvy with better apps and technology for the benefit of patients and communities.
  12. We need to change our expectations of what we believe our ‘rights’ are in terms of health and social care. As an example, people phone up a GP surgery and want to see a GP. But there are MANY other allied health and social care professionals who may be better placed to sort out the problem. However, a recent survey in Gosport showed that of the people who phoned up wanting to see their GP, only 9% of them actually needed to see their GP and the rest would have been dealt with more effectively by someone else. We need to get used to the fact that we don’t have enough GPs available for everyone to be able to see one every time they would like to, but there are other professionals who are equally able to help. Another example is that everyone wants to safeguard their local hospital and we tend to have a fixed belief that being in hospital when we’re ill is the best place for us. Actually, especially when we’re older we can receive just as good care at home or in a nursing home and being admitted to hospital adds very little benefit. However, in order to have smaller and therefore more affordable hospitals, we really do have to ensure we have the necessary infrastructure and staffing around community nursing, social care and General Practice. Currently this is not the case and it takes time and investment to grow this workforce.
  13. We need ensure we are training and recruiting the right skill mix of people for the right jobs. This means we need to think at least 20 years ahead with the predictive statistics we have available to us and do some proper workforce planning. We’re are far too short sighted. This will take financial investment now, as stated above, but if we get it right, will leave us with a far more effective and efficient living system in the future.
  14. Our medical, nursing and therapeutic school curriculums therefore need to ensure they are training students for the kind of future we need. We need a complete redesign of some of the curriculums and we need to change the way training is done. As part of this, we need to ensure we are raising good human beings, not just good professionals, with values, culture and great communication skills built into all of the process.
  15. We have to redesign the contracts, as unfortunately without this, some of the behaviour changes simply will not happen. The current contracts across health and social care are the very antithesis of what is needed.  This will take some bravery and leadership, but it is time to grasp this nettle. Without this, we will behave perversely because the incentives driving the system and the nature of competition laws are detrimental to the collaborative future we need.
  16. We can only do all of this together. This means our staring place in all of this is to own up to the fact that in all of the above, we simply don’t know. From the place of not knowing, we can ask great questions, bring our bits of expertise to the table and build a jigsaw. There is expertise in national and local government, but certainly not all the answers. There is expertise in the health and social care clinicians, practitioners and managers. There is expertise in our communities and with people who have lived experience of the various complex issues we face. It is only together that we can face the future. Let’s break out of our camps, our deeply entrenched belief systems and find a new way of dancing together. The future belongs to us all. Together we can.

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Changing the Culture of the NHS

imgresI had the very real privilege of listening to and interacting with Prof Mike West of the Kings Fund as part of a Cumbria Wide learning collaborative a few days ago. It was utterly engaging and inspiring. His basic strap line is this: “The vision of health and social care is to deliver continuously improving, high quality and compassionate health care to all in our community.” The problem is that we’re not doing this, and we’re not doing this because there is something deeply wrong in our culture. And so how do we change a system, especially when it feels that the odds are seriously against us? How do we recover compassion? How do we envision a floundering workforce and help them to believe? Why are there some beacons of light in each organisation and some really dark holes? Why are we not learning more readily from areas of good practice and challenging those that are way below par?

 

There are some seriously problematic things for us to face up to, and although I love to take a ‘solutions-focused’ approach, I do believe that sometimes you have to face up to your reality before you decide to move into a different kind of future. We could talk until the cows come home about the potential dismantling of the NHS, the low morale of staff and this ‘black hole’ of debt. But what I want to focus on in this post is the cultural deficit. Previous governments have tried to address this with targets, competition and inspections, but each of these, although I think introduced with good intentions, have backfired spectacularly and driven morale lower without improving the culture at all.

 

imgresStress is defined by Mike West as a poisonous concoction of high work demand, low control and poor support. Chronic high stress levels are significantly higher in the NHS (26.8%) compared to any other sector (17.8% on average). High stress is detrimental for people’s health and a well known cause of early death. And so in an organisation in which we have 1.4 million people spending on average 80000 hours of their lives caring for other people, we are literally killing them by not caring for them. This is a paradox in an organisation which is supposed to have compassion at its core. And yet we know through significant evidence that the lower the morale and health of your team, the worse the outcomes for patients will be. Stress in the NHS and the lack of compassion with which we treat our own staff is a more significant health risk to the population than many of the issues that we give far more attention to.

 

So, what can we do? Are we doomed to serve systems that de-humanise people and devour them like bread? Must a system be driven by what Foucault calls ‘biopower’, ie using human beings as the fodder to drive the machine? Can the systems be harnessed and redeemed and made to work for us rather than served by us? Yes! I can say that this is happening here in Morecambe Bay and I see evidence of it in many areas. Nationally, we can take comfort from 2 things, in particular. Firstly, although the truth about our current culture is uncomfortable, the truth is now available to all, so change really can happen. Secondly, the vast majority of people genuinely want the culture to change and the dominant minority in the centre of toxic cultures can no longer hold. Mike West says systems can change, and he has gathered some good evidence to back this up. But it takes time (5-6 years), it takes focus and it takes consistency. He breaks cultural change down into 6 key elements that are well worth exploring.

 

6 Key Elements of Cultural Change

 

1) Vision, values and strategy. It is absolutely vital in order for a culture to change that the direction of travel is obvious to all. Salford Royal Hospital in Manchester have for years had the same vision statement: “To be the safest hospital in England”, and they have done it! A vision has to be clear, it imgreshas to mark ambition for the future and be able to guide and inspire the whole organisation towards change. However, it takes 5-6 years to embed this through an organisation. So those who communicate a vision to staff and then wonder why they haven’t got it yet need to understand that a paradigm shift in thinking doesn’t happen overnight. A change in direction of the rudder doesn’t turn the ship in one go. The vision needs to be communicated multiple times in multiple ways to multiple audiences. It needs to be inspiring, owned by all and makes clear commitments to the direction of travel.

 

2) Clearly aligned goals at every level. If a vision is to be cast, there must be measurable goals along the way, so that a team knows they are heading in the right direction. These goals have 2 key elements. Firstly they must be clear and achievable (so not more than 5 or 6). Secondly, they must be aligned to vision, measurable and challenging. People must be challenged to reach an objective, so that the process is both stretching and fun, and there needs to be celebration of goals being reached along the way. Problems emerge here when leaders don’t want to hear about problems that are being encountered. The team needs to be responsive to barriers. For example, there is no point wasting time and energy on collecting data for the sake of it. We want to collect data that actually helps improve patient care or helps staff do their job more effectively. If we want our staff to treat people with care and dignity, then we must treat our staff with care and dignity and that means listening to them and responding to them as we head into uncharted waters.

 

3) Leaders need to manage and engage with their staff well to gain high quality care. The high level ofimgres chronic stress in NHS staff proves that this is not happening as well as it needs to. The Kings fund have discovered some key themes from their research in this area: a) patient satisfaction rates are far higher where staff have clear goals and are working together as a team to achieve them, b) staff views of their leaders is directly linked to patients’ views of care quality, c) staff satisfaction/commitment predicts patient satisfaction, d) if staff feel high work pressure, low control over this and low support then patients will also report low staffing numbers, insufficient support, privacy and respect, e) poor staff health and well-being is directly linked to high injury and mortality rates, and good HR practices lead to lower and decreasing levels of patient imgresmortality. Another key factor is the reduction of hierarchy. The John Lewis Partnership has consistently had the highest level of staff morale for the last 180 years. one key factor is this: there are only 3 levels of hierarchy – CEO/board/partners. Staff/partners feel empowered to make changes and they are listened to.

 

We are not managing our staff well in the NHS. 24% of staff report regular bullying by ‘management. Discrimination is higher especially for those of Black-African and Black Afro-Caribbean descent. It is still high for those from Asia and 18 times higher for Muslims than for any other group and is also high for those who are not ‘heterosexual’. If you have white skin, you are three times more likely to be imgrespromoted into senior leadership positions, when account for numbers is made. And despite the suffragettes we continue to see discrimination against women in certain specialties, most notably, surgery. This is not an acceptable culture. We need to change the culture. Leaders need to learn to be present for their team. Mike West puts it so well: “Leaders need to learn to listen, with kind eyes, full of care and fascination (just as we would want our patients to be listened to). We need to learn empathy, to communicate well and take intelligent action.” Engagement with our teams is about really engaging at an emotional level and this takes trust. Our management styles must change towards being far more inclusive, empowering and under-girded with our values and integrity. For staff to feel happy, there needs to be a sense of a stable senior leadership team. There should be a real sense of anger about how badly staff in the NHS are currently treated but a clear positive attitude towards affecting change. Leaders must help process negative emotion in their teams and deal with quarrelsome, disruptive behaviour that spoils the hope for a different future. Poor performance and attitude has to be challenged if we are to create the kind of culture we need and want to see.

 

There are many situations and systems in which an entire culture can be toxic, with top down bullying as the order of the day. Creating resilience in our teams is not about toughening people up to go back into toxic situations until they finally break. No, we need something far more creative than this. It is impossible to change a culture as a lone shark. Mike West talked about gaining ‘minority imgresinfluence’ – good examples of this are found in the Feminist movement and the Green Party. A small group of committed and determined people can accomplish an incredible amount. But if the culture will not change, then wipe the dust off your feet and go and give your energy elsewhere. Systems can change if there is desire enough to change them. There are hospital trusts in the UK that report significantly higher staff morale than anywhere else. We must learn from places like Salford Royal, Royal Wolverhampton Hospitals, St Helen’s and Knowsley, Bedford and Frimley Park. Here in Morecambe Bay, where the maternity service has been at rock bottom, we are part way through an incredible cultural shift and many other departments throughout the country are beginning to turn here and ask us what we’re learning in our journey of change.

 

4) Learning, Quality Improvement and Innovation. This is a very straight forward point, but one to which we do not pay enough attention. Learning organisations facilitate the learning of all staff and the system itself to continuously improve. If we’re not improving, we are going backwards. We must learn to learn from failures and create a culture where this is acceptable. Learning organisations are characterized by systems thinking with information systems that can measure performance. In such a system, staff are encouraged and motivated to focus on improving quality (why would we want to do a shoddy job?). Learning is done in teams and crosses the boundaries of role and specialization and there is always dialogue going on around this. Prof West says that a key question to continually ask is this: “What do we need to change around here to enable you to be able to do your job more effectively?” We must make a promise to learn and a commitment to act. Where staff have a focus on continually improving patient care and this is embedded in the culture, targets become obsolete. Reflective practice and learning becomes endemic. All staff are accountable and all staff are enabled and empowered to bring about change.

 

5) Team working. Teams need clear objectives, roles, communication and learning. In the NHS, 5% of people say they do not work in a team. 40% of people feel they work in an effective team. That leaves 55% of people who consider the team they work in to be dysfunctional. Stress, injury, bullying and errors are all higher in ‘pseudo-teams’ and the mortality rates are significantly lower for patients who are cared for by teams that function well. Interpersonal conflict is a disaster for effective team and inter-team working. The imgresKirkup report into Morecambe Bay and the Francis report into Stafford both highlight the appalling and detrimental effects of the breakdown of relationship between consultants and hospital departments.  It is estimated that up to 30000 deaths per year could be prevented by more effective team working. This conversation really matters! We have to change our culture.

 

To develop good teams, we must encourage positive and supportive relationships, resolve and prevent conflicts, create a positive group attitude to diversity, be attentive and really listen to our teams, encourage inter-team cooperation and nurture team learning improvement and innovation. Our teams must develop reflexivity. Teams are more effective and innovative to the extent to which they take time out to reflect upon their objectives, strategies, processes and environments and make changes accordingly. The best response to pressure is not to work even harder, but to stop, take a step back and reflect. This is true even in emergency situations, as evidenced by the pilot who handed over the controls to his co-pilot whilst he took time to assimilate his options and decide on a strategy to land US Airways flight 1549 in the Hudson river in 2009.

 

iu-46) Collective Leadership. Leadership is the responsibility of all. It is for anyone with any kind of expertise to take responsibility where and when appropriate. Leadership is shared in teams across the whole community. It is interdependent and collaborative, working together to ensure high quality health and social care. This is our experience through Better Care Together in Morecambe Bay. It needs to be both clinical and managerial. The more hierarchy there is, the less opportunity there is to innovate. There are lessons for us to learn from more collaborative leadership styles like ‘The Art of Hosting’. We would do well, to take heed and learn some vital lessons from teams daring to do things differently.images

 

Mike West finished his lecture with a very beautiful summary: Health and Social Care is about the core value of compassion. We want to create compassionate communities that listen with fascination and are empathic. We have to begin with ourselves. We need to take intelligent actions around this so that we can create the kind of cultures we want to see.

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