Inconsistent and Incongruent Messages

The King’s Fund have just released an excellent video to help explain how the NHS works and some of the complex things going on in it at the moment. It doesn’t shy away from making it crystal clear who is in charge of the money, nor the difficulties we’re facing in staffing and resource allocation. Have a watch of it and then keep reading!

 

 

What is particularly important to understand, especially where we are learning to work in new ways together, like here in Morecambe Bay, is just how inconsistent and incongruent the messages are that we receive from the leadership structures of the NHS.

 

So, here in the Bay, we are forming an Accountable Care System, which brings together different health & social care commissioners and providers to work more effectively together. We are forming great relationships, breaking down walls and barriers to work together, whilst tackling significant budget issues as we try and ensure that we deliver care in the most excellent, safe and sustainable way for our population (whom we are trying to include fully in the co-design of the services we provide).

 

One might think, as we are being actively encouraged to reorganise ourselves in this way, that the Department of Health, NHS England, NHS Improvement and the CQC would all be pulling together to support these changes. One might presume that they would ensure the various contracts and ways of paying and assessing us would enable us to do this important work – the opposite is in fact the case!

 

On the one hand we are encouraged to ensure we work more efficiently and “cut the waste” out of our system, but when we do so, the contracts in place are working against us!! we literally being told to work one way and then penalised if we do! It is an entirely schizophrenic existence and creates an extraordinary amount of wasted time and energy.

 

I’m not exactly sure what it is that is causing the disconnect between the different regulatory bodies. However, as they require of us a new collaborative way of working that ensures greater efficiency and improved models of care…..perhaps it could be better modelled and enabled by those in the “centre”. This would give the entire reorganization a great deal more integrity. Cultural and behavioural change is talked about a great deal and we are enacting it despite the perverse drivers working against us. I wonder if the same is true at HQ, Elephant and Castle. This mixed messaging needs to stop and those of us leading systems, working with great complexity, need to be given the permission, support, and enablers to really flourish.

 

 

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What Lies Beneath?

Do you sometimes wonder what is really going on? As the furore around the planned 5-day strikes by junior doctors unfolds, with all the clamour and the noise, the positioning, the power plays, the arguments and the counter-arguments, I wonder where is the truth amidst the madness? How have we reached a stage in which the government and an army of medics, surgeons and psychiatrists are at such loggerheads? What lies beneath all of this?

 

Theresa May, our Prime Minister tell us that “doctors have never had it so good” – I wonder when she last shadowed a Senior Registrar for Acute Medicine on a Friday night in an understaffed hospital? Jeremy Hunt tells us that he is a modern day Aneurin Bevan (I wonder what AB would think of that?!), whilst his shadow counter-part, Diane Abbott retorts that this is a ridiculous suggestion. The PM and the Secretary of State for Health both agree that the junior doctors are playing politics, something the other side refutes, but all agree that this is a disaster and patients lives may well be put at risk. The right wing press tell us it is all about pay and that the doctors are being greedy, whilst the left wing press tell us it is all about an underlying agenda to privatise the NHS. The Junior Doctors admit that some of this is about pay (who would want a significant pay cut for working long and unsociable hours?) but that it is more about resisting a policy to deliver a 24/7, 7/7 NHS, which they believe to be unaffordable and unstaffable due to shortages in funding and recruitment. Senior colleagues appear to be split down the middle in terms of support for the strikes, patient groups are understandably concerned and yet a solution does not appear to be forthcoming.

 

Shouting, anger, fighting, noise, name-calling, power-plays, hate and hollering. So, who will seek the welfare of the people and the nation? Who will make for peace? Both sides tell us this is what they are doing and this is why they stand their ground. The government apparently want to deliver the same standard of service throughout the 7 day week. The Junior Doctors say they are the ones really standing up for the people by resisting that which is unsafe and unfair.

 

So, let us learn from the peacemakers to find a way through. In apartheid South Africa, peace was not reached through hate and vitriol. It took deep courage from men and women to expose lies, to speak truth to power, but most importantly to tell their stories. It was not about the one man, Nelson Mandela, but the many together waking up to an alternative future that was fairer for everybody. In the battle for civil rights in the USA, a nation was awakened to the reality of injustice within its own borders. The story of one woman, Rosa Parks, who refused to be humiliated on a bus became a people movement as numerous as the stars, shining together for an altogether different day. In Rwanda, after the appalling genocide, those who lost everything, found a voice to communicate to their very oppressors, those who had raped and murdered their own families, not only their story, but forgiveness for the atrocities caused and found a way through to a new future. If we want peace and a better future for everybody, then we need to face up to our reality, be willing to really listen and then find that together we can embrace a new future.

 

We have an apartheid of globalisation and free market capitalism across the entire world. Every day, the gap between the rich and the poor is widened. Our entire economic system, founded on the oppression of Empire through expansion (via military violence), the creation of debt (through an errant banking system) and the rule of law (held in place by the state of the exception) is no longer fit for purpose. We see it in the plight of refugees stuck between war and barbed wire fences in a land they cannot call their own. We see it in the disproportionate imprisonment of Black American males in the USA. We see it in the vile island detention centres of Australia. We see it in the slums of New Delhi, the townships of sub-Saharan Africa and the Favelas of South America – in the eyes of children dying from such ridiculous things as diarrhoea and starvation. We encounter it in the streets of Athens and the public squares of Madrid. And yes, we find it in the midst of our NHS and social care system. Our world as we have known it is broken and no matter how much sticky tape or wrapping paper we apply, the centre simply cannot hold. The core is unstable. Everything is shaking. We must have the courage to let go of what we have known and embrace an altogether different future, a future that is fairer for everybody, where things don’t simply trickle down to the poorest, but in which the balances are re-set.

 

We have become slaves of the ‘free market’, fodder of the beast that requires ever more of us. What lies underneath the row over Junior Doctor pay and the forthcoming strikes is a great gaping hole that scares the hell out of many of us. Oh, we can sling mud until the cows come home, but it’s not going to get us anywhere. Top down, pyramidal, heroic leadership that stays its course and demands it’s own way is simply not going to cut the mustard. We must have some brave and difficult conversations about the detrimental effects of making policy from the safety of ivory towers, and learn to really listen to the stories of those affected. We have so much to learn from the Leeds Poverty Truth Challenge, the Homeless Charter in Manchester, the Community Conversations in Morecambe Bay, the Cities of Refuge initiative, the Civil Rights movements, the Mediation work done in Rwanda…..we don’t have the answers right now. The problems facing the NHS are fare more complex than trying to ensure an undeliverable manifesto promise is outworked. We need humility on all sides, collaboration and partnership.

 

It goes deeper than people right across the UK needing to manage their own health and wellbeing more effectively. It is more complex than needing to recognise where there is waste and dealing with it. It isn’t just as straight forward as needing to talk about chronic under-funding and under-recruitment. We face an existential crisis, an ontological question about the future of humanity together. Resting back onto familiar ways of operating or antiquated leadership styles will simply not work for us any more. The black hole we face is either a death or the opportunity for re-birth. A squeeze that will force us into something new. We can’t keep dancing around it forever. We must take the plunge, accept that there is no going back and see what new creation we might just co-create with Love on the other side. Don’t be afraid…….there is light at the other end of the tunnel.

 

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Making a Key Distinction in the NHS

There are two different narratives that are shaping the debate around the NHS at present. They are different stories, but they are becoming dangerously intertwined. I want to highlight the two stories and make a clear distinction between the two.

 

The first story is that there are some ways in which the NHS needs to be more efficient, work more smartly, integrate its services more effectively, cut some unnecessary waste, be more collaborative and ensure that the service it provides is as affordable as possible in a manner that is safe, learning, compassionate and continually improving. Some of this involves working with communities to help us live in a way (individually and corporately) that helps us to be more healthy and well, taking some strain from the system. It also involves some restructuring and rearranging of services to enable them to deliver care in a more streamlined way. This is a true story.

 

There is another story that is told that sounds like it has some similarities, but it is not the same story. This is the story that tells us the NHS is unaffordable, that it is failing and that we need parts of it to be privatized for it to survive. This is based on an idea that we have to balance our books, cut our cloth, tighten our belts and ‘live within our means’. This story is not true. It is not true because no country has ever lived within its means. Countries are nothing like households. Households are very simple. The economies of nation states are not. Households do not have banks in their back gardens that print money when things go wrong. Households do not give special privileges to rich friends, making life easier for them, whilst treating poorer friends like servants, taking away things they need and telling them are lazy and need to work harder, whilst blaming their problems on other friends who have moved into the area aka immigrants. Cutting public services and seeing the gap between the rich and poor grow ever wider whilst taking away the welfare that helps families in genuine need, cutting the services available to help them (pretending these are efficiency savings and not cuts) is a choice being made by our politicians. We are told there is no other choice, but this is not a true story. The NHS could be better funded (it is currently one of the most under funded health care systems in the entire developed world) and we could choose to manage the money of the country in an altogether different way! The NHS is affordable and the first story is helping to make this more true, but it needs greater investment, not the removal of vital services. Do not confuse the two stories.

 

 

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Commissioning the 3rd Sector for the NHS

imgresAmidst the current ‘efficiency savings’, or cuts by any other name, in the NHS, the voluntary or 3rd sector, including the faith communities are an absolutely vital partner in health and social care. Here in Morecambe Bay, we are seeing incredible work done by this sector. Genuinely, the safety net created across this Bay for people with significant mental health issues, chronic physical health complaints, those at the end of life, the isolated and lonely etc is amazing. However, as the financial squeeze increases on the NHS, the 3rd sector, although phenomenally resilient and full of social entrepreneurs with good heart, is really beginning to struggle to secure funding. If the 3rd sector, (which gives far more for far less) begins to crumble, then we will see health and social care completely collapse.

 

I wish truth and solutions were all black and white, but there is complex grey for us to wade through, if we are to see a more resilient 3rd sector emerge for the sake of our communities. The relationship between the NHS and 3rd sector is complex but vital. I want to briefly highlight some of the main issues and then look at two possible solutions.

 

  1. Evidence: in order for commissioners to fund projects/organisations, we need evidence that the money invested a) makes a difference and b) makes a saving. Unfortunately data is often not robust enough to make recurrent funding possible.
  2. Fairness: there is currently great injustice built into the the NHS/3rd sector relationship. For example, I know that some of our more struggling publicly funded services, are now referring huge numbers of people into the voluntary sector, as they can’t cope with the capacity, but the funding does not then follow these people. In essence the NHS is dumping people onto the 3rd sector and the 3rd sector is buckling under the weight of it. But the blame is not on the NHS nor the 3rd sector. I’m afraid under resourcing from central government is a key issue here…..but this isn’t going to change any time soon, unless we have a revolution (!), so we need to be creative.
  3. Numbers: commissioning services is really complex. When there are loads of small charities, often doing quite similar things it can be really hard to know who to fund and how to monitor outcomes and effectiveness (like it or not, we do have to give an account for the money we spend!).

So, where might some solutions lie? I would like to suggest two broad possible solutions. I admit they are not perfect and they certainly won’t be the only solutions.

 

imgresFirstly, here in Morecambe Bay, we are developing ICCs (Integrated Care Communities). These are built around General Practice (be that one or many practices in a geographical area) but incorporate GPs, District Nurses, Community Matrons, Long Term Condition Teams, Community Therapists, Mental Health Teams, Social Care, the City Council, the Poimgreslice, the Fire Service and the Third Sector all partnering together for more effective working and therefore better care for all. One option would be for each ICC to have a capitated budget which would allow each team to decide which voluntary sector organisations would meet the need of their particular areas most effectively and fund them accordingly and fairly.

 

imagesA second solution could be for the 3rd Sector to form one or several larger co-operatives. The huge advantage here is that it would then allow a more straight forward commissioning relationship and would allow the many to be become stronger and more resilient together. In a co-operative model, it would be easier to build research partnerships and accountability between members. It would also give the sector more clout as a partner round the table with the various public sector organisations.

 

My work has taught me how vital the Voluntary and Faith sector is to the ongoing health and social care of our communities. It needs adequate funding and support, without which it will crumble. We need to help partner together to make it more resilient, but in order for this to happen, the 3rd sector must deal with some of it’s default towards self-protectionism and find creative solutions towards a more sustainable future……

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