Transforming systems Connected Health Campus Keynote Dr Martin Connor Deputy CEO Trafford PCT May 7 2009
Sound familiar? “ [There was]…a panoply of ‘special commissioners’, backed by their own bureaucratic apparatus, for different facets of the four year plan, often without clear lines of control, not infrequently overlapping or interfering… It was a recipe for administrative and economic anarchy” Ian Kershaw, ‘Hitler’ p. 367
The strategy needs not to be about marginal adjustment but about system transformation
<ul><li>Who am I? </li></ul><ul><li>Two case studies </li></ul><ul><li>Some key concepts </li></ul><ul><li>A novel idea (perhaps) </li></ul><ul><li>A work in progress </li></ul><ul><li>Outcomes of case studies </li></ul><ul><li>Conclusion </li></ul>Contents
<ul><li>In September 2002: </li></ul><ul><li>146,800 patients were waiting for a first outpatient assessment </li></ul><ul><li>54,600 patients were waiting 6+ months </li></ul><ul><li>16,100 were waiting more than 18 months </li></ul><ul><li>Some patients waiting up to 10 years </li></ul>Case Study One: Northern Ireland Access - Outpatients
<ul><li>In September 2002: </li></ul><ul><li>60,200 patients were waiting for inpatient or daycase treatment </li></ul><ul><li>28,300 patients were waiting 6+ months </li></ul><ul><li>9,200 were waiting more than 18 months </li></ul>Case Study One: Northern Ireland Access - Surgery
Individual specialties – maximum treatment waiting times Case Study One: Northern Ireland Access Specialty Sept 2002 Cardiac surgery 5 years Ophthalmology 5 years Orthopaedics 7 years
CASE STUDY TWO: A failing inner city comprehensive school
‘ Sink school’ cycle of low attainment In this cycle, results will always be poor Results Spare capacity Directed entrants Traditional recruitment Behaviour standards We start here with a history of poor results and behaviour problems. This impacts on our recruitment from our feeder schools, giving small Year 7 groups… … which results in a lot of spare capacity. This means very high numbers of non-traditional entrants destabilise the school In the absence of an effective behaviour management strategy, this causes a major deterioration in standards Which leads to poor results
KEY CONCEPT ONE: DROP THE PILOT It’s not about pilots because: They suffer from the problem of scope ‘ Transferable solutions’ don’t transfer Solutions at scale are different in kind to successful projects – Because of risk (and therefore permissions) Because of management resources Because something will happen that will touch everyone – this is scary
KEY CONCEPT TWO: WHOLE SYSTEM CHANGE MEANS A WHOLE DIFFERENT APPROACH If it’s not about pilots, then what is it about? It’s about the top of the shop ( first … to make the strategic offer authentic) It’s about the patients (nothing about me without me – populations too?) It’s about the data and information (frequency, quality, timelag) It’s about the doctors (for permission and insight… and when the going gets tough) It’s about the nurses and AHPs (the vanguard of the revolution) It’s about the general management (for project management, resources and assurance) It’s about the institutions (existing… and new?) And… It’s about the vision thing…
The difference between a vision and an aspiration: Whilst they are both about notions of a better future… An aspiration is a vague description without sufficient clarity to enable a connection between the desired future state and the next immediate action A vision is a vague description (and necessarily ambiguous to enable ownership) that is sufficiently clear to ‘reach back’ into the present and act as a guide to the range of next steps that could be taken to move towards the goal
KEY CONCEPT THREE: IT’S AN UNCERTAIN WORLD There are (I argue) five distinct species of uncertainty: Ambiguity (the source of most conflict, and the death of effective strategy) Vagueness (the reason for most failure from design to execution) Indeterminacy (the risk of freedom) Agent (what might the other fellow do?) Future (time goes by at one unique second per second)
THE PHILOSOPHY OF LEADERSHIP Story telling Virtues Quantification Three pillars Personal Community Cosmic Gentleness Humility Compassion (Unambiguous)Definitions Diagnosis Monitoring
So what’s exciting NOW! (I feel hungrily ignorant – bring it on!)
THE TRAFFORD GAMBIT (Could we leapfrog Kaiser in the NHS through structural reform?)
… and secure appropriate differentiation of specialist surgery to introduce world-class models of care… … whilst bringing together the various strands of acute medicine, A&E, urgent care, out of hours and intermediate care to deliver a more effective unscheduled care system. Beds & Theatres Outpatients Primary care Community Nested Capacity We should explore the introduction of office medicine to replace the primary care/ outpatients distinction…
Inaugural Trafford Clinical Congress Process and proceedings 23 rd / 24 th September 2008 “ Exploring integrated services”
How do we go forward? There was unanimous support for the principle of integrated service provision from the clinicians that attended the Congress. During the final session, the general management community was mandated to bring forward proposals for how this might be organised. This paper lays out these proposals at their preliminary stage of development. 13
Feedback (VIII) Quantitative Questions <ul><ul><ul><li>1. There were opportunities for the group as whole to find its own direction? </li></ul></ul></ul><ul><ul><ul><li>2. The group as a whole used the opportunities given to it, to shape the direction? </li></ul></ul></ul><ul><ul><ul><li>3. The congress enabled the group as a whole to learn and talk about their own processes and interdependences </li></ul></ul></ul>21 Min - quartiles- max
Feedback (IX) Quantitative Questions <ul><ul><ul><li>4. From a group perspective there was a willingness to build a negotiated view of how to proceed in terms of integrated services for Trafford </li></ul></ul></ul><ul><ul><ul><li>5. Please circle where you think we are currently as an integrated organisation </li></ul></ul></ul><ul><ul><ul><li>6. Please circle where you think we can be as an integrated organisation in 18/12 time </li></ul></ul></ul>3 20 14 2 1 9 1 12 16 Taken from Parker Palmer - Movement Model of Change Taken from Parker Palmer - Movement Model of Change 22 Min - quartiles- max Fragmented Integrated
Present high-level commissioning Acute provision PCT … and we have persistent issues of poor integration, resilience and perhaps quality… is there a structural problem? GP1 GP4 GP2 GP3 GP n Community services Non-PbR services Outpatients and diagnostics Inpatient, daycase, specialist (Independent)
Future high-level commissioning? Acute provision PCT And social services..? Integrated Care Record Community services Non-PbR services Outpatients and diagnostics Inpatient, daycase, specialist GP1 GP4 GP2 GP3 GP n (Independent) Consultants, GPs and nurses/ AHPs as partners?
Tackling the democratic deficit/ enhancing local control PUBLIC ENTERPRISE COMPANY/ COMMUNITY FT…? … MADE UP OF ‘MEMBERS’ ON GP LISTS…? Community services Non-PbR services Outpatients and diagnostics GP1 GP4 GP2 GP3 GP n (Independent) Consultants, GPs and nurses/ AHPs as partners? Integrated Care Record
FOUNDATION LEVEL TWO LEVEL THREE LEVEL FOUR Surgery Diagnostics Medicine HEALTHCARE COMMISSIONING PROSPECTUS General medicine, family medicine, continuous care Definitive differential diagnosis, specialised condition support Invasive work and exacerbation support Specialised services General Practice General practice, provider services, OP, diagnostics FT/ NHST/ IS Regional and sub-regional centres Regional and sub-regional centres General Practice ICO ICO + any willing provider GMS/ PMS Post-PbR PbR/ Post-PbR Specialised commissioning agreements Designation Function Present Future Funding Delivery
GOVERNANCE PACE OF CHANGE 2009/ 2010 2010/ 2011 2011/ 2012 Memorandum of Understanding (Heads of agreement) Formal joint venture (new financial flows) New institutional framework Independent development partner?
Conclusion <ul><li>Things can – they really can – be much, much better – but let’s think in 10s of %, not marginal improvements </li></ul><ul><li>Transformation requires thoughtfulness, patience, a touch of Machiavellianism – and the application of systems logic </li></ul><ul><li>In healthcare, I believe one of the new challenges is to build new institutions that are professionally led and individually responsive </li></ul><ul><li>And finally… </li></ul>
Ultimately, it’s not about the system… <ul><li>“ Men try to escape the darkness </li></ul><ul><li>Without and within </li></ul><ul><li>By dreaming of systems so perfect </li></ul><ul><li>That nobody needs to be good” </li></ul><ul><li>- T. S. Eliot </li></ul><ul><li>Choruses from ‘The Rock’ VI </li></ul>I believe we should consciously resist this temptation and instead use technology to better support human judgment within professional relationships. Ultimately – quality scares notwithstanding – we need to carry on trusting each other.
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