Managing complex change

I am in a situation right now where change is inevitable, it is just a matter of how to manage it. I keep referring back to the matrix on managing chance. (from Knoster T, Villa R, & Thousand J. (2000). A Framework for Thinking about Systems Change. In R. Villa & J. Thousand) I had been looking at it from the point of view of the big picture; do we have everything from the top row in place that will allow change to happen.

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As always there are some people that find change difficult. While pondering on one particular situation I realised that the last column, the one that shows the outcomes when any particular aspect is missing, could be use to work backwards and figure out why individual people are struggling with change.

I knew that one person was very resistant to change. Rather than just push that person to join in the change, I looked back though the matrix and realised that maybe they didn’t have the incentive to change. I also knew that this person was confused by some of the changes and realised that maybe this person either lacked vision, or had different visions to the rest of the team.

I now have a frame work that can allow me to support individual people though a system change by looking at how they are reacting to it and making sure that they get the support they need so that the whole team can put their energies into moving forward.

Rather than looking at the system as a whole, sometimes we can use the same tools work with individuals.

Do, don’t, can’t, won’t – why Doctors don’t think…

I had one of those embarrassing moments recently during a meeting at my GP surgery. I was sitting beside our senior partner and did one of those things where you start a sentence but then pause in the middle. The sentence went like this:

Doctors don’t think…

That wasn’t what I meant of course, and after the laughter died down I hastily apologised to the GP beside me,trying to explain what I meant. I didn’t have my trusty white board to hand, so I couldn’t explain fully what my thought process was, so I thought I would try to do it here.

It started some time ago when I was thinking about decision matrices at the same time as thinking about how patients and medics communicate. What came to mind probably isn’t really a true decision matrix, but I thought it would illustrate one of the problems that comes up when patients and doctors meet; what to tell the doctor, and what to keep to themselves

Do

Can’t

Don’t

Won’t

The patient’s disclosure matrix – helping the patient to think about what information they should share with their medic.

Do

There are some things that we easily do tell our medics when we meet. We tell them what our basic problem is. We tell them why we have come today to talk to them. It might be painful feet, or a headache, or general ongoing aches and pains. These are the straight forward medical symptoms. This is the green light.

Don’t

But there are also things that the patient doesn’t tell the medic. Because of the way the NHS is structured, most GPs and often consultants too are limited to 10 minute appointments. Patient are sometimes told tto bring only one item at a time to a consultation. This puts pressure on the patient to restrict what they bring with them to the consultation so while they will happily tell the doctor they have painful feet, they might not reveal that they have had back ache as well. The patient may also not realise that some diverse symptoms could related, such as joint pain and Irritable Bowel Syndrome, or leg weakness and loss of sense of taste. The patient might tell their medic about the most troublesome symptom, but not the other more minor symptoms. They also may not think to tell the doctor about any psychosocial problems they are having. This isn’t deliberate on the patient’s part, they may not have the medical knowledge of symptoms that the doctor has and just not realise the importance of the symptoms or  the environmental situation.

Because the patient doesn’t know what is and isn’t important, it should be up to the medic to decide. Sometimes it feels to the patient that the doctor is ignoring some symptoms, but that is probably because they have listened to all the symptoms and have quickly decided that they aren’t relevant to the current consultation.

The ‘don’t’ square information is available, but not as available as the ‘do’ square so it is up to the patient and medic to work together to make sure the relevant information is shared.

Can’t

There are some things that we just don’t know about. This could be tests not yet ordered, results not yet sent from the lab. Those are simple things that can be resolved easily. There are more difficult areas though, such as family history and genetics. Some families keep skeletons firmly stashed in closets. This might be because of the shame of a mental health or developmental disorder. Some families have distant relatives that were never mentioned. There is also the possibility that one’s father is not the biological father.

Another possibility is error in medical records. As more and more GP surgeries are allowing online access to patients’ own records, errors are being found and corrected. However there are still many errors buried, and a patient may not know that due to a coding error they been erroneously labeled with a mental health problem when they don’t have one. This could be considered a type 1 error or a false positive.

A similar type of error, type 2, would be where a new diagnosis has been accidentally entered onto the incorrect record. A patient may have been given a diagnosis but if it was entered into the incorrect patient record, it would appear that the patient doesn’t have that diagnosis. This is confusing and frustrating for the patient. This can happen easily if a patient has a common surname. It could be easy to sort out by cross referencing with other patients with similar names. But if is a random error and a  patient’s diagnosis has gone missing, there is no easy way to find something that you don’t know should be there in the first place.

Again these problems are not deliberate on the patient’s part, they and the clinician may not be aware of them, but most will eventually be brought to light and dealt with.

Won’t

The final category is probably the most difficult one for the clinician to deal with, and can have the highest impact on the patient. These are the things that the patient deliberately withholds from the doctor. This could be the fact that although they said they had stopped smoking, they have started again. The number of units of alcohol is another example. The patient might feel guilt at the amount they are drinking or they might be in denial. It could be that someone else is putting pressure on the patient to not disclose, which is common with domestic abuse and violence. Or it could be something as simple as losing one’s job or feeling depressed, but being to ashamed to tell anyone.

This is where the clinician has to build up a high level of trust so that the patient will feel they are safe to disclose.

Why is this important?

If a patient doesn’t fully disclose their symptoms, or deliberately withholds information from the doctor, then the doctor doesn’t have the full picture and may not come to the correct diagnosis. And if the doctor doesn’t have the full picture then doctors don’t think…

…to refer patients to the right place.

Okay, I admit, it was badly worded, I should have said ‘If patients don’t give doctors the full picture, both medical and psychosocial, then the doctors won’t think to refer the patients to the right place.”

We had been discussing a new initiative in our area called Social Prescribing It is about giving GPs a wider range of opportunities to meet the non-medical needs of their patients. But as the article above says, some GPs find it hard to refer patients to a social prescribing service. And if the patient chooses not to share information with the doctor, or even to deliberately withhold it, then the doctors won’t even think to refer them.

When a patient is considering what to disclose to their medic, and what not to disclose, they would do well to think about the consequences of keeping information to themselves. Patients easily ‘do’ tell their medic,  and with a bit of thought what they ‘don’t’ say can be turned around into a ‘do’ say situation. There isn’t much they can do about the ‘can’t’ know, much of that information is under the control of the system, or out of reach. But patients can improve their own out comes by making sure they make an honest disclosure and turn all those ‘won’t’ say items into ‘do’ say items.

Chris Ham speaks at the Gloucestershire CCG commissioning day

On September 3 2015 I attended the Gloucestershire Clinical Commissioning Group AGM. The main feature of the day was the keynote speech from Professor Chris Ham, chief executive of the King’s Fund. This is my interpretation of the talk, all errors are my own.

He started by showing us a slide of the ranking of the health services around the world where we came out at number one. Before that we were in the middle. And until 18 months ago were were doing well. If we weren’t doing so badly why does the government want to constantly reform our health services?

One of the problems for the future is that there has been a cut in social care. Twenty-five percent fewer adults are receiving social care. Under the collation waiting times started to get longer again.

The government has put in the extra £8 billion, but the NHS still needs to find a further £22 billion in productivity improvements and social care needs another £30 billion. We have never achieved this before, despite previous challenges, such at the Nicholson Challenge of 2006-2012.

The Three Challenges

We have three challenges: sustain existing services; develop new ones; achieving both while engaging staff and reforming from within.

Chris outlined some of the important aspects of sustaining existing services such as patient safety, maintaining good performance on key targets like waiting times. Developing new models though the Five Year Forward view, expanding and extending Devo Manc, giving priority to prevention and population health, and embracing new technology. Although he mentioned that there were some unanswered questions about Devo Manc.

The focus on population health systems include integrating mental and physical health care, primary and secondary care, and social and health care. By bringing everything together we can improve the health and well being of the whole population.

To reform and improve from within we have to look at what does and doesn’t work. Increased regulation and the command and control approach has had little positive impact. Other countries work better by appealing to professionalism. To reform the NHS from within we have to go beyond the hierarchy, inspection and markets. Chris showed us examples from around the world, and he pointed out that this wasn’t just book learning, he spent time in all these countries. The common characteristics were high preforming quality of care, not just relying on inspection, regulation and targets. They didn’t have competition and choice, they invested in care and people.

The lessons to be learned from these other countries were that organisational stability was important. Their leaders were in the role for 10-15 years, creating a continuity in leadership. They also had a vision for safe high quality services, and they systematically measured how they progressed to those goals. They understood what matters to patients, and actively seek patient feedback. They had staff and leaders who listen and engage with patients and staff. Happy patients makes for happy staff, happy staff makes for happy patients.

Practical Terms

So what does this mean in practical terms. It isn’t just a different approach. We need more time to make the changes. We need an aggregation of marginal gains; doing lots of little things better rather than trying to do one big thing well. We need politicians to stop doing harm and to stop constantly changing things. We need to make sense of the health and social care act. Chris said he was amazed by the different number of organisations, and how fragmented the NHS now is. We need to find a way to make sense of the mess.

We need systems of care, not a single fortress of care. We need to work in collaboration, but that doesn’t mean merging into larger organisations. He cautioned us to not merge unless there is no other alternative, mergers cost time and energy and are huge distractions. We need more collaborations, alliances between teams. We need to agree on how to share the risk, and ask the question, how do we get the most experienced teams to work together.

He mentioned several King’s Fund publications, one of which is The Practice of System Leadership Being Comfortable with Chaos. We need to lead from behind and bring people together to deliver improvements.

So what next for general practice?

It has a key role at the heart of new care models. He sees a future where practices work together in collaboration, federations. These federations will become the building blocks for providing out of hospital services. They will need technology support to allow care to be delivered in different ways. Federations can engage with specialists to proved more care out of hospital as argued for by the RCGP. Out of Hours (OOH) services and others should work together. Chris sees the solution to the seven day working that the politicians want as greater development for federations engaging with hospital specialities

Commissioning and Funding for General Practice – making the case for family care networks , was another publication recommended.

Also Specialists in and out of hospital settings – case studies.

The key to it all is to strengthen GP practices and strengthen the federations.

The previous night he had been at a BMA dinner, addressing the workforce challenge, how to attract new doctors and increase the number taking up general practice. If we ignore these issues we will lose general practice.

He feels that the government understands these things, but that there are governmental tensions. Control of spending vs quality of care; this will have a large impact as the treasurer is pulling the strings for funding but they aren’t experts in health care. Devolution vs centralisation; most regulation is about central control. But Chris wonders if they are trying to control people more so that they are likely to rebel and push for more devolution, which it move the risks from the centre to the devolved areas. The third is priority for prevention vs cuts in public health. The treasury has cut public health budges again, and they can’t reconcile that with the desire to improve public health.

The immediate prospects

Something will have to give. The Carter Review will be used to exert pressure on the NHS to use resources more efficiently. The current government will not want to preside over the slow demise of the NHS, so they may have to go back on some of the things they have said at the beginning of this current government. After the Olympics the people were more proud of the NHS than the Olympics, and the government notices surveys like that, it will have given them pause for thought. No one wants to be the PM that watched the NHS die. The public won’t want to be let down, so there will have to a solution.

A positive proposal

It should be about improving value, outcomes and experiences. Improving and changing clinical practice, not reducing management will be the answer. Also look to the past at what we did well, another publication recommended was Better value in the NHS – The role of changes in clinical practice

Whether this succeeds will depend on every clinician playing their part by reducing errors, reducing variation, and providing better care at a lower cost. Some things will need more money, like 7 day working, but that won’t be necessary in all areas. Like other countries, we need a programme of work to develop over 10-15 years, but we need to make these programmes start to happen faster than they have been done.

Questions from the audience

There was just enough time for a few questions, the first coming from Becky Parish, the associate director of patient experience with the CCG. She asked Chris to expand on the unanswered questions about Devo Manc.

Chris explained that he was excited about it, there had been limited success so maybe it could be developed to work better, but the question was how. He says that it could end up with more variation reflecting important issues locally, but this could result in a post code lottery. There is also the question of what the role of the national regulatory bodies will be. Will their remit be the same in the devolved systems as in the centrally controlled ones? There are debates going on in the house of Lords over the devolution bill right now and Lord Warner has been raising challenges. Much of this devolution idea has come from the treasury as they want to support a northern powerhouse. Maybe also a southern one too? But the treasury isn’t a good place to deal with health matters. We used to have Whole Place Community budgets but that was when the money was flowing. Now there isn’t any money, and this might be connected to the situation, they might blame devolution for the use of money.

A member from Public Health at GCC raised the issue of having a core vision and the time to make it work, asking how can we have the space and time to make it work.

Chris suggested that the NHS has done it with Salford Royal Hospital, but they started that while the money was still flowing. Now maybe the lack of money will prove to be a stimulus. If devolution means greater freedom, it may allow people to do what other countries have done. It is all about health and wellbeing, not just care and regeneration. If areas are given more control over things so that they can make things different for a wider variety of situations, it could stop people from getting too ill.

A GP had the next question. He wanted to know how we can do things without the excessive risk management. We have become so risk averse that we can’t be freed up for prevention, we tolerate risk poorly.

Chris said that the public and patients have a part to play in this. But if doctors engage in shared decision making and not the old paternalistic model, then patients will take a more conservative position. It is about engaging the patients.

Another GP asked what was meant by federations.

Chris said not the super partnerships, but bottom up volunteering, getting GP practices to get together so that they can share experiences, back office work and specialities. This is happening because GPs want it to happen, it hasn’t been directed to be done by the DoH. GPs want it to happen because they need to do it to survive.

It was a great privilege to hear Chris speak, and I am grateful to the CCG for inviting members of Patient Participation Groups who were able to sit alongside clinicians, commissioners, governors and others involved in health and wellbeing, allow us all a better understanding of each other and our goals.

Humanising Healthcare

A tweet from Jonathan Tomlinson caught my eye a couple of weeks ago. It had the hashtags #nuka and #humanisinghealth attached to it.

“Community ownership of heath services in Alaska- 40% drop in A&E and 20% drop in GP attendance btw 1997 and 2007 #humanisinghealth #nuka”

It got my interest. As a Canadian with Inuit and First Nations relatives (by marriage) how they go about things is always of interest to me. A conversation ensued between a few of us, including Dr Margaret Hannah, deputy director of Public Heath in Fife,  the author of the book referred to in the tweets: Humanising Healthcare – Patterns of Hope for a System under Strain.

Knowing a little bit about the community, cultural and geographic differences between a northern North American town and the cultural and physical compactness and yet churn of the UK population, I had difficulty getting my head around how Margaret, Jonathan and others though Nuka could translate into the NHS. Native populations are less mobile, their towns more isolated, and family still plays a strong part in the community. By contrast in the UK we have a mobile population, a loss of the extended family, and a lack of community continuity. So I bought the book to find out.

The first impression on opening it was one of caring and compassion. It is hard to put it into works, but I think it was the illustrations that did it for me. They came across as warm and caring.

The book is split into three sections: The Contemporary Challenge which looks at the past and how the NHS and medicine came to where it is today; The Response, looking at how we are dealing with it now; and Another Way is Possible, looking at different healthcare systems that Margaret has come across and one that she was involved in setting up.

The first two sections of the book were good and sound. Most of the people involved in health and social care, be it at the bottom as patients or further up as practitioners, would recognise the scene as set out. There were a few things that did make me go ‘ah’ where Margaret showed a different aspect, but there were no great surprises.

It was the third section that got exciting. It was here I got my pen out and scribbled in the margins, crying ‘yes’. Margaret showed that Nuka could indeed work in the UK.

The first chapter of the third section looks at the South Central Foundation healthcare system in Alaska.  Margaret sets out the historical setting for the development of SCF, then goes on to describe how it actually works. This is were things started to fall into place for me.

One of the first examples that hit me was the use of a ‘talking room’ where the consultation takes place, and an adjacent examination room if that is required. Much of the consultation work takes place over the phone, and if you need to see a doctor in person the interview can take between ten and forty minutes.

This reminded me of my sole practice GP in Toronto in the early 1980s. You spoke to him or his wife to explain the situation, so only if an appointment was needed did you go in to the surgery. That meant that there was no waiting to see the doctor when you arrived. His office was comfortable and homely despite the large oak desk between patient and doctor. I never saw this as a problem as I always find it easier to make eye contact when sitting opposite someone rather than beside them. But then we didn’t have big computer screens between us in those days, it was all on paper.

Patient notes were in open shelves behind the patient, and if he hadn’t already found your notes before you arrived, the patient would fetch them down off the shelf. And maybe it was just the informality of the Canadians but patients and doctors were on a first name bases which helped foster the feeling of trust and cooperative care. We were in this together. There was an examination room behind, but I rarely went into it.

As Margaret said on twitter: “We’re not so much innovating or inventing, rather re-discovering what has been forgotten.”

She goes on to show examples of how this style of healthcare has been used in small areas. One such example that was highlighted on a BBC 4 documentary about health before the NHS was the Peckham Project.  I can’t help but think that the original Sure Start Local Programmes before they were taken over under the Labour government and turned into Sure Start Centres would have been similar. Perhaps a more recent and closer to home example would be my local hospital Tetbury Hospital Trust.  When the NHS tried to close it down local people got together, set up a trust and bought the hospital

However both Peckham and Sure Start lost their way, and I am not sure how Tetbury Hospital as a private trust fits in with keeping the NHS publicly owned. I was still unsure of how Nuka could translate to UK communities. As Margaret says:

With a small investment in catalytic funding – and learning – and a smart policy framework to support it, everything could be different. It just requires the political will to set in place enabling conditions for the kind of innovation this book advocates rather than implicitly crowding it out in favour of approaches that are more familiar, effective up to a point, necessary but not sufficient and that offer only false hope for the future.”

But where is that political will? How can patients whose voice so often seems to be lost, help those few people that have this type of vision implement a new way of doing things?

It was the final chapter Creating the Future where everything fell into place for me. Margaret tells of the Fife Shine story, a ‘programme designed to help older people live longer and more fulfilling lives in their own homes and to enable earlier discharge from hospital…’ In essence there was a shift from the normal routine assessment to a grown up conversation between the elderly being discharged from hospital and their families, and staff assessing their needs at home. What started with occupational therapists soon spilled into small social enterprise and volunteer involvement, and a greater satisfaction for both staff and patients, once they were able to find their place in this new way of working.

I was immediately reminded of the difficult problems facing those parents with young adult children who have learning difficulties or Autism, as so eloquently highlighted by Mark Neary and Sara Siobhan.  Maybe instead of waiting for the change to come from the top down, we could work from the bottom up and start to make these changes ourselves. By all accounts everyone is happier with this way of working, from the patients and their families who are at the centre, to the administrators, clinicians and other support staff.

It will take a change in culture, in practice and in ourselves. I will leave the last word to Margaret herself, “But the prize is great: to restore effectiveness in a healthcare system that remains accessible to all, free at the point of delivery, meeting contemporary patterns of illness and as part of an integrated approach that sustains healthy, fulfilled lives. And all that at a fraction of the current cost.”