'Tis the season to be Jolly.

Christmas is one of those times when the cynics seem to take to the streets.

"There's no santa"

"It's all about the money"

"its marketing for churches"

They go on and on.  In a way its good because they leave healthcare alone for a little while. The "overpaid medics" and "lazy nurses" become NHS Heroes, with the NHS becoming a cherished institution. The regular sight of carol singers busting in on ward rounds, reeking of over zealous application of hand gel and grateful relatives dropping off Grannie who's suddenly become unsafe to leave at home alone over the season.

The rest of the year those cynics denegrate , deride and thoroughly disrespect the NHS.

The worst part is that many of those cynics inhabit the NHS, some in senior positions.

 They might not recognise themselves, but they are the one who say-

"We tried that it didn't work"

"What's the point there's no money in it"

 "Its more complex than that"

"what you've got to understand is.."

"what's in it for me/us/the patient?"

These sad individuals live trapped in cages of their own making, believing that the NHS is doomed, a belief reinforced by their very actions.

Perhaps they might try and take something of the festive season into the new year with them. Perhaps the belief and optimisim of Christianity, the love for fellow mankind, the care for those in need and the understanding that every day our actions, however small, count in the lives of others.

It's a small world.

Half way through a study tour of the Boston Healthcare system there are a few key points bubbling around the group.
Before I move to that it would be remiss not to mention the very warm welcome expressed by all the people we have spoken to, from "ward to board" in every Hospital or care setting we have visited.
So what are they saying?
Like the UK American healthcare is not broken but needs fixing. It is in the foothills of a politically instigated reorganisation which will also be visible from space.
I took the decision to view the trip through the lens of sustainability, i.e. Value, Toxicity, Waste and Evolution.
US healthcare does set out to deliver value and is working out what that means, we met a surgeon who is collaborating with Michael Porter, the father of Value Stream Analysis, we heard from providers keen to demonstrate quality through adoption of external standards such as Magnet Accreditation, we met providers who recognise that cost reduction is sine qua non for survival, so the equation value= quality/cost was visible as a thread.
Avoidance of Toxicity shone through at Mass Generals modestly named "the future of ambulatory care practice". This Physicians office based service has completely stripped out the old processes and assumptions which could shackle us to practices of the past. Direct access by e-mail triage, proactive management by a multi disciplinary team, patient rooms not doctors rooms, virtually all toxic habits and accumulations abandoned. Whether it could be delivered in a system that is set in its ways is unsure. The lead physician describes it as a "start up" and it most certainly is.
The reduction of Waste was a main driver behind one provider units use of Magnet Accreditation, in a Hospital where the senior team has been in place for over a decade, the concept that nurses could leave after being trained and developed seemed like a waste, so they undertook an onerous project to achieve a standard which makes them attractive to nurses and reduces absenteeism, turnover and unhappiness with career path.
Evolution is not something you see directly, it deals with timespans greater than our visit allowed, but even so the evidence of natural selection was everywhere, new buildings and developments in some sites, integrated or hybrid theatre suites in others. Reduction in length of stay to two days after a hip replacement and then returning home is impressive.
Will this make the US system sustainable? Is the "big bird" of American healthcare an Auk (extinct) an Ostrich (struggling) or a Turkey (seasonally overpriced) ?
It's impossible to say, but there are certainly signs of sustainability that can be taken back across the pond. it is a small world.

A religious experience?

This week has seen the launch of a new nursing strategy which involves six words starting with C. It's a brave attempt to sum up the values that make a person a good nurse. My dad and one of my brothers are nurses, so I've got a reasonable insight, especially since the Nursing Times was significant in my ending up with sufficient grades to enter medical school.
The trouble is I'm not sure a 6cs list addresses the issue. Here's how my thinking goes.
Many of the caring professions are a "calling" - something not religious in nature but a heartfelt belief that those that have the drive can follow.
If you have that inner motivation, intrinsic drive, yearning, then pretty well regardless of conditions you will exercise your right to choose the freedom how to behave ( See Victor Frankl for details). In Frankls case selfless acts of charity in concentration camps proved that we can choose to follow our callings regardless of circumstance.
I met a nurse who always wanted to join the profession, but in his culture it was a womans job, so he became a mechanic, joined the military and then, having established his credentials, he became a nurse, and a bloody good one.
Would the 6Cs have made him that good?
If the 6Cs turn out to not be the answer can I suggest we take a leaf out of the Derren Brown play book?
Mr Brown used a mix of psychological techniques to expose an atheist to a "religious conversion" - in effect a moment of insight/ joy/ karma that could, if followed up, have resulted in the atheist developing a belief in God.
Perhaps we ought to address the psychology of our staff and seek to promote and reinforce the feeling of a devotion or calling to the nursing profession.
I'm not advocating brainwashing or NLP, simply the idea that we should recognise our nursing sisters and brothers as having a calling, treat them with the respect due to one who puts others before themselves and maybe they will respond by putting others before themselves.

MedOblique

I don't know how familiar you are with Brian Eno.
On one level he's a composer, creator of some seriously interesting music.
On another level he's a thinker, a challenger of ideas.
His Oblique Strategies are an iconic set of inspirational cards designed to help you approach challenges in new ways, with ideas freed from context, hence oblique.
For a while I have been toying with the idea of creating a set of "oblique strategies" for clinical care.
Based on the premise that good clinical care is a triad of science, art and craft, clinical oblique strategies, or MedObliques would act as a knowledge base to support the art of medicine.
After all we have huge knowledge bases to support the science of care, but little to stimulate the art of care.
I would suggest it is the loss of the art of care, an art which invokes passion, emotion and interaction, which contributes to the failure of systems in which knowledge is applied without passion, without care, without feeling. A failing perhaps best illustrated by Mid Staffs.
So the challenge arises what would a MedOblique look like? What would it mean?
I don't know the answer, but that's ok, it's an art not a science.

Of course in the 21st century the cards will be an App, for android or iPhone and in spirit with Web 2.0 users can submit and share their own MedObliques - co-creation is also part of the art.

Towards Equity and Sustainability

In the growth years of health much emphasis has been placed on equity in all it's guises. However as need rises and resource falls the challenge of sustainability grows.
Recognising that healthcare is a complex system, and further an ecosystem, offers the chance to use principles of ecological sustainability to guide changes required in delivery and philosophy.
Enrich Coiera in 2007 borrowed the work of Natural Step to suggest system principles. https://twitter.com/enricocoiera/status/244583214931378176 We can take these principles and clean them up, fit them closer to the NHS.

Principle Of Recycling.
Healthcare must use resources at a rate which equals or is less than the economic benefit it delivers.

Principle of Accumulation.
By products of a system should not accumulate. Waiting lists, outpatient attendances should become static or decline.

Principle of Wastage.
Resources must not be wasted. Staff trained in NHS should be retained, theatres should be "sweated" etc.

Principle of Evolution.
The system must change to fit the societal and economic drivers in the environment.

Although there are similarities with the QIPP agenda, I believe that national, regional and sub-regional systems will be better served by considering the sustainable nature of our system, rather than the QIPP focus, which has, to date, been organisationally driven rather than system led.

As CCGs take system reins the sustainability principles should be written on the back of the hand of every commissioner. System success depends on it.