What's your tribe?

A colleague of mine has always been keen to describe fellow clinicians as tribes. The "ortho tribe", the "respiratory tribe" etc.
Aside from the usual comedy routine of "what's the collective noun for a tribe of urologists" the tribal thinking is a shorthand for shared values and beliefs.
There is a suggestion that the institute in which those tribes work should become "the home team".
I'm not so sure I want to be cared for by a surgeon who feels an alliance to either the clinical tribe or the organisation which employs them.
I would like someone who cares about my tribe to care for me.
So here's the dilemma, if I want to care for a patient as part of their tribe I need to know in which tribe they consider themselves to belong- this could be tricky.
Perhaps geography could be a good proxy? The Kirkby Urologist, the Anfield gynaecologist are equally as plausible as the Liverpool Football Club doctor.
Who knows? Maybe clinicians concerns for the tribe might improve health and reduce costs?
Of course it means the exclusion of secondary care clinicians from CCGs and Health and Wellbeing boards is clearly a flawed plan which only makes sense if you belong to the political tribe.
The answer to the collective noun conundrum? - a bladder of urologists of course.

Dragons Den

Imagine the scene, a young entrepreneur has a plan which will make millions, he goes to the dragons den.
The pitch is good, solid, his idea has been tested out on colleagues and friends, he knows it's good.
He finishes the pitch, silence descends and Theo speaks..
"That's nice, but we're the dragons and we decide what happens"
Our hero is confused.
Peter Jones clears his throat.
"Theo is right, you have to realise we are the new dragons, we decide what happens and we also come up with the ideas"
An uncomfortable pause, before Duncan moves on his chair.
"let me tell you where I am on this- I'm a dragon, we have the money" he says patting a large pile of notes, "and we will decide who gets the money, we also have the ideas"
This isn't working out as expected our heros idea seems to have missed its mark, the dragons seem intent only in enforcing the mantra of their power.
There is only one dragon left to take an interest in the idea.
She looks up from her papers.
"I'm sorry I'm far too busy ticking boxes proving I'm a dragon, have the money and ideas to take an interest in your scheme, come back to me in a few months."

Although this distorted den is clearly a fantasy, the reality is that across the country CCGs are playing those difficult dragons, whilst a diverse group of clinicians, managers and organisations are seeking support, not necessarily investment, for new ideas. Once our CCG dragons relax, secure in their positions things might improve for the entrepreneurs. Until then it's likes to be a frustrating experience in the dragons den.

a Quote we need to hear

If Kennedy did the NHS: "we choose to reform healthcare in this decade not because it is easy, but because it is hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win"

Jenga Commissioning

I have always been slightly concerned by the shroud wavers who say that any change in commissioning will result in the destabilisation of their organisation. Their premise appears to be based on a belief that maintaining the status quo is a desirable outcome.
Put 100 clinicians in a room and I suspect you won't find anyone prepared to state that the current system is incapable of improvement. So what is the reason for their predictions of doom and gloom as CCGs develop.
The literature on change management is clear as to how these refuseniks should be dealt with, but what if they have seen something that others have not? What if they are the Cassandras of current day NHS?
Complexity and chaos predict that in order to change a system from one attractor state to another it must be disrupted. The work of Clayton Christensen suggests this disruptive innovation is sine qua non for health service reform.
The worry eating at my cortex is that we cannot afford to break healthcare in order to re-make it.
Perhaps there is a different way to play this game. Think of the children's game Jenga. The tower of wooden blocks is gradually removed one block at a time, the aim being to ensure your opponent takes out the last block which causes the tower to fall. Suppose for a moment that your local NHS economy is that tower and one by one the various services which are re-commissioned are taken out and placed elsewhere, for example ultrasound services provided out of hospital. If CCGs play a competitive strategy, or even just a non strategic current best move strategy, the tower will fall.
Now step out side the game as we currently play it.
Imagine a system in which commissioners and providers agree the old tower needs to change, be smaller, be redistributed. Imagine a system in which the players agree that once the blocks come out of the tower they are assembled in a coherent new model, closer to home, redesigned and cheaper through efficiency. At the same time the old tower is steadily made smaller, but without the collapse into chaos.

Is it possible to play the game in this way?
I believe it's a yes, but only if the players agree the principles and trust each other.
Simple.

Striking is not a game- or is it?

Game theory has been back in my thoughts this week.
Principally I've been looking at whether models of ultimatum and dictator games have a role in decisions take around clinical commissioning shifts.
At a tangent the medical profession has voted to undertake a day of action, which will see many Doctors dealing with only urgent or emergency activities.
In theory they are striking to show that they care about their pensions being changed by the government to give a poorer deal.
However that response is not just a response in the ultimatum game played by the politicians, the one that says "here's our offer, like it or not that's the offer -take it or leave it- your choice". It will be perceived as the first move in a new game played with patients. In the patient game the profession plays the role of dictator, "this is our offer- one day no routine care - no choice,tough luck pal".
There is a reasonable body of research behind game theory and the strategic choices made in the simple Dictator and Ultimatum games. In ultimatum games the offer is usually less "unfair" and more altruistic than when the dictator game is played, most offers see both sides achieve significant benefits. The dictator games are different. When the dictator is protected by anonymity the choices work out to be more extreme.
Almost unwittingly the UKs medics are being manoeuvred into a game they do not want to play, the damage will be significant, the belief that "my GP" has "my best interests" at heart will be demonstrated to be patently untrue, not just for the loss of routine care for that one day, but for the way in which the game has been played with patients.