The Unsinkable Titanic

Expectations are an individual viewpoint. They are a synthesis of past, present and future models which govern our actions in the present. They are animal in origin. An example of animal origin would be a badly treated dog,whether it cowers, bark or bites is not purely a function of your actions, but on its past experiences and therefore expectations.
Dogs are not amenable to reason, you can't say "but that was then, and I'm different".
Are humans any different?
In some respects yes, they can be reasoned with, their expectations can, sometimes, be explored. In all cases our expectations can be managed.
It matters not whether the staff on a budget airline are always smiling, we've paid for coach and we're getting it. If a flagship company such as British Airways, or Cathay Pacific deliver less than perfection their expectation raising advertising causes a tsunami of complaint.
Perhaps the Titanic would have been a far less tragic event if the appellation of"unsinkable" had not been applied. It would probably have faded in memory, alongside similar tragic incidents.
So what does this have to do with healthcare?
As we move to a patient centered care system we are likely to aim for and promise better outcomes. This promise might well be a justification for unpopular changes in service, a means of selling a different model. "Closer to home", "nearer the patient", "patient centered" all raise an expectation of service, of something different and better than our current systems.
Expectations raised so high, service delivery inevitably likely to fail on occasion, it seems inevitable that individual and possibly community ire will be heaped upon those who fail to deliver.
Perhaps we need to think carefully and honestly about how we change the system, perhaps are slogan should be "The NHS, doing it's best to please everyone and failing in places".

Run that past me again

Here's an interesting thought.
If your brightest creative mind comes up with an idea what do you do?
The chances are is you would put the idea through some sort of technical assessment.
Ask the numbers guy, the operations girl, the team who "sense check" for a practical solution.

So what happens if the numbers man comes up with a way to slash the costs?
I'm willing to bet that most organisations in healthcare say "Ok let's do it!"

Maybe if you have a clinically led organisation you might run it past the Docs.

But would you run it past the out of the box thinkers?

Why do we subject the creative solution to technical scrutiny, but not subject technical solutions to creative scrutiny?

I would suggest that our society has developed a trust of the "real" the empirical, the concrete.
However transformation and evolution are the outputs of the creative, abstract and "wrong".

I'm not suggesting that every hospital or practice needs to employ a team to "think out of the box" or that the finance department is wrong to point out that a proposed solution is not cost effective.
I am suggesting that any one and every one should take a moment to check out the the latest idea, mandate or proposal twice.
The first time work in your preferred mode, creative or technical, reach a decision then stop.
Run that same idea again but think in your best attempt at your non preferred mode.
Does it make practical, financial cost effective sense? Does it make creative, innovative, developmental sense?

Ideas, initiatives, solutions or projects that deliver in both modes will be the ones that really deliver in new ways.

How you act now will decide your legacy.

Services are changing. Commissioners are changing. Organisations are fighting their corner.
Much of how the system develops and transforms will depend on the actions of the leaders within the organisations.
Leaders at all levels are faced with choices, however the nature of the choices is not labelled or rational. The actors within subsequent decision frameworks also find themselves coping with world changing outcomes.
An example of things to come include consolidation of specialist surgery such as vascular surgery. Right now across the country various hospitals are vying to become vascular centres, treating complex cases, making a difference to patients lives.
Unfortunately the various organisations who have a stake in the dealings don't always act rationally.
On the face of it shifts in service which should be clear, based on good data, good analysis and good procurement/ commissioning of the service appear to be being made slowly.
Unfortunately that apparent clear process masks some aberrant behaviours which are not professional, organo-centric and motivated by values other than patient care.
There is no easy solution to address these behaviours, they must be recognised, identified, and possibly named. Individuals need to be engaged, their damage and apprehension recognised and they must be engaged in a vision and journey to the future.
Easier to write than to do.

Innovation or Procrastination?

One of the challenges facing all clinicians is how to stay up to date when new treatments emerge.

Inevitable much research has been carried out looking at early adopters, late adopters, laggards and luddites. Usually the research focus shifts to the "barriers" of innovation.

It is often the dissemination and adoption phases of innovation which pose the highest challenges. Much focus is placed on "removing" the barriers.

Despite this research, mountains of evidence and guidance, adoption is slow, patchy and possibly dangerous for many of the newest treatments.

Perhaps we should look at the other end of the problem.

As clinicians we all intend to do the right thing, but somehow it just never seems the right time/ option/ circumstance for us to use the drug or treatment.

Our slowness to adopt is not necessarily a negative act. It could actually be a positive, but subconscious, choice to procrastinate.

Peers Steel, in the Procrastination Equation proposes a theory which describes the complex organic choices which result in many of us not accomplishing those tasks we should do or even those we choose to do.

My contention is that Innovation or procrastination are reciprocal in nature. Over time we live with choices, the world changes, we either do or do not change with it. When it comes to professional practice there are things we "should" do, because evidence, guidelines, dictat, all say we should.

Steel proposes that Value, Expectations and Time are all related to how badly we procrastinate. Do we value the change? What's in it for us? Can we physically accomplish it now, given all the competing distractions which are prioritised in our routines.

Already it would appear that a reward system, with time and financial consequences are sine qua non for innovation.

So perhaps Innovation: Health and Wealth will remove the incentives to procrastinate.

The National Scorecard?

Although the NHS looks like a single organisation to those on the outside, once you enter a "pathway" of care you realise that your journey takes you through a series of gardens, sometimes using gates, sometimes jumping fences I order to access the next stage.
Measuring and improving performance across this system is a matter of luck.
Luck in that if you can find a metric that is agreeable across the gardens you will be lucky to find it being measured in the same style in any garden, if at all in some. Taking the metric back to basics is a hope, did this event happen to this patient?- yes or no, means that data finite ones become less troublesome.
So looking around in healthcare why do we have so few National metrics?
Sweden, arguably one of the best performing healthcare systems has a series of national registers, which drive a metric based system.
The NHS has an excellent QOF system, but only in primary care. This system takes a cohort of patients and measures the outcomes of treatment. If QOF extended through the garden of primary care into secondary care we would know now whether all patients receive the right treatment, at the right time in the right place.

At present the best we can do is stitch together a series of indicators and cross our fingers.