Do the basics

If you've checked out my linkspage you will know I'm a fan of TED.com, recently listening to a talk by Abraham Verghese on the importance of touch as examination, ritual and therapy I was reminded of another passion of mine which has consumed weekends in the last month- rugby.

The good Doctors call to arms was to treat patients well, to treat them as people, to use touch rather than data as the means to interface with a patient. He gave the case of a woman with breast cancer who had four opportunities go by before someone took the opportunity to do a physical exam and found the tumours.

What has this to do with Rugby?

Well, the English team has left the world cup, only Wales remains of the home nations. How can this be? What was their secret?

In both diagnosis and sport there are certain set pieces, certain formalities which comprise the basis, the essentials of the craft. For both Dr verghese and Wales the secret of success is simple:

Do the basics well

If the basics are all present be it , kick off, line out, ruck, scrum or, introduction, history, examination, explanation and treatment then what follows will be a firm foundation for a successful performance.

It's not a rocket science insight, but given the plethora of discharge letters without a given diagnosis, or the patients perception that they were told nothing about their diagnosis perhaps is is time to make sure we do simply "get the basics right"

When conversation is better than commissioning

A hero of mine, Enrico Coiera, once wrote a paper entitled "When conversation is better than computation" you might expect that kind of title from a luddite, with anti technology principles, but at the time Enrico was a Vice President at Hewlett Packard in their special research division.

Enrico argued that despite all the computational power available there were times when developing a relationship and establishing communication was the right thing to do.  I would like to suggest that the same principle might apply to commissioning. We have services that could be improved by stepping back, starting again with a clean sheet of paper and buidling the perfect pathway. Although this risks the God Complex, it will be appropriate at times.

What would happen with conversation?

If there was an outcome which was less than expected it could be talked through and the incremental changes required could be put in place without the need to start again, spend hours redefining and re-procuring the system.

Cynic will argue that talking will just support the status quo, but they miss the point, the incremental change means that the status quo moves whether it wants to or not.

Perhaps the next time you have a letter from a hospital which asks you to look up blood results on the same hospital system the consultant could use, and furthermore to send it to the consultant, rather than moaning about being made to act like  a house officer (F1) you could always initiate a conversation- try it, you'll be surprised.

Losing the God complex

It's often said that doctors act like they're gods. They believe they are right, have the solution, can totally understand the problem. Ok this is a caricature but it has a basis in health systems. We often believe that there is a right answer, that we "know" the right thing to do in any situation. Our science of evidence based medicine simultaneously destroys and supports this view. It destroys the god complex by providing proof of the effectiveness of an intervention in any clearly defined, tightly controlled situation. However, armed with "the evidence" it delivers cast iron certainty that we are right, totally, infallibly correct.
The trouble is that health systems are not simple randomised double blind controlled trials. They are complex adaptive systems which do not respond in linear ways to defined, evidence based interventions. Complex systems require us to let go of the approach which says " I alone have the answer" and further more "this solution is the only one way to succeed".

Considering the NHS in it's current reformation it would appear that our solutions to the Nicholson challenge will emerge not from the top, not even the political direction of the Houses of Parliament, but instead from those near the front line who are able to experiment with the system, take chances on a trial and error basis, tinkering with the system to rapidly follow examples which provide good outcomes, rapidly abandoning features which produce lesser outcomes.

It won't be easy for us to shift from evidence based certainty to evidence based action not because it requires doctors and politicians to admit that they are not correct, but simply because it requires them to admit that they don't have the answer but are willing to learn.

Buy, Make or Partner?

One of the issues that seems to be hindering the NHS is the belief that the structures currently in place, both organisational and financial, are preventing the creation of a collaborative, patient centred system which offers the chance to deliver improved quality with improved productivity.
Granted we can argue that every organisation has a responsibility to achieve financial balance. However it is not the only requirement on NHS organisations. The real duty of every organisation is to deliver the best it can for it's customers, be they stakeholders, shareholders, paying clients or non fee paying service users.
The NHS has two blind spots, one is the payors, this Americanism translates to the commissioners, and the other is the service user, in our case the patients. Hospitals, practices, community trusts all forget that they have payors, commissioners who have an expectation of value and performance and instead focus on being the best organisation that they can. Although I don't believe we have a total blind spot for patients we often don't accord them the true status of customers, i.e having choice, power or purchase and a right to expect good service.

Is there a fix for this dichotomy, good organisation and good patient service?

The answer I believe is almost certainly, yes.

Commercial organisations can deliver financial success, efficiency and value. They also deliver customer focus and survive in harsh competitive environments. In that world view it seems obvious that competition is the answer to the NHS.

However if a commercial provider wanted to be the best it could, deliver most value it would also seek to expand it's market, it's influence. Examples such as Facebook, show a service provider who is now partnering with Spotify and other media providers to improve the range of services and value to it's users. Amazon achieved similar benefits when it bought out Audible to enable customers to choose printed, e-book and audio versions of it's products.

So it would seem that acquisition, alliance and collaboration is also the answer.

In the new NHS we now need an understanding of when to choose collaboration, competition or merger as the right blade on the NHS Swiss army knife.

Irreconcilable Differences?

Writing in his book Blink, Malcolm Gladwell tells the story of a marriage guidance counsellor who is able to predict success or failure of a couple after only a few minutes of interview time. The key he believes is contempt, if couples show contempt then all is lost, the relationship is doomed.

This week I have been speaking to people in primary care and secondary care.

In truth there were times when it did feel like being a marriage guidance counsellor.

All the red flags for relationship arguments were being waved in to the debate. The sin of absolute generalisation-"You always (then insert the apparent sin) in primary/secondary care" - really?- We always send out letters late? We always fail to refer appropriately? The sin of dragging in the in-laws "social care doesn't do its job and that's your responsibility to commission" is guaranteed to raise hackles.

Once absolute generalisation is used it tends to suggest that a fight is on the cards and that ignorance of each others feelings and functions is the underlying cause.

The main tragedy this week is that there is starting be be a little hint of contempt. "I never take my child to the GP he's rubbish- I don't know why any parent would."

Really? All GPs are rubbish?

Perhaps we should take a leaf out of the marriage guidance book and concentrate of creating a conversation in every health community which might just avert contempt, otherwise we will really find Irreconcilable Differences